San Francisco Chronicle - January 13, 2009
Diane V. Havlir

The United States, under the Bush administration, has begun to make significant progress in this area, particularly in expanding global access to HIV/AIDS treatment via efforts led through the State Department. In her proposed post in the Obama administration, Hillary Rodham Clinton should be a strong voice for deepening our collaboration with other nations in this work. But, our success on AIDS now faces a major challenge that threatens to undermine the progress made to date, and that is the deadly rise in drug-resistant tuberculosis.

There is a deadly synergy between HIV and TB. TB is the major cause of death among persons living with HIV. Further, TB can spread easily, from a cough or a sneeze or by breathing in the exhaled air from a TB-infected individual, and too many HIV patients may be acquiring tuberculosis as they sit in health clinic waiting rooms. In our community, cases of TB among persons living with HIV are few and declining.

However, from time to time, as happened recently in San Francisco, new cases of TB are identified in a high transmission risk setting, our public health department mobilizes to protect the health of the community. We know that support of HIV/TB surveillance and vigilance in its execution are critical and here in San Francisco, 2008 ended with the fewest cases of TB reported since tracking of the disease began. Our global neighbors in Africa are not so lucky.

With funding from such sources as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, about 3 million people around the world are now receiving medicines that both extend lives and can reduce the spread of HIV. But, at least one-third of the 33.2 million people living with HIV worldwide are carrying TB and have up to a 15 percent risk of developing active TB disease every year. Inadequate TB-control programs jeopardize success of these efforts, and fail to prevent the emergence of drug-resistant TB. Drug-resistant TB strains produce high death rates, especially among persons already infected with HIV.

In 2006, a terrifying strain of highly drug resistant TB broke out near the South African town of Tugela Ferry. Of the first 53 patients diagnosed, 52 of them died within 16 days of their diagnosis. This situation requires fast action, and that is why it is especially troubling that the largest source of TB funding, the Global Fund, has been forced to postpone needed grant-making because of the failure of the United States and other donors to provide the contributions requested by the fund.

U.S. leadership on HIV and tuberculosis in poor countries ravaged by these two epidemics can make a profound difference. First, it is vital that the United States continue to enhance its commitment to global AIDS and tuberculosis, a commitment that was renewed when Congress reauthorized the lifesaving PEPFAR program this summer. The provision of antiretroviral therapy to persons with HIV is absolutely vital to protect persons with HIV from death and disability from tuberculosis. Expanding access to HIV treatment must continue, and earlier access to HIV treatment for persons with active TB is warranted. Screening persons with active TB for HIV in countries where both infectious diseases are endemic makes good public health sense. Screening persons with HIV for TB, and providing prompt treatment for both conditions, will save lives. To accomplish this, the United States should provide $2 billion to the Global Fund in 2009 and $4 billion for bilateral TB programs over five years, as Congress has already agreed in principle to do. Strong leadership in Congress, in particular from Speaker Nancy Pelosi, will be crucial in addressing the shortfall faced by the Global Fund and to fulfill the United States' bilateral funding pledges.

Because in the developing world, HIV and TB often coexist in the same person, it makes no clinical sense to consider these two infections as separate conditions, requiring separate facilities, medical personnel, budgets and treatment protocols. U.S.-funded clinics charged with providing HIV care and treatment must be required to meet basic infection control standards. It is unacceptable that many patients risk contracting tuberculosis by keeping their appointments at the HIV clinic.

Some would say fulfilling those commitments will be difficult, given the financial crisis confronting the United States and the rest of the world. But we have a moral and a public health imperative to respond to this epidemic as it is experienced by some of the poorest people in the world in some of the poorest countries of the world - as an epidemic of HIV and TB. The inauguration of Barack Obama and the confirmation of Secretary of State Clinton will provide an opportunity to reaffirm our leadership and put the U.S. response to global disease on a par with other foreign policy challenges.

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Dr. Diane V. Havlir is a professor of medicine at UC San Francisco and a member of the Scientific Advisory Committee of the Infectious Diseases Society of America's recently established Infectious Diseases Center for Global Health Policy and Advocacy in Arlington, Va.

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