World AIDS Day 2008 Editorial Packet: Fighting AIDS Means Fighting TB
President-elect Obama Must Build Upon Successes in Global Health
November 2008 — As President Bush and his administration prepare to leave the White House, historians and pundits are already debating what his legacy will be. While some policies lend themselves to partisan debate, one achievement that has been lauded from both sides of the aisle is the remarkable gains that have been made in global health, particularly in sub-Saharan Africa.
Despite President-elect Obama's wish to bring change to the executive office, this is one area where he must not back down. He must ensure that the five-year, $48 billion Lantos-Hyde Act that he helped pass as a senator this summer is fully funded, allowing the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR), as well as programs for TB and malaria. PEPFAR has been regarded as a major success. Among other achievements in its five years of existence, PEPFAR has helped raise the number of people receiving treatment for HIV/AIDS from 50,000 to 1.6 million. The incoming Obama administration must see that an even larger percentage of people in need of treatment receive it.
Indeed, there is ample room for improvement, which is important to remember as the world observes World AIDS Day. Each year, World AIDS Day is marked by politicians with speeches, proclamations, and other well-intended acknowledgments of this global pandemic. However, despite the enormous amounts of effort and resources invested into HIV/AIDS, the leading cause of death among AIDS patients, tuberculosis, is largely ignored by the global community. Events such as World AIDS Day have helped build a consensus that fighting HIV/AIDS is the strategic and morally right thing to do, but few realize that an explosion of drug-resistant TB (MDR- and XDR-TB) in southern Africa threatens to undermine the progress made and billions invested in AIDS treatment scale-up.
As HIV weakens the immune system, TB preys on people living with AIDS. One-third of the 33 million people living with HIV/AIDS worldwide are infected with TB, and over half of all AIDS deaths in some parts of the world are caused by TB. According to the World Health Organization, people with HIV are up to 50 times more likely to become sick with TB than those who are HIV-negative. While there is no cure for HIV/AIDS, TB is curable in most cases with drugs that cost as little as $20 for a full 6 to 8 month course of treatment. Without proper treatment, 90 percent of those living with HIV/AIDS die within months of contracting TB. Overall, TB will kill 1.7 million people this year.
Access to testing for both TB and HIV is critical. Less than one percent of people living with HIV/AIDS are tested for TB. More resources devoted to TB-HIV prevention could make it easier for patients to be tested in the same place, and receive timely results. Currently, patients in most of the developing world have to make arduous trips to HIV clinics, which are often not equipped to also test for TB. Patients must then wait weeks, sometimes months, for results, as most countries do not have the laboratory facilities to make an accurate diagnosis.
The World Health Organization has calculated that universal access to coordinated TB-HIV services could be achieved, and TB-HIV deaths could be reduced by 80 percent, with a worldwide investment of $19 billion between now and 2015. But this goal cannot be met without the support of major donors. Funding for global TB control programs has not kept pace with investments in other disease priorities. The Obama administration must not only ensure that all global health programs, and international initiatives like the Global Fund to Fight AIDS, TB and Malaria, are fully funded, but that adequate resources are devoted to joint TB-HIV prevention and treatment.
Drug-Resistant Strains of TB Increase Urgency
The identification of extensively drug-resistant TB (XDR-TB) in a South African hospital and now in 49 countries - including the U.S., Canada, and Mexico - underscores the urgent need to link AIDS and TB treatment efforts. A result of the improper management of TB treatment, XDR-TB is resistant not only to the most effective first-line drugs, but also to critical second-line drugs. Current methods of testing for drug-resistance can take 6 to 16 weeks, so many patients with drug-resistant TB die before the disease can be accurately diagnosed. These deadly new strains of one of humanity's oldest diseases have been called an "emerging threat to the homeland" by the Department of Homeland Security.
In the first reported cases from a South African hospital, 52 of 53 patients died from XDR-TB within a matter of weeks. All 47 of those tested for HIV were HIV-positive. South Africa's XDR-TB outbreak drives home concerns about the potential of drug-resistant TB to undermine the billions invested and enormous progress achieved in reducing deaths from AIDS through rollout of antiretroviral treatment (ART). The XDR-TB strain identified in this outbreak was, in fact, initially passed within an ART support group. Recent South African health statistics now show that XDR-TB has more than quadrupled in Western Cape province in the past three months.
What the New Congress and Administration Can Do
Last year, Congress took a bold step in the fight against infectious disease by passing the Lantos-Hyde Act, which authorized $48 billion over five years to renew PEPFAR and to fund programs to fight TB and malaria. $4 billion of this was designated to fight TB. This year, Congress will vote to appropriate these funds. We hope that the new Congress recognizes the good work that has been done, and fully funds these initiatives. In doing so, our leaders must allocate enough resources specifically for TB-HIV that would help the U.S. meet its commitment to the WHO's call for $19 billion through 2015. President-elect Obama has stressed his desire to continue the work of President Bush in fighting AIDS and TB in the developing world. Recognizing the importance of providing access to both TB and HIV treatment would be an enormous step in ending the AIDS pandemic once and for all.
Winstone Zulu's Story
Winstone Zulu was born in 1964, in Lusaka, Zambia, the sixth of thirteen children. He was diagnosed with polio at the age of three, has been living with HIV/AIDS since 1990 and became sick with — and was cured of — TB in 1997. In the years since his own HIV-positive diagnosis, he has watched all four of his brothers die of TB, the last passing away in March 2003 as a result of a lack of access to the TB drugs that would have cured him and extended his life. These experiences have made him a leading global advocate on TB and HIV/AIDS.
In Winstone's own words: "My brothers Erasmus and Christopher got tuberculosis at around the same time. It was so tragic, Erasmus died on the 7th of December 1990 and his wife died the following day, and then Christopher died a week later. And then there was Shadrek, he was the eldest of all of us, he worked for BP, he was a truck driver. He left 6 children. He died in 1996 from tuberculosis as well. His wife died the following year. Danny, he was the youngest. Danny was a really good musician, he used to work in South Africa. Then he came back and we started living close to each other, we became very close. He died in 2003.
They shouldn't have died. TB is preventable, whether people are HIV positive or not. TB treatment gives patients more time. If my brothers had survived TB they might have lived long enough to access HIV drugs like me.
We adopted my son Michael before the era of prevention of HIV from mum to child. He is 9 years now and has had TB but got cured. He is on antiretrovirals for HIV infection. I also directly support Matildah and Clara who are my late brother Shadreck's daughters, Musa and Morey who are late Christopher's kids. There are other nieces and nephews that I help too but they are looked after full time by my sisters."
Winstone's story highlights that we cannot separate the epidemics of TB and HIV/AIDS and that unless we act more urgently and with the resources commensurate with the problem, TB will continue to be a needless tragedy that aggressively kills those with HIV/AIDS.
While there is no cure for AIDS, there is a cure for tuberculosis. This World AIDS Day, we cannot forget that the fight against AIDS cannot be won without the fight against TB. The new administration must ensure that we fight these two pandemics head-on, in order to build a better, safer world in the future.