From the start of the AIDS pandemic, HIV and tuberculosis (TB) have operated in lethal collaboration. Indeed TB, the millennia-old scourge, remains the single biggest killer of people living with HIV/AIDS, claiming the lives of more than 800 people every day. A powerful new film will premiere on PBS this week , about drug-resistant TB in communities hard hit by HIV in Swaziland, reminding us of the urgency of this dual crisis.
The President’s Emergency Plan for AIDS Relief (PEPFAR) helped pioneer some of the earliest TB-HIV investments and has laid important groundwork in the response to the co-epidemic. In line with World Health Organization recommendations, PEPFAR and its partners provide testing, preventive therapy, and treatment in countries with high burdens of both diseases. The recent PEPFAR Blueprint rightly identifies TB-HIV integration as “critical to achieving an AIDS-free generation.” What PEPFAR does going forward—its ambition to take life-saving TB-HIV interventions to scale—will be instrumental in determining if and how quickly we defeat these killers.
Every year, an estimated 3 million people who become sick with active TB, a full third of new cases, are not being reached with quality care. Among people living with HIV who become sick with TB, the statistics are even worse: as many as half will miss out on the care they need. To reverse these trends, we must do more financially and programmatically. This includes increasing TB efforts to reach the unreached, strengthening TB-HIV collaborative strategies, and ambitiously expanding access to HIV treatment, which also has enormous benefit in preventing active TB.
HIV-TB Funders’ Commitment
If we’re to make real progress we must continue to change the resource picture. PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria , the world’s largest external funder for TB, will need to play a central role in supporting countries to tackle the co-epidemic moving forward. The Global Fund has just begun requiring countries with high incidence of both TB and HIV to submit a joint proposal that addresses the diseases together. The historic commitment by President Obama to provide up to $5 billion to the Global Fund will help drive this work. Strong U.S. bilateral support for tuberculosis is similarly essential, as is continuing to ambitiously expand access to AIDS treatment. New reporting requirements of the 2013 PEPFAR Stewardship and Oversight Act will help us measure our progress and will show whether high-impact interventions—including the number of people living with HIV/AIDS starting isoniazid therapy to prevent TB— are being successfully scaled up.
New Tools Key to Success
Over the last two years, PEPFAR has helped roll out an important new molecular diagnostic tool for TB, enabling more rapid and accurate diagnosis, including for drug resistance, so that individuals can access needed treatment more quickly. Ultimate success against TB will turn on our ability to develop even more powerful tools, including a point-of-care diagnostic, drugs that can significantly shorten treatment, and an effective vaccine. On a global level, TB research and development is chronically underfunded, and so too are both TB control and collaborative TB-HIV programming.
We must continue robust ART scale-up for HIV-positive people—which pays dividends for both diseases—and commit to investing ambitiously in the range of interventions that we know work against the co-epidemic. As the late TB and HIV activist Winstone Zulu reminded us so pointedly, we need to be at least as smart as these two diseases are: if TB and HIV can work together in such deadly synergy, then we need to work together aggressively to defeat them.