The Burden of Tuberculosis

By Brittney Sullivan and Laura Pulscher

Dr. John Bartlett’s presentation last week was a great introduction to Dr. Carol Hamilton’s TB lecture today, emphasizing challenges of TB/HIV co-infections and growing drug-resistance, both causing individual and structural (e.g. systemic) barriers to global TB control.  Although TB is a major challenge in India and China (accounting for 35% of the global burden in just those two countries alone), a lot of Dr. Hamilton’s lecture focused on the concentration of TB/HIV co-infection in sub-Saharan Africa as well as drug-resistant TB.  Brittney just returned from five weeks working in multi-drug resistant tuberculosis (MDR-TB) hospitals in South Africa (in the KwaZulu-Natal and Eastern Cape provinces) where 70% of MDR-TB patients are co-infected with HIV. We think Dr. Hamilton’s points about current TB treatment being problematic were well stated and cannot be under scored enough – especially within certain populations such as children or those co-infected with HIV.  The treatment burden can be immense; for those infected with MDR-TB daily treatment consists of approximately 15-20 pills per day along with a daily injection for up to six months during the intensive phase of treatment. 

For individuals co-infected with HIV, pill burden and drug interactions may be increased.  Despite this, initiation of antiretroviral therapy (ART) is recommended in all patients co-infected.  Attached is a recent meta-analysis measuring “The Effect of Early Initiation of Antiretroviral Therapy in TB/HIV Coinfected Patients: A Systematic Review and Meta-Analysis” which assessed 2,272 study participants from 6 trials where early ART initiation (2-4 weeks versus 8-12 weeks) was conclusively found to reduce all-cause mortality in TB/HIV co-infected patients (Abay, et al. 2015).  This evidence strengthens many national TB control program guidelines, although implementation of recommendations surely will be a challenge.  In settings where lack of reliable supply chains exist, access to care and poverty are daily concerns, and poor diagnostics and/or lack of provider awareness of proper protocols is common; dual therapy for TB and HIV is, and will continue to be, challenging.  Translating this dilemma to the pediatric population only adds complexity.  The photo (from the TB Alliance) below illustrates just how demanding of a regimen we ask patients to accept. 

As a final thought, story telling is another way in which to raise awareness to global health challenges in a unique way.  In order to get grants funded or manuscripts published we need decent data.  We all know that.  However; the human connection and the stories behind the numbers are what call most of us into this field, and what bring us satisfaction after arduous days in the field, or sleepless nights writing, reading, and interpreting our data.  These are a few more stories worth highlighting the impact and burden of TB in addition to Thembi Jakiwe’s story of strength we shared earlier.

• Dalene von Delft – a physician from South Africa tells her battle with MDR-TB
• Dr. Lucica Ditiu (Executive Secretary of the Stop TB Partnership) talks about the stigmatizing language surrounding TB.
• Phumeza Tisile: HearNo Evil – a South African woman who survived XDR yet suffers from permanent hearing loss due to kanamycin (causing severe ototoxicity) discusses her journey through treatment and life after TB.
• Thato Mosidi - a physician in South Africa tells her story of being diagnosed with XDR and the isolation it caused her from her husband and 3-year-old daughter. 

*Footnote: the photo that  Brittney could not post in her reply comment to the HIV blogpost from Shengjie is shown here:

HIV - Not a Monster

by Shengjie Xu

Several months ago I received a phone call from a friend who expressed her panic about having had a dinner with a friend who MAY have a seropositive partner. She was considering stopping contacting her friend because of that. I was shocked.

30 years ago when HIV was first identified among homosexual men, because of ignorance people were scared. It was believed to be a punishment to gay people since it was mostly prevalent among the homosexual community. As we know now the method of transmission is through blood, blood-contaminated body fluids and mucosal contact as the virus can breach through the mucosal membranes. However even though we know about the science behind the nature of the virus, there’s still a big hurdle that prevents the society from accepting HIV seropositive people.

I spent hours try to comfort her, telling her that there’re many unknown factors that will lower the possibility of her being infected by dining with her friend. My arguing point is that physical contact and saliva are not the method where virus gets passed among people. I’m sure my friend knows about all the science, but when there’s a slight chance that she may get contact with “HIV” this word, she couldn’t pick up her mind to think rationally.

There are probably many people that still panic when hearing the word HIV even in a well-developed country. The social stigma and isolation of seropositive people remains a big problem of this battle. We have the resources to prevent and control viral spread, diagnose, and also treat patients for free. We know the science behind this sneaky virus. We know how to prevent and treat it. We even have research studies going on constantly to test for prophylaxis and vaccines. But why panic? The reason I used the title “not a monster” is because when we don’t know about a threatening creature, we call it “monster”. But when we start to know the nature of the unknown species, we start to face it calmly and start to call it “shark” or “lion” or “tiger”. HIV is like it: small amounts of people know the nature of HIV thoroughly and fight against it at the front line fearlessly. But the vast majority still sees HIV as a “monster” and even refuses to get contact with the warriors who risk their life helping the ones in need.

Educating the public should be an ongoing program of this campaign. The focus of the education part was on prevention. As the prevention part has done great jobs in reducing the incidence quite a lot in the past decades, maybe we should start bring our attentions to those underrepresented population who live with HIV in our society.

As Dr. Bartlett pointed out in his lecture about the antiretroviral study HPT 052, the use of antiretroviral therapy can reduce the sexual transmission of HIV-1 in serodiscordant couple by 96%. When the viral load of patient is minimally detectable, the risk of transmission is much reduced. This stunning number indicates that even as a HIV carrier, it is possible to live a normal life not passing the virus to their loved partner. There are also effective pre-exposure prophylaxis and post-exposure prophylaxis available for people who are at high risk of exposing to HIV. Science has also made it possible for HIV seropositive people to have healthy children. With the right treatment, living with HIV is not impossible. As we have good control and treatment methods, we may want to reconsider our unconscious discrimination against HIV+ population because of our ignorance.