Tuberculosis TB

Today, on World TB Day, we must recognize the urgent need to end the TB epidemic around the world, especially among people living with HIV.

TB remains a leading cause of severe illness and death among people with HIV. According to the World Health Organization Global TB Report 2022, people with HIV are 14-18 times more likely to fall ill from TB compared to people without HIV. About one in three AIDS related deaths were in 2021 were due to TB.  We cannot allow this to continue. We must ensure that all people living with HIV and those vulnerable to TB have access to TB prevention, diagnosis, and treatment services.

We continue to miss opportunities to deploy the tools we have against HIV / TB co-infection.  Almost half of people living with HIV who developed TB in 2021 were not diagnosed or reported to have TB and coverage of TB preventive therapy among eligible HIV positive persons remains at only 42%.

Like in the responses to HIV and COVID 19, inequalities are the root cause making some people at higher risk of TB, due to social economic, geographic, gender factors and humanitarian and crisis situations. Legal and policy environments also affect access to health services for those who need them the most. We shall not forget that for any health programs to work, we need to put people at the center and engage beneficiaries, particularly the less served communities, to be part and parcel of the planning, implementation and monitoring the response.   

Today on World TB Day, I would like to call on all our partners to redouble efforts to ensure early identification, treatment, and prevention of TB in people living with HIV by scaling up the recommended screening and diagnostic tools, providing integrated quality treatment and care, rolling out short-course TB preventive treatments, and removing barriers that affect the smooth implementation of programs.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Tuberculosis (TB) is a preventable and treatable disease, yet it continues to claim millions of lives each year and remains the leading cause of death among people living with HIV.

While progress has been achieved in recent years, there have been some reversals due to the COVID-19 pandemic. There has been a steady decline in the estimated number of incident TB cases among people living with HIV. However, just 48% of the estimated 787 000 TB episodes globally among people living with HIV in 2020 were diagnosed and notified. This reflects a decline for the first time since 2004 in the percentage of estimated incident TB cases among people living with HIV that were notified, from 56% in 2019.

Fully 88% of people living with HIV who were diagnosed and notified with TB were provided with antiretroviral therapy, corresponding to 42% of people living with HIV estimated to have developed TB in 2020. While until 2019 there had been a gradual increase in the number of TB patients living with HIV who were on antiretroviral therapy, 2020 data reflect a decline in the percentage of incident TB cases of people living with HIV who received antiretroviral therapy for the first time since 2004, from 49%. There was also a decline in the number of people living with HIV who received TB preventive treatment between 2019 and 2020.

While the United Nations High-Level Meeting on Tuberculosis target of 6 million people living with HIV having received TB preventive treatment between 2018 and 2022 has been reached ahead of time, with 7.5 million people living with HIV having received TB preventive treatment between 2018 and 2020, there is still a long way to go to reach the 2025 target of 90% of people living with HIV having received TB preventive treatment.

There were an estimated 214 000 TB-related deaths in 2020 among people living with HIV, a 62% reduction since 2010, when TB claimed the lives of 563 000 people living with HIV. For the first time since 2006, there was an increase in the estimated number of TB-related deaths among people living with HIV between 2019 and 2020, from an estimated 209 000. The 2021 United Nations Political Declaration on AIDS requires an 80% reduction by 2025 (compared to a 2010 baseline).

On World Tuberculosis Day 2022, UNAIDS is calling for urgency in diagnosing and treating TB as TB deaths among people living with HIV rise for the first time after years of progressive decline

GENEVA, 23 March 2022—Tuberculosis (TB) is the leading cause of death among people living with HIV, accounting for around one third of AIDS-related deaths globally. Coordinated and scaled up efforts to prevent, diagnose and treat the two diseases had resulted in a 68% decline in TB deaths among people living with HIV between 2006 and 2019. However, in its 2021 Global Tuberculosis Report, the World Health Organization announced that TB deaths among people living with HIV increased for the first time in 13 years, from 209 000 in 2019 to 214 000 in 2020.

“The increase in TB deaths among people living with HIV is alarming and demonstrates the fragility of pandemic progress,” said Winnie Byanyima, Executive Director of UNAIDS. “When COVID-19 hit, global attention on HIV and TB shifted as the world focused on tackling the new pandemic. This has meant lives needlessly lost and important targets missed for HIV, TB and other diseases. Urgent action and increased investments are needed to get us back on track.”

People living with HIV are 18 times more likely to develop TB disease. Although around 85% of people who develop TB disease can be successfully treated, the treatment success rates for people living with HIV are much lower, at around 77%. This demonstrates the importance of scaling up prevention efforts as well as treatment for the two diseases.

Concerted and collective action in this area has saved lives in recent years. Between 2018 and 2020, some 7.5 million people living with HIV were given preventive TB treatment, surpassing the global target of 6 million. But much more needs to be done to address the underlying inequalities that continue to fuel the spread of HIV and TB.

Refugees and displaced people are at particularly high risk of developing TB. At the end of 2020, the Office of the United Nations High Commissioner for Refugees estimated that 82.4 million people around the world were displaced from their homes. The war in Ukraine has already forced 3.5 million people to flee the country and millions more are internally displaced. It is critical that Ukraine and its neighbouring countries receive urgent support to provide essential health services for people affected by the war, including services for TB and HIV.   

“In this time of crisis, there is an opportunity to build a pandemic-resilient future if leaders work together to tackle the inequalities that endanger us all,” said Ms Byanyima. “While AIDS, TB and COVID-19 each spread in unique ways, we are watching as each is driven by social and economic inequality that leaves some communities more vulnerable and the whole world at risk. We can address those inequalities, or we can let these pandemics continue—the power is in our hands.”

The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is the leading international funder of TB programmes; however, COVID-19 has had a devastating impact. Between 2019 and 2020, the number of people treated for TB in the countries where the Global Fund invests fell by around 1 million. This year, at its seventh replenishment, the Global Fund is calling for an additional US$ 18 billion to save 20 million lives and get the world back on track towards ending HIV, TB and malaria. To end the three diseases by 2030 and build strong national health systems to respond to emerging pandemics, it is essential that the Global Fund be fully funded.

UNAIDS is continuing to work with partners to reach the HIV/TB targets set for 2025, which include ensuring that 90% of people living with HIV receive preventive treatment for TB and reducing TB-related deaths among people living with HIV by 80% (from a 2010 baseline). To make this happen will require the Global Fund to be fully funded and that investments be made in research and development, in expanding services as well as in adopting new and innovative strategies to reach everyone in need.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Despite the great progress made since the early days of the HIV epidemic, the HIV response for children is still lagging behind the response for adults.

Children living with HIV are particularly susceptible to tuberculosis (TB), one of the leading causes of AIDS-related deaths. In 2020, according to government statistics, 9400 people died of AIDS-related illnesses in Côte d’Ivoire, including 800 children under the age of 14 years. There were 21 000 people under the age of 15 years living with HIV in the country—only 49% had access to antiretroviral therapy. How to correct such an inequality was the question at the heart of a national consultation on paediatric HIV and TB that was held from 8 to 10 June in Abidjan, Côte d'Ivoire.

The consultation, Acting Together for a Generation without AIDS and Tuberculosis, was aimed at improving the prevention and management of HIV and TB among children and adolescents in Côte d’Ivoire.

In her opening speech, Dominique Ouattara, the First Lady of Côte d’Ivoire, called for “The development of an ambitious road map that will enable Côte d'Ivoire to achieve its commitments.” She invited all the participants to engage in a dialogue on the challenges and priority actions needed, and to discuss the roles, responsibilities and contributions of each partner.

The consultation is part of the Confessional Initiative, a UNAIDS and United States President’s Emergency Plan for AIDS Relief initiative that is organizing national consultations and training in Cameroon, Côte d’Ivoire, Kenya, Nigeria and the United Republic of Tanzania.

“The consultation presented the national situation regarding diagnosis, treatment and prevention of HIV and tuberculosis among children, identified the key challenges, outlined the solutions, priority actions and resources needed to improve the national roll-out of optimal paediatric HIV and tuberculosis treatment and diagnosis and identified good practices for replication through civil society and faith-based organizations,” said Patrick Brenny, the Director for the UNAIDS Regional Support Team for Western and Central Africa.

The targets in the 2016 United Nations Political Declaration on Ending AIDS and in Start Free, Stay Free, AIDS Free for paediatric AIDS have not been met. Globally, during 2020 an estimated 160 000 children acquired HIV, far from the global 2020 target of 20 000. Modelling has also shown that the COVID-19 pandemic could have a major impact on new HIV infections among children in sub-Saharan Africa.

Ms Ouattara appealed to the 350 participants to work towards reducing inequalities and asked all stakeholders to join forces to achieve certification of the elimination of mother-to-child transmission of HIV. “Today, in 2021, no child should die of AIDS or tuberculosis in our country," she added.

The World Health Organization estimates that, globally, more than 1 billion people (15% of the world’s population) have a disability. Disability is increasing in prevalence due to ageing populations, trauma, accidents and chronic health conditions, including HIV, tuberculosis (TB) and COVID-19. 

Persistent discrimination against and exclusion of people with disabilities, in particular women and girls with disabilities, increases their vulnerability, including their risk of HIV infection. People with disabilities, in particular women and girls with disabilities, also experience barriers to accessing HIV services and are left behind in HIV policy-planning, programme development, service delivery and data collection.

People with disabilities face stigma and discrimination in families and communities, lack transport to health-care facilities and are faced with poor attitudes of health workers while seeking health care.

Since 2004, the AIDS Service Organization (TASO), based in the Mulago Hospital Complex in Kampala, Uganda, has attempted to reach out to people with disabilities. However, it has had limited success due to the complexities of community-based care.

In 2016, in response to these challenges, Positive Women with Disabilities (POWODU) was formed out of TASO to pay special attention to people with disabilities living with HIV in order to reduce AIDS- and TB-related deaths, stigma and discrimination and to promote sexual and reproductive health and rights.

POWODU is headed by Betty Kwagala, a formidable advocate, trainer and woman living with HIV who has 25 years’ experience serving as a counsellor at TASO Mulago. Ms Kwagala is a respected and well-known figure in the community, who has uplifted the lives of many people living with HIV in Uganda.

POWODU, in partnership with TASO Mulago, reaches out to people with disabilities in the urban districts of Kampala, Wakiso and Mukono. According to TASO’s client register, there are more than 13 000 people with disabilities in Kampala and Wakiso enrolled into HIV care. Seventy per cent are women and the majority are homeless.

HIV testing and TB screening are integrated into every POWODU community outreach. “The services are always offered near to where people with disabilities reside because of mobility and transport challenges,” says Ms Kwagala.

If a client tests positive for HIV, POWODU offers immediate initiation of HIV treatment, as per the Ministry of Health guidelines. If a sputum TB test is positive, POWODU will refer the case to the main laboratory for further investigation and proper management. POWODU will then follow up, and, with the support of a TB focal person, arrange pick up for the client in a TASO van to escort him or her to receive the appropriate health service.

Other services offered on site by POWODU include sensitization on adherence to both HIV and TB treatment, prevention of HIV, TB and COVID-19 and accurate information on sexual and reproductive health and rights among people with disabilities.

“The COVID-19 pandemic has led to clients who have been lost to follow-up because they are homeless or reside in informal settlements. The lockdown caused more challenges, such as lack of food and a significant disruption to the usual activities that give them some income, such as begging,” says Ms Kwagala.

During the COVID-19 lockdown, UNAIDS supported 200 people with disabilities living with HIV with food rations, personal protective equipment and personal hygiene kits. It also supported a project to equip 40 people with disabilities with skills on how to identify income-generating activities. They were provided with popcorn-making machines and groundnut grinders.

TASO members were provided with megaphones and sensitized members of their communities on HIV, TB, COVID-19, sexual and reproductive health and gender-based violence.

“POWUDU and TASO have shown remarkable resilience by putting people at the centre during the COVID-19 pandemic by ensuring that people with disabilities living with HIV are safe and not left behind,” says Jotham Mubangizi, UNAIDS Country Director, a.i., for Uganda.

Globally, the number of people living with HIV who died from tuberculosis (TB), a curable and preventable disease, has fallen from almost 600 000 deaths in 2010 to just over 200 000 in 2019, a fall of 63%. In 2016, a global target was set by the United Nations to reduce TB deaths among people living with HIV by 75% between 2010 and 2020. Nine countries (Djibouti, Eritrea, Ethiopia, India, Malawi, South Africa, Sudan, Thailand and Togo) achieved or exceeded the global target by the end of 2019, one year ahead of schedule.

Further progress towards the global targets has been made in making TB preventive treatment more available to people living with HIV. TB preventive treatment greatly reduces their risk of falling ill and dying from TB. In just two years—2018 and 2019—5.3 million people living with HIV received life-saving TB preventive treatment. That is already 88% of the 6 million target set for 2022 in the 2018 United Nations Political Declaration to End TB.

While progress in some countries is to be applauded, these successes mask the many inequalities and gaps that remain in providing the best integrated care for people living with HIV and TB. These gaps resulted in an estimated 208 000 preventable TB-related AIDS deaths in 2019—about one in three AIDS-related deaths.

“One of the greatest disparities in the global response to HIV and TB is in reaching children,” said Shannon Hader, UNAIDS Deputy Executive Director for Programme. “Much better tools to prevent, diagnose and treat TB and drug-resistant TB for young children are now available, but they are still not enough. Too many children are still not being reached with these new tools. Some health-care workers lack the confidence to manage TB among children living with HIV and, for fear of causing harm and a desire to be protective, they don’t always act. Children are being “protected to death”. We need to build confidence to manage TB and HIV in young children and reach transformational goals.”

TB is especially difficult to diagnose among the youngest infants and children living with HIV—those less than two years of age. The most severe forms of TB—disseminated TB and TB meningitis—are common among this age group and they are life-threatening without prompt diagnosis and treatment. Major advances have been made in improving TB diagnosis for children. Child-friendly medicines for the treatment and prevention of TB are available at low cost from the Stop TB Partnership Global Drug Facility. The challenge is to take these innovations to the scale and quality needed to reach all children living with HIV in need.

The Rome Paediatric HIV & TB Action Plan, part of the UNAIDS and United States President’s Emergency Plan for AIDS Relief Faith Initiative, is closing the gaps for children living with HIV. It is a unique multistakeholder partnership that has stimulated unprecedented collaboration among the faith community, private sector, regulators, donors and others to accelerate the development and implementation of better diagnostic tests, preventive measure and treatments for HIV and TB among children living with HIV.

In 2019, less than half (49%) of the estimated 815 000 people living with HIV who also have TB disease were reported to be receiving both HIV treatment and TB treatment. This demonstrates that large gaps remain in screening, testing and treatment for both HIV and TB. To address this, national programmes need to go beyond traditional health facilities to find the missing millions of people who are still in need of treatment for HIV, TB or both. An integrated, community-based and person-centred approach is needed. Multidisease family and community screening for TB, HIV, COVID-19, high blood pressure, diabetes and other common conditions can be de-stigmatizing and can reduce costs for programmes and people. It is critical to encourage all people recently diagnosed with HIV, TB or COVID-19 to allow confidential screening of their family, household and community contacts, including children and young people.

Already, the clock is ticking for us to reach the ambitious new 2025 targets for TB and HIV laid out in the new global AIDS strategy for 2021–2026. Achieving these targets will place the world back on track to end AIDS and TB by 2030. A collaborative and integrated response to the pandemics of TB, HIV and COVID-19 is needed. The response must be rooted in affected communities and centred on the needs of the most affected people. Addressing the inequalities that drive TB and HIV will help to close the “deadly divide” between global commitments and the lived reality of TB- and HIV-affected communities. By ending inequalities, we can stop adults, young people and children living with HIV from dying of TB.

All (100%) of people living with HIV newly started on antiretroviral therapy should receive either tuberculosis (TB) preventive treatment (blue bar) or TB treatment (orange bar)—together, they represent “optimal TB care”. The green bar shows the percentage of people newly started on antiretroviral therapy who did not receive optimal TB care and are vulnerable to falling ill or dying from TB.

All people living with HIV who are newly enrolled on antiretroviral therapy should receive “optimal TB care”—either TB preventive treatment or TB treatment. Since 2012, the World Health Organization has recommended that all people newly diagnosed with HIV should be screened for TB. If they do not any have symptoms of TB (cough, coughing up blood, fever, night sweats, weight loss, chest pain, shortness of breath or fatigue) they should receive TB preventive treatment. If they have any TB symptoms, they should be fully investigated for TB disease. If they are found to have TB disease, they should be started on TB treatment immediately. If there is no evidence of TB disease, they should be started on TB preventive treatment.

TB is the commonest cause of hospitalization and death among people living with HIV. In 2019, TB was responsible for 208 000 (30%) AIDS-related deaths. Yet, TB is curable and preventable. TB preventive treatment reduces the risk of developing TB disease and can reduce deaths among people living with HIV by almost 40%. Without treatment, a person living with HIV who has TB disease is likely to die.