Fireworks in Barcelona, but where was TB news?
WHO initiative tried for coverage
As the 13th International AIDS Conference in Barcelona, Spain, drew to a close in July, some TB experts were dismayed that, despite all the clamor and rhetoric about AIDS, there’s much less attention about HIV’s deadly companion, TB.
"All week long, we’ve been hearing how AIDS cases are off the boards, but there’s hardly a word about a disease that kills more people than any other," says Lee Reichman, MD, MPH, director of the National Tuberculosis Center at the New Jersey Medical School in Newark. "People still don’t think TB is that important. It’s very discouraging."
The silence was broken briefly midweek, when the World Health Organization (WHO) announced a new initiative — which was actually a re-emphasis of an initiative already under way — aimed at increasing collaboration between HIV and TB programs in poor countries. The initiative is pushing TB programs in the developing world to work harder at testing their patients for HIV; and conversely, for HIV programs to test more of their patients for TB.
Other aims include getting TB prophylaxis to more HIV-infected people at risk for TB, as well as evaluating pilot programs aimed at getting anti-retrovirals to AIDS patients in resource-poor countries.
Public health policy-makers are paying especially close attention to these pilots, some of which are run by nongovernmental organizations, and others of which are bilaterally funded. In Haiti, for example, a Partners in Health initiative has been successfully treating both AIDS patients and TB patients with multidrug-resistant TB, despite the country’s notable lack of health care infrastructure.
HIV now drives TB epidemic
The WHO also released figures that show how disastrously HIV and TB have already collided in poor countries. HIV now accounts for 8.2 million new TB cases, and 1.82 million TB deaths worldwide — or 9% of all new TB cases globally, and 12% of all deaths.
In Africa, the co-epidemic’s impact is even more dramatic. There, new TB cases attributable to HIV infection make up 31% of the new case total, and deaths from TB attributable to HIV account for 39% of TB mortalities. In some areas, TB cases are up sixfold due to HIV, experts say.
One bright spot for TB news was a two-part special on TB that fell midway through the AIDS conference, and aired on National Public Radio’s (NPR) "All Things Considered." NPR devoted a 20-minute segment to directly observed therapy in a village in Kenya, and a second to explaining how the co-epidemics are intertwined in the developing world.
In the second portion of the show, Kevin De Cock, MD, who heads a Center for Disease Control and Prevention AIDS project in Kenya, noted that TB patients were often resistant to getting tested for HIV because of the stigma that attaches to AIDS. Though a DOTS-like structure could in theory provide anti-retroviral medication to AIDS patients, De Cock said that Kenya’s TB infrastructure, already straining to keep up with burgeoning case loads, would be overwhelmed if hit with an influx of AIDS patients.
IOM report may stir controversy
If the ravages of the TB/HIV co-epidemic aren’t enough to stir the consciences of rich countries, a forthcoming report on emerging infectious disease from the Institute of Medicine might do the trick, says Jim Kim, MD, PhD, executive director of the Cambridge, MA-based nonprofit Partners in Health.
The IOM report is expected to predict a new wave of AIDS-like viruses and drug-resistant pathogens, Kim says. When that begins to happen, "we’re going to have to scale up capacity in these poor countries, very quickly indeed," he notes.
Kim has little patience with one component of the public health community’s reaction to the co-epidemic: "We need to fight this notion, so entrenched in public health, that our job is to keep doing as much as possible with as little as possible," he says.
Nelson Mandela, former president of South Africa and one of the Barcelona conference’s closing speakers, made the same point. If poor countries and individual patients suffer silently instead of continuing to protest, "then you’re signing your own death warrant," he said.
$1.25 billion sought from U.S.
Richard Feacham, the new administrator of the Global Fund To Fight AIDS, TB, and malaria, said the fund needs $10 billion for 2003, plus an additional $3 billion for TB and malaria. He called on the United States to give $1.25 billion of that. So far the White House has blocked legislation in Congress that would have upped the U.S. contribution, which now stands at $500 million for the next five years. President Bush, U.S. Secretary of Health and Human Services Tommy Thompson, and administration insiders have cited concerns about corrupt governments in Africa, lack of infrastructure, and lack of safe-sex behavior as justification for the fiscal restraint.
It was probably that line of reasoning Feacham had in mind when he told listeners in Barcelona the story of two men walking down a country road in rural Africa. The men come upon a bus that capsized and was filled with injured and dying children. "Quick, let’s get these children to a hospital," says one man. "No," says the other. "Let’s go to the legislature and pass some better seat belt legislation. That’ll make better economic sense in the long run."
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