HIV & TB

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JULY 2018 GLOBALCAUSE.CO.UK MR SIDIBÉ, UNAIDS “We need an integrated approach that considers the person, not their disease” P2

READ THE IAS’ 2018 ANNUAL LETTER ‘Who are we ending AIDS for?’ P6

WHY Controlling TB would be “a game-changer” for HIV patients P9

DR ERIC P GOOSBY

HIV & TB

Mothers in rural Zimbabwe proudly pose with their HIV-free babies.

PHOTO CREDIT: JAMES PURSEY FOR THE ELIZABETH GLASER PEDIATRIC AIDS FOUNDATION, 2010

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More “awareness and money” needed in the fight against TB Dr Lucica Ditiu, Stop TB Partnership.

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What must be done if we are to end the TB epidemic by 2030?

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HIV and TB–two sides of the same coin Tuberculosis — the leading cause of death among people with HIV — has to be thought of as a social justice issue rather than just a disease, says Michel Sidibé Executive Director, UNAIDS.

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ou’re about to read a story of two halves: HIV and tuberculosis (TB). As far as HIV is concerned, it is no longer the world’s leading infectious killer. That title has now been claimed by TB. There is, however, a deadly crossover between the two diseases. At least one-third of people living with HIV have latent TB; and, indeed, TB remains the leading cause of death among people living with HIV. No-one should be under any illusions: TB can be fatal. Yet it is also very curable. So, what’s going on?

TB should be considered a social justice issue For too long, tuberculosis has been thought of as ‘just another disease’

— a medical problem that can be addressed by technicians, doctors and other medical professionals. This must change.

Instead, the TB response has to be reframed as a social justice issue because, like HIV, it often affects the poorest and most vulnerable in society — such as migrants and refugees — millions of whom are not being reached by HIV and TB services.

It was a dynamic social movement that called for change and pushed politicians at the highest levels to respond to the deadly danger of HIV. A similar movement is needed — and quickly — if we are to counteract the deadly danger of tuberculosis. The UN High Level Meeting on TB in September is an important opportunity in this regard.

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Reducing time between diagnosis and treatment

Michel Sidibé Executive Director, UNAIDS

We need a fully in eg integrated approach that considers the person, not their disease.

I said that this is a story of two halves, and that, actually, is part of the problem, because HIV and TB are really two sides of the same coin. We cannot deal with these two diseases in isolation. Instead, we need better collaboration between HIV and TB programmes and a fully integrated approach that considers the person, not their disease.

We need strategic HIV and TB services that are readily accessible to people wherever they live and work, so they can receive rapid diagnosis and treatment at community level. We need to reduce the time to minutes — not months — between diagnosis and treatment; and we need new TB drugs, diagnostics and vaccines. Current treatment is long,

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antiquated and toxic with side-effects that can lead people to stop taking it, with disastrous consequences.

Save lives by screening for TB and HIV, together There are reasons for optimism. Malawi, for example, offers a one-stopshop for free-of-charge TB and HIV services. Ninety-eight per cent of its people living with HIV are screened for TB; and 85% of those presumed to have TB are tested for HIV. What’s more, treatment is immediate. This type of joined-up programming saves lives.

So, let’s stop putting HIV into one corner and TB into another. The fact is that HIV and TB are working together in order to kill people. The TB and HIV movements must now work together in order to save them.

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Don’t ditch CD4 testing — it’s crucial in the fight against HIV Funding drives countries to choose between CD4 testing and viral load campaigners need to step up and shout about why it’s so significant to use both.

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or too long, CD4 testing has been on the wane in countries with high incidences of HIV. Yet it is the recommended way to identify people in advanced stages of the disease and whose reduced immunity therefore exposes them to potentially fatal, opportunistic infections.

Indeed, the importance of CD4 testing cannot be understated.

In July 2017, The World Health Organization (WHO) issued guidelines to advise that it’s an essential part of the initial diagnosis and management of advanced HIV disease.

Greater uptake of CD4 testing needed Despite this plea from the WHO, Debi Boeras, CEO of The Global Health Impact Group, is concerned that there is still not enough uptake of CD4 testing to support the WHO guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy. “I’ve had conversations with various key opinion leaders who are worried about this,” she says. “We hope that this is just a short lag in moving forward. We need funding and human resources in place to support testing.”

“However, we quickly need more advocacy around the importance of CD4 testing. There still seems to be confusion — particularly among funders — about the roles for CD4 tests and viral load tests and their need for patient management and monitoring. They each have their much needed roles, and we badly need to get that message across.”

Viral load tests cannot replace CD4 tests A patient’s CD4 count is measured via a simple blood sample. If it’s found to

Tom Chiller Chief, Mycotic Diseases Branch, the Centres for Disease and Control & Prevention

Debi Boeras Scientist, London School of Hygiene & Tropical Medicine, CEO, Global Health Impact Group

Ben Cheng Specialist Consultant working to develop technology to aid treatment and diagnosis of HIV

There still seems to be confusion — particularly among funders T — about the roles for CD4 tests and viral load tests and their need for patient management and monitoring. be below 200, it indicates that they’re at high risk of further disease progression and death, and so in urgent need of treatment. A viral load test, meanwhile, measures the number of HIV particles in a millilitre of blood, and is an important way to monitor disease progression — and therefore if treatment is being effective. But the truth is, both of these tests are needed to effectively manage HIV patients.”

The danger of Immune Reconstitution Inflammatory Syndrome Lack of CD4 testing presents another danger to patients with advanced HIV disease, notes Tom Chiller, Chief of the Mycotic Diseases Branch at the Centres for Disease and Control and Prevention (CDC). “Medical professionals trying to save the lives of HIV patients with antiretroviral therapy

(ART) may end up — unwittingly — doing them more harm than good,” he says. “Because, if individuals with advanced stages of the disease are given ART, they’re liable to suffer from potentially fatal immune reconstitution inflammatory syndrome, or IRIS.”1 The problem is this, says Chiller; while antiretroviral therapy can boost a patient’s immune system by reducing the HIV virus in their body, circulating pathogens in their system may cause a reaction that can lead to early mortality. “The way to avoid this is to identify those with a low CD4 count and screen them for invasive fungal diseases,” he explains. “These can be treated appropriately if they exist — and then the patient can be started on antiretroviral therapy for their HIV.” Chiller believes that simpler ways

to gauge a patient’s CD4 count will be needed in future. “These tests don’t have to be quantitative,” he says. “And they don’t have to be perfect. I just want to know if the patient has a CD4 count of below 200 so I know they are at risk. I can then make the best clinical decisions on their behalf.”

Getting tests to remote communities is only half the challenge Ben Cheng is a Specialist Consultant working to develop technology to aid treatment and diagnosis of HIV. He admits it can be difficult to deliver tests to high-risk communities, particularly if they are based in remote areas.

“Point-of-care devices and professionals have to be delivered to the right locations in order to run CD4

tests properly,” says Cheng. “That’s not always easy in countries that have poor infrastructure or where roads get washed out in rainy seasons.

But it’s not just about delivering tests to these communities. The right medications have to be available, too. After all, there’s no use identifying someone with a low CD4 count if they’re not immediately able to access the right package of care for their needs.”

Getting the CD4 message out to funders Nevertheless, there are examples of countries who have found a solution to this logistical problem. “For example, Uganda has developed a comprehensive ’hub and spoke’ transportation network,” says Cheng. “The hub does the testing while the spokes provide it with samples via motorcycles, bicycles, and other kinds of transport.”

Cheng is optimistic that the world will see greater uptake of CD4 testing. “I think countries are becoming aware that it’s something they need to do if we are to reduce advanced disease morbidity and mortality,” he says. “We now have to get the word out to funders who have been focusing on viral load testing and side-lining CD4. Without their help, it’s going to be very difficult to make any significant impact.”

Tony Greenway References: 1: HIV & immune reconstitution inflammatory syndrome (IRIS), Surendra K. Sharma and Manish Soneja, Indian J Med Res. 2011 Dec; 134(6): 866–877. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3284095/

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People think the threat of TB is over; they are wrong The world is in the middle of a TB epidemic — although complacency, lack of awareness and lack of investment is hampering our ability to decisively deal with the disease.

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eople should be under no illusion, warns Dr Lucica Ditiu. Tuberculosis (TB) is a killer.

“It kills more people than malaria and HIV/AIDS combined: more than 4,400 people a day,” says Ditiu, Executive Director of the Stop TB Partnership, an international body that aims to push tuberculosis up the political agenda. “Around one third of the world’s population is infected with TB and 10% will develop the disease in their lifetime. And because it’s airborne, no-one can be protected. It poses a level of threat that is very different from other diseases.”

Not enough people know about TB The good news is that TB has been curable for decades and, for normal TB, the cost of drugs is low. UN member states have also committed to ending the TB epidemic by 2030.

The bad news is that the global health community has paid more attention

Dr. Lucica Ditiu Executive Director, Stop TB Partnership

W are fighting a We very smart bacteria with sticks and stones..

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to tackling other diseases so, at the current rate of progress, the Stop TB Partnership believes this will take another 150 years at least. There is also a frightening lack of awareness about TB among the general population.

Ditiu says: “Some partners of ours went onto the streets of London and — without using the word ‘tuberculosis’ — told people about a deadly infectious disease spread through the air that has a drug-resistant form. They filmed their reactions for an awareness video. Everyone they approached was shocked and said: ‘We have to do something about this!’ But the moment they were told the disease was TB, they said: ‘Oh – that one.’ They felt it was a problem that was over.”

But TB is not over. Not by a long way. That’s why, in the runup to the UN General Assembly High-Level Meeting (UNHLM) on TB in September, five Key Asks have been developed by TB stakeholders and communities. These are priority actions that must be taken by heads of state and governments to accelerate progress towards the end of tuberculosis.

Around 10.4 million people have TB. How do we tackle it?

The first Key Ask is to make sure that people with TB don’t fall through the treatment gaps. “An estimated 10.4 million people have TB; but just 6.3 million are diagnosed and treated,” says Ditiu. Secondly, the response to TB must be transformed to ensure it is ‘equitable, rights-based and people-centred’ — which means removing discriminatory laws against people with TB and treating them as individuals with individual needs.

Third, the development of essential new tools to end TB must be stepped up, including point-of-care diagnostics, a two-month or less oral cure for TB and its drug-resistant forms, and one or more vaccines. “Currently, we are fighting very smart bacteria with sticks and stones,” says Ditiu.

More investment for better treatment To achieve universal health coverage (ensuring that everyone has access to health services and no-one is left behind) more investment is

needed. “To ensure service delivery and implementation, there is an estimated need of $13 billion globally with a $6 billion gap every year.

Most important, we estimate that $2 billion is needed annually for TB research and development,” says Ditiu. “Last year, the maximum available was $700 million.” The cost of non-investment will only slow the response to TB and, ultimately, result in more deaths.

Finally, there must be a commitment to decisive and accountable actions, including an independent, high-level body and regular UN review based on ongoing reporting, all centered on communities and civil society. “We need accountability both at country level and globally,” says Ditiu, underlining why September’s UNHLM is so crucial.

“This is a historical meeting, which finally brings TB to high-level attention. But if we are to see any progress by 2022, it’s make or break time.”

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Gender equality: bringing the world closer to ending the HIV/AIDS epidemic While significant strides have been made in combating the current spread of the virus through prevention of new infections, girls and women continue to be disproportionately affected by the HIV/AIDS epidemic as a result of structural inequalities embedded in society.

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uch inequities stem from unequal power relations, lack of female access to and control of resources and opportunities, a disproportionate balance of decision-making power between genders, and unfair division of labour due to patriarchal expectations.

The metrics around HIV/AIDS reflect this: young women are twice as likely as their male counterparts to acquire HIV infections, with adolescent girls between the ages of 10-19 accounting for the highest number of new HIV infections. To successfully combat the virus, it is of paramount importance that we address these inequalities that predispose women and girls to a higher risk of HIV infection.

H.E. Mrs Toyin Ojora Saraki Founder-President, The Wellbeing Foundation Africa (WBFA)

Salome Nthenya Nzuki Youth Partner and Author, The Wellbeing Foundation Africa/ Wellbeing For Women Africa

Young women are twice as likely as their male counterparts to acquire HIV infections.

In Kenya, women are among the key populations that are disproportionately affected, placing them amidst some of the highest-risk category, alongside men who have penetrative sex with men, people who inject drugs, and sex workers.

The National AIDS Control Council estimates that 30% of new HIV infections in Kenya are among people from these key populations – but given that women comprise such an enormous percentage of the Kenyan population, it is deeply worrisome that they are amongst some of the most-at-risk of all people nationally.

There is need for gender mainstreaming in policies, programmes, and legislation aimed at combating HIV/AIDS. This should include laws that promote gender equality.

Increased efforts in promoting girl child education, access to sexual reproductive health and rights for women and girls, and economic empowerment for women is vital.

Education should encompass comprehensive sexuality information where girls need to be equipped on bodily integrity, body autonomy,

sexual consent, and safe sexual practices. It is also important to engage men in ending violence against women and protecting women’s rights.

About The Wellbeing Foundation Africa The Wellbeing Foundation Africa (WBFA) was launched by H.E. Mrs Toyin Ojora Saraki in 2004 to transform health outcomes for women, infants and communities. Last year the WBFA established ’Wellbeing for Women Africa’, a global editorial platform for Youth Partners so that their academic, professional and lived experience can be shared around the world. Working closely with our editorial team, Youth Partners craft and launch hard-hitting editorial content on gender equality, mental health, respectful relationships and sexual, reproductive, maternal, newborn, child and adolescent health. By fairly compensating our Youth Partners for their energy and youth insight, we hope to create a systemic practice in the development community for young people to always experience meaningful, sustainable and ethical engagement.

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Who are we ending AIDS for?

The following is an excerpt of AIDS is (still) political - the International AIDS Society 2018 Annual Letter.

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he HIV community’s insistence on equitable access to the fruits of scientific advances has forever changed the global health field for the better. Yet the truth is that we are not living up to our rhetoric. Increasingly, we are witnessing declines in new infections in many generalized epidemics, but also an alarming shift in disease burden towards key populations, including gay men and other men who have sex with men, people who inject drugs, sex workers and transgender people.

In 2016, key populations made up 44% of all new HIV infections, including 80% of all new infections outside sub-Saharan Africa[3]. Even in epidemics that are declining overall, entire groups of people are being left behind. For example, while South Africa has made important gains in reducing new HIV infections, nearly 2,000 adolescent girls and young women (ages 15-24) become infected with HIV every week. Similarly, in the United States, new HIV infections overall have fallen, but new data released by the Centers for Disease

IN 2016 KEY POPULATIONS MADE UP

44% OF ALL NEW HIV INFECTIONS

Control and Prevention indicate that many black Americans are being left behind as they are least likely to learn their HIV status, receive antiretroviral therapy or achieve viral suppression[4].

Unless we act to reverse these trends, the future of the epidemic looks far more precarious than the global discourse of “ending AIDS” suggests. On the current course, we may be able to bring some measure of control to a handful of generalized epidemics that are primarily driven by heterosexual transmission. But without radically improved success in reaching all populations, HIV could well become endemic in marginalized populations across much of the world.

Recent trends suggest that this is precisely what is happening as the share of new HIV infections among key populations continues to rise[5].

Though prevailing disparities are not just about politics (stigma is both intrinsic to and distinct from politics), it is hard to miss the political biases that undermine efforts to ensure that the gains of the AIDS response are equitably shared. Take as an example the epidemic’s extraordinary impact on adolescent girls and young women.

Four in 10 adolescent girls (aged 15-19) in Africa have experienced physical or sexual violence from an intimate partner[6], and the evidence is that gender-based violence is associated with a significantly greater risk of acquiring HIV[7]. Yet few countries have invested in comprehensive programmes to combat gender-based violence or to ensure ready access to adolescent-friendly sexual and reproductive health services.

Because of bad policies that reflect ideology and bias rather than science, those most vulnerable to HIV are deterred from accessing the services they need. For example, when known HIV infection itself can be criminalized or when the behaviours that are central to personal identity or one’s way of life are prohibited by law, individuals understandably fear coming forward for HIV testing. Seventy-two countries specifically allow for the criminalization of HIV non-disclosure, exposure or transmission, with marginalized groups often at greatest risk of being prosecuted[8].

More than 70 countries criminalize same-sex relations[9], and the global war on drugs has created daunting barriers to ready access to essential

“BECAUSE OF BAD POLICIES THAT REFLECT IDEOLOGY AND BIAS RATHER THAN SCIENCE, THOSE MOST VULNERABLE TO HIV ARE DETERRED FROM ACCESSING THE SERVICES THEY NEED.”

harm-reduction services.

From the outset of our fight, the AIDS response was understood as part of a larger fight for social justice. We must demand the repeal of punitive laws, effectively support communities to reach those who are being left behind, and refuse to declare victory until AIDS is ended for all populations.

References: [3]

UNAIDS, Ending AIDS: Progress towards the 90-90-90 targets, 2017

[4]

Crepaz N et al., Racial and Ethnic Disparities in Sustained Viral Suppression and Transmission Risk Potential Among Persons Receiving HIV Care – United States, 2014, MMWR 2018;67(4):14-18

[5]

UNAIDS, Ending AIDS: Progress towards the 90-90-90 targets, 2017.

[6]

WHO, Adolescent pregnancy – Factsheet, 2018

[7]

Jewkes RK et al., Lancet 2010; 376:41-48

[8]

Bernard EJ & Cameron S, Advancing justice 2: Building momentum in global advocacy against HIV criminalization, HIV Justice Network and GNP+, 2016

[9]

ILGA, State-Sponsored Homophobia, 2017

Read the full IAS ANNUAL LETTER at iasociety.org

FOUR IN 10 ADOLESCENT GIRLS (AGED 15-19) IN AFRICA HAVE EXPERIENCED PHYSICAL OR SEXUAL VIOLENCE FROM AN INTIMATE PARTNER

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Hyderabad’s distinctive auto-rickshaws carry posters displaying anti-TB messages through the city’s winding streets. India has one of the highest burdens of TB in the world.

Haven’t we done enough to end HIV and TB? Industry innovation is critical to end global TB and HIV epidemics.

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epidemiologists say that an HIV vaccine with 50% efficacy would have an impact on the HIV infection curve. Of course, we want to do more than that and get to north of 70% or 80% protection.

I think a vaccine could be a very effective tool for controlling HIV infection in the world — but getting there is going to be a step-by-step process.

Q: Why is it important for pharmaceutical companies to focus on HIV and TB?

We cannot be complacent about HIV because it’s far from over. Therapies are good at controlling HIV, but patients must take them for the rest of their lives. It is difficult to be compliant with medicine for such a long time, so a lot of work needs to be done to make treatment more manageable and reduce the potential for drug resistance. And, also, could an HIV cure be generated?

Tuberculosis is causing an enormous public health problem, mainly in low- and middle-income countries.

Scientifically, TB is a very interesting space because trying to solve antimicrobial resistance (AMR) and multi-drug resistant TB (MDR-TB) could lead to new TB treatments and the development of new medicines in other fields. Companies need to approach it with open minds.

Q: How optimistic are

you that an HIV vaccine will be developed? What impact could it have?

The first HIV vaccine, which was tested in Thailand, showed efficacy of 31.2%, which demonstrated that it is technically possible. The question now is: ‘Can we develop a vaccine that delivers more than 50%, or more than 80%, or close to 100% protection?’

If we could, what would the impact be? Well,

Paul Stoffels M.D. Vice Chair of the Executive Committee & Chief Scientific Officer, Johnson & Johnson

20 years ago, when mothers died, many, many children were left on their own.

Now, we have a much more stable society. I think that is a huge victory for medicine and science.

Q: What needs to be

done to end HIV/AIDS?

Every innovation that can be generated to help stop HIV infection is important, from the likes of an antiretroviral vaginal ring currently under regulatory approval, to long-acting injectable antiretroviral treatments. We should not discard any of these technologies, because the world will need different protection methods for the next 10, 20, maybe 30 years. But we also need a vaccine that offers protection.

It is also important to prevent people from getting HIV; and that, of course, is done by educating them to ensure they understand how infection occurs — and what they need to do to protect themselves.

Q: What scientific

About Paul Stoffels

innovations have been made in the fight against TB in recent years?

Paul began his career as a physician in Africa, focusing on HIV and tropical diseases research, when the HIV epidemic emerged.

He now spearheads the Johnson & Johnson research and development efforts and steers the company’s global public health strategy to develop innovative medicines and technologies that would otherwise not be developed and make them accessible to the world’s most underserved populations.

We are in dire need of more innovation regarding TB, although there has been some progress, which I find encouraging. There have been diagnostic improvements, for example, and several new therapies.

The TB Drug Accelerator Program, supported by the Bill and Melinda Gates Foundation, is speeding up drug discovery. So, the field is not ‘dead’ — but it is not like cancer treatment where there are thousands of new medicines in evaluation at any one time.

Q: Why has TB science been overlooked?

There is quite an effective therapy for drug-sensitive TB — although it needs compliance and good implementation. Multi-drug resistant TB and extensively drug-resistant tuberculosis (XDR-TB) is another story. These are extremely difficult to treat, sometimes requiring 24 months of therapy on toxic and challenging medication.

MDR-TB and XDR-TB are largely found in the developing world where the market is challenging. It is very difficult in a free market to say to companies: ‘Why don’t you spend the next 10 years developing an XDR-TB drug?’ But the problem is, if TB is not diagnosed correctly and then treated quickly, we cannot cure it — so it continues to spread and becomes more expensive and difficult to address. Technically, scientifically, it is possible. More effort is needed to get there.

Q: How important is it

that companies invest in these spaces?

When I worked in Africa at the start of my career, the HIV epidemic was at its height and patients in hospital typically did not survive for more than six months. Now, people with HIV can live 10, 20, 30 years or more if they take their medicine. They can see their children grow up. Twenty years ago, when mothers died, many, many children were left on their own. Now, we have a much more stable society and I think that is a huge victory for medicine and science.

So, it is very important that companies invest in these spaces. On the other hand, industry cannot solve HIV and TB on its own.

What is needed is collaboration between industry, governments, academic centres, NGOs, institutions and others. And to attract them to this environment they need to be given some kind of incentive.

Tony Greenway Find out more at jnj.com/hiv & @jnjglobalhealth

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Children in Zimbabwe are members of an AIDS-free generation because of the combined efforts of the ministry of health, the Elizabeth Glaser Pediatric AIDS Foundation, and other partners.

Q& Why I’m optimistic that we’ll A win the war against TB

PHOTO CREDIT: JAMES PURSEY FOR THE ELIZABETH GLASER PEDIATRIC AIDS FOUNDATION, 2010

8 GLOBALCAUSE.CO.UK

Collective action and better political leadership is needed if the world is to combat the scourge of TB.

Q: Why should

Q:

Does TB just need more funding?

people who care about HIV/AIDS care about TB? The sad reality is that TB is the biggest single killer of people living with HIV/AIDS, but it’s so cheap to cure.

We’re in a situation where, rightly, we’re investing a huge amount of energy and time making sure we find people with HIV so we can get them onto treatment.

But then they acquire an opportunistic infection of TB — and that can be fatal.

Q: Why has TB not had much political attention?

Just like HIV, there’s huge stigma associated with TB, so it doesn’t generate a pool of advocates willing to speak out against the disease. We’ve become illinformed about TB because no-one has been doing the informing. But take the strategic fightback we’re now seeing in South Africa. That’s an outstanding example of what happens when political attention is paid to TB.

Aaron Oxley Executive Director, RESULTS

There’s huge stigma associated with TB; people don’t speak out about it.

More money is one of the commitments we’re looking for from the UN High Level Meeting (UNHLM) on TB in September. But all the political will in the world and the greatest research and development capabilities don’t mean a thing if no-one is prepared to fund the work.

Q: Will the UNHLM yield

real results?

I’m optimistic. Over the last few years there has been a real sea change among the global TB community. It feels as though we’ve reached a tipping point and TB has become impossible to ignore. Enough countries in the world now view this as a problem that we all need to solve — together.

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“Pursuing the global TB strategy within post-2015 global health diplomacy” at the 45th Union World Conference on Lung Health in Barcelona, Spain, 2014.

We need better diagnostics and drugs to defeat TB

Controlling tuberculosis would have a dramatic impact for HIV patients who can die of opportunistic tuberculosis (TB) infections. To prepare for the fight, we need better diagnostics and drugs and greater political will.

B

ringing the global tuberculosis epidemic under control would revolutionise the outlook for HIV patients, says Dr Eric P Goosby, former US Global AIDS Coordinator and current UN Special Envoy on TB. “It would be a game-changer,” he insists. “TB is the leading cause of death among HIV patients around the world, with the exception of Western Europe and North America. Right now, the number of co-infected people — those with TB who are also HIV patients — is calculated to be around 400,000. If we could control TB, we’d see a dramatic drop in the annual death rate from HIV, which currently stands at 1.2 million.”

Unfortunately, there are still many challenges to overcome before TB can be defeated, says Goosby. First, the ongoing burden of the disease is overwhelming, with 10.4 million new infections every year.

Better diagnostics are needed Secondly, a third of the population on the planet is infected with the disease; and although only 10% will go on to develop active TB, it means that a large, latent, or unrealised, reservoir of infection is already in our communities. “Latent TB is one of the biggest problems we face,” says Goosby. “It becomes active when immune

Dr Eric P Goosby Special Envoy on Tuberculosis, United Nations

1/ of the 3 people on the planet haveTB.

systems wane due to various factors — one of which is HIV.” Another challenge is finding more effective, faster ways to identify those with TB so that treatment can begin. “In R&D terms, we need to develop new ways of making diagnosis quick and easy,” says Goosby. “Right now, the standard diagnostic test for TB in high-incidence countries is to culture sputum over a six-week period. That’s too slow. And, anyway, in HIV patients, sputum cultures are usually negative — so the TB diagnostic test for the most at-risk group is extremely poor.”

The polymerase chain reaction (PCR) test for TB is one solution says Goosby, as it does away with the need for cultures, is logistically easier to deliver and returns quicker results.

Newer drugs with low side-effects New drugs are also vital — ones that don’t cause adverse side-effects. “Older drugs are toxic and require blood monitoring,” says Goosby. “This means that a patient needs to be closely managed to see how they react to the medication and pre-empt any damage that may occur, specifically to their liver.

Thankfully, two new drugs have now emerged that are very effective in treating TB, and have the additional advantage of low side-

effects, so don’t require the same rigorous monitoring as others. However, they are not yet widely available in high-incidence countries.”

Three new drugs are also in the pipeline.

Years of inaction have stalled TB elimination The World Health Organization believes that universal health coverage — where everyone can access health services without financial hardship — is a human right. It’s one of the targets that countries set when adopting the UN’s Sustainable Development Goals back in 2015.

“Yet we won’t achieve universal health coverage unless we engage and deal with the large killer diseases — and TB is the largest,” says Goosby.

“The UN High Level Meeting in September is an opportunity to highlight the tragedy of this curable disease, the elimination of which has stalled through years of inaction.

We are smart enough and capable enough to rally the troops globally and reinvigorate our response to TB.”

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PHOTO CREDIT: THE GLOBAL FUND / PHOTOGRAPH

A global commitment for TB research T

Eliud Wandwalo Senior Disease Coordinator, Tuberculosis The Global Fund to Fight AIDS, Tuberculosis and Malaria

uberculosis kills more people than any other infectious disease, yet funding for research and development for this millennia-old disease is woefully lacking. If we want to reach the goal of ending the epidemic by 2030, we need significant change on multiple dimensions in how we’re tackling the disease. Increasing research and scientific support is one of them.

Implementers of global health programs play an important role in bridging research gaps to better address service delivery, translating science into practice that can save more lives. TB prevalence surveys conducted in countries in Africa and Asia have changed the landscape of TB epidemiology, for example, allowing us to gain a much better understanding of the burden of disease and to identify ways in which TB control can be improved through more targeted investments.

Operational research can lead to improvements in program performance; information from operational research on shorter drug regimens for multidrug-resistant TB in a number of countries was critical in WHO’s recommendation on the use of shorter treatment regimens for drug-resistant TB, for example.

TB detection has also been revolutionized by the introduction of GeneXpert, a cutting edge device used by governments, health agencies and implementers of health programs that looks like an espresso maker but can conduct molecular tests of TB bacteria and detect drug resistance.

There are reasons for optimism, but only a multidisciplinary approach will get us there. With TB being the leading cause of death for people living with HIV, it is imperative that we renew interest in research for TB if we are to end both epidemics.

PHOTO CREDIT: ERIC BOND/ELIZABETH GLASER PEDIATRIC AIDS FOUNDATION, 2016 THE GLOBAL FUND / PHOTOGRAPH

Through the technical assistance of the Elizabeth Glaser Pediatric AIDS Foundation, nurses in Cameroon have been trained in HIV testing and treatment. This has been a crucial improvement for mothers like this one, whose twins were born prematurely and required extra attention in the neonatal unit. This mother feels reassured that her babies have gotten the care they need, including HIV testing.

Chip Lyons President and CEO, Elizabeth Glaser Pediatric AIDS Foundation, (EGPAF)

Until no child has AIDS

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his summer, global stakeholders will convene in Amsterdam to consider the future of their battle against the HIV epidemic.

Many of them will increasingly focus not just on the virus that causes AIDS, but also on its frequent accomplice: tuberculosis (TB).

Coinfection of HIV and TB is both common and dangerous, as each disease reinforces the other’s attacks on a person’s health.

HIV is the leading risk factor for TB, and TB is among the greatest threats to the health and survival of people living with HIV, particularly children. TB coinfection can derail HIV care by complicating treatment, interfering with follow-up, and accelerating the rate at which HIV replicates inside the body.

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) is among the organisations that has made TB prevention and care a fundamental component of its efforts to end HIV and AIDS. “We can’t expect to win the fight against one disease if we’re not prepared to fight the other at the same time,” Chip Lyons, President and CEO of EGPAF, says. “Integrating TB prevention, diagnosis, and care into our HIV services will not only limit the harm TB inflicts on children with HIV, but also allow us to increase diagnosis and treatment of HIV infections in women and families.”

For more information on EGPAF and how it is working to fight both HIV and TB, visit pedaids.org

Reaching vulnerable populations to end South Africa’s HIV crisis In South Africa’s fight against HIV/AIDS, the focus needs to be on marginalised populations, better interventions for young women and girls and better education for men.

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involves better lifestyle choices and increased medical research.”

themselves and their partners, otherwise we will continue to perpetuate gender imbalance and the vulnerability of women.”

South Africa must target vulnerable groups

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outh Africa is currently fighting four epidemics at once: maternal, newborn and child health; HIV/AIDS and TB; non-communicable diseases such as cancer, cardiovascular disease and diabetes; and domestic violence and injury against women.

“We have one of the largest HIV/ AIDS epidemics at a global level,” says Professor Glenda Gray, CEO and President of the South African Medical Research Council (SAMRC). “And with HIV/AIDS we have co-morbidity of TB. Reducing the burden of non-communicable diseases

There have, however, been some breakthroughs. South Africa has managed to increase life expectancy of HIV patients with one of the largest antiretroviral programmes in the world. It has also made strides in preventing motherto-child infection, and implemented effective screening, antenatal care and treatment programmes. More work now needs to be done to target marginalised and vulnerable populations with HIV interventions, and particularly young women and girls.

“If we don’t reach vulnerable populations, we’re never going to be able to control HIV,” says Gray. “We must be sure that young women and adolescent girls can protect themselves and, if they become infected, are able to receive treatment and care. But we cannot simply focus on women. We need to find ways of involving men in this fight and empowering them to protect

Partnership is crucial for health success

Professor Glenda E. Gray CEO and President, South African Medical Research Council (SAMRC)

W have one of We the largest HIV/AIDS epidemics at a global level..

Joined up thinking is pivotal to the success of eliminating all four epidemics, says Gray, because it can provide better resources, increased funding and more cutting-edge innovation and logistical power.

“Public-private partnerships and philanthropic relationships, NGOs and pharmaceuticals are critical if we are to address some of the R&D challenges we face, particularly regarding TB,” she says.

“Take drug discovery, which is expensive. We must work with industry and other international partners to get drugs through clinical research. We need to make sure we don’t leave any diseases behind.”

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Nelson Mandela

The

effect

Nelson Mandela has been credited with “changing the AIDS agenda in South Africa.”

That’s because he wasn’t just a political visionary, says Professor Glenda Gray. He understood that social inequality was a driver of HIV and TB. “Nelson Mandela saw the link between pathogens and poverty,” says Gray. “He was passionate about HIV because the disease was emerging in our country — and claiming the lives of huge numbers of women and babies — around the time he became our President. He also recognised the devastation wrought by TB, which was associated with populations such as mine-workers and migrants. He saw the injustice of these diseases and was determined to drive them up the political agenda.”