The New York Times - July 15, 2004
Lawrence K. Altman

"We cannot win the battle against AIDS if we do not also fight TB," Mr. Mandela said at a news conference on Thursday. "TB is too often a death sentence for people with AIDS."

Mr. Mandela has acknowledged that as president he did not recognize the severity of the AIDS epidemic in South Africa, which now leads the world with 5.3 million people infected with H.I.V., the virus that causes the disease.

Since he left office, he has embraced the fight and has pushed his successor, Thabo Mbeki, to confront H.I.V. and tuberculosis. In some regions, tuberculosis causes as many as half the deaths among H.I.V.-infected people, making it the most fatal illness among people with AIDS, according to the World Health Organization.

While AIDS and the tuberculosis bacterium each can be fatal, the two diseases can also form a deadly combination, with each amplifying the other's progress. By weakening the immune system, the AIDS virus leaves infected people particularly vulnerable to developing tuberculosis.

Mr. Mandela said he spoke about his case of tuberculosis because he felt that the disease was ignored and to help the Bill and Melinda Gates Foundation open a $44.7 million program for research into the control of tuberculosis in communities where there are many cases of H.I.V. He said that prison doctors diagnosed his case of tuberculosis and determined it would take four months to cure.

Mr. Mandela said that, after prison doctors diagnosed his tuberculosis, he told his friends in prison.

"My friends objected to me sharing my personal affairs," he said, but added that his openness about his illness helped his recovery.

"I consoled them and told them that the doctors and hospital staff knew about my status, and I therefore had no reason to hide this information from those close to me," he said, adding that he took the same steps in disclosing his more recent case of prostate cancer.

"I knew that once people were aware of the effects, they would support me," he said. "I'm convinced that the support of my family, friends and the public in general contributed to my healing process."

Mr. Mandela said it was a blessing that "the world has made defeating AIDS a top priority." But an additional fight against tuberculosis is required, he said.

Determining whether tuberculosis or H.I.V. caused the death of a person with AIDS can be difficult and depends on specific medical facts in each case. Because such determinations involved medical judgments, the percentage of deaths caused by tuberculosis has varied widely in different studies.

The confluence of AIDS and tuberculosis, said Dr. Richard Chaisson of Johns Hopkins University in Baltimore, a recipient of one of the new Gates grants, is "a catastrophic collision of two epidemics."

Tuberculosis was prevalent even before the AIDS epidemic began to take hold in 1981. But now more people are dying from tuberculosis than ever, according to United Nations figures. Of the estimated 1.6 million deaths that tuberculosis causes each year, one-fourth occur among H.I.V.-infected people. Worldwide, as many as 50 percent of H.I.V.-infected people develop tuberculosis.

In sub-Saharan Africa, where 25 million people are infected with H.I.V., two-thirds of tuberculosis patients also have the virus.

Treatment of tuberculosis can prolong and improve the quality of life for H.I.V.-infected people, but cannot alone prevent people from dying of AIDS.

The current strategy for managing tuberculosis in poor countries generally depends on patients' seeking care and aims at treating patients with active tuberculosis, not those with silent infection.

The Gates Foundation grants will support research on the cost-effectiveness and feasibility of improving the detection of tuberculosis cases and of preventive therapy with a drug called isoniazid.

Research has shown that isoniazid can be more than 85 percent effective in reducing a person's risk of developing active tuberculosis. But scientists have not determined the effect of widespread isoniazid use in a tuberculosis epidemic.

The Gates studies will be conducted in Brazil, South Africa and Zambia and take more than seven years to complete. The Global Fund spends from 15 to 20 percent of its $3 billion budget on tuberculosis.
040715
NYT040709