Mail & Guardian (Johannesburg) - September 19, 2003

In South Africa more than half of all TB patients are also infected with HIV/Aids. TB is the most common opportunistic infection related to HIV/Aids. The idea put forward is that where TB programmes are working, ARV roll-out could piggyback on those programmes, a link that could bolster both.

The co-infection of TB and HIV is estimated at about 55% in South Africa, Lindiwe Mvusi, chief medical officer of the national TB control programme in the Department of Health, told the Mail & Guardian.

Today South Africa ranks seventh on the list of 22 high-TB-burden countries, with 75% of all TB cases in the country in four provinces: the Western Cape, KwaZulu-Natal, the Eastern Cape and Gauteng. Last year there were 224 420 reported TB cases, and of those 98 800 were infectious. Coughing spreads the disease and it is estimated that by the time a person is diagnosed he or she has already infected 10 to 15 people.

Since August this year, when the Cabinet instructed the health department to draw up a national plan for the provision of ARVs, there has been debate on the link between TB and HIV/Aids.

As Quarraisha Abdool Karim, associate professor in epidemiology at Columbia University and coordinator of the Southern African Fogarty Aids Training Programme, put it: "Given that TB is the most common Aids-related opportunistic infection, that the majority of HIV-infected persons are unaware of their HIV status, this is an ethical, efficient and effective way of identifying persons with advancing HIV disease to initiate highly active ARV treatment and [select] who would benefit most."

Until recently TB programmes have been marginalised by the HIV epidemic, which is seen as more urgent. Yet, as Mvusi pointed out, "TB infects more people" than HIV and the death rate is increasing, despite the fact that TB is curable.

She said most companies have HIV/Aids workplace policies in place, but few have policies that address TB, despite its easy communicability.

The health department has implemented a joint HIV/Aids and TB programme led by Dr Nono Simelela, head of the HIV/Aids directorate. Collaborative activities are being implemented to ensure that a person co-infected with HIV and TB is provided with comprehensive care.

"The approach is to have voluntary counselling and testing as the entry point, and those found to be HIV-positive [should] be screened for opportunistic infections, TB included," said Mvusi.

But there are problems. Take the case of Matlodi Modiga, a TB support-group leader in Mabopani outside Pretoria. She is a 34-year-old mother of three who lives on an occupational disability grant, which she spent on ARVs. She was diagnosed HIV-positive in 1994, but stopped taking ARVs after her third bout of TB. She said the combination of the TB drug and ARVs made her nauseous and unable to eat.

"You are not supposed to get opportunistic infections if you are on ARVs," Modiga believes. But while on ARVs she contracted TB-meningitis.

Mvusi recognises that treating patients who are on both TB and ARV treatments will be difficult. "The ARVs will not cure TB in HIV-positive individuals as the increased pill burden and side effects associated with both drug regimens might result in poor compliance. Intensive follow- up and support will be necessary to prevent this."

Modiga's experience as a support-group worker has made her aware that many people do not finish their TB treatment because they feel healthy after a few months.

Yet, Abdool Karim told the M&G, because TB therapy is directly observed, it would be beneficial to use this approach with ARV treatment. It would enhance ARV adherence during the first six months, in the period prior to patients switching to self-administration.

She said that "with careful preparation and implementation, my sense is that [ARV roll-out] would strengthen the TB services. We don't know which way it will go, but it will be important to monitor."If we don't use the ARV drug introduction opportunity to strengthen TB services, then we would have missed a very useful opportunity for integrating the two services for mutual benefit."

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