Here is a sobering reminder of how the COVID 19 pandemic has exacerbated the situation for a disease intrinsically linked with HIV: Tuberculosis.
In fact, until the pandemic, TB was the leading cause of death from a single infectious agent, ranking just above HIV/AIDS.
Therefore, as we assess the situation of HIV globally and in India, it is imperative to be cognizant of the linkages between these two deadly diseases, and possible policy mechanisms to counter TB-HIV especially in the context of COVID-19.
A 2021 WHO factsheet states that people living with HIV are 18 times more likely to develop active TB disease than people without HIV. Both diseases are lethal when in combination and accelerate each other’s progress.
In 2020, about 2,15,000 people died of HIV-associated TB.
According to the WHO’s Global TB Report 2021, reduced access to TB diagnosis and treatment, because of the COVID pandemic, resulted in an increase in TB deaths and low notification.
Best estimates for 2020 are 1.3 million TB deaths among HIV-negative people (up from 1.2 million in 2019) and an additional 2,14,000 among HIV-positive people (up from 2,09,000 in 2019), with the combined total back to the level of 2017.
Against this global backdrop, India’s TB situation certainly merits contemplation.
The WHO Global TB Report stated that in India, HIV-positive TB incidence stood at 53,000; a reduction from 71,000 the previous year which, in the pandemic setting, can be likely attributed to decreased testing/detection and notification.
HIV-positive TB mortality went up from 9,500 in 2019 to 11,000 in 2020 reflecting worsening of situation.
However, the national TB program deployed mitigation mechanisms that helped to offset the adverse impact of the pandemic whereby TB patients who were HIV-positive and were successfully put on antiretroviral therapy for the year stood at 95 percent.
Further, it must also be noted that the treatment success rate for HIV-positive TB cases registered in 2019 was 71 percent.
The national TB program must, undoubtedly, be commended for ensuring that TB-HIV risk factors remain high priority and targeted countermeasures are implemented accordingly.
In fact, the program tracks two critical indicators related to HIV which are collated as part of the State TB Score and used to monitor the performance of state and district TB programs – these include the percentage of TB notified patients with known HIV status and the percentage of people living with HIV (PLHIV) given TB preventive therapy.
Recognition of the seriousness of the dual infection and laying out a blueprint accordingly has helped the TB program to stay the course towards TB elimination
The National TB Elimination Programme (NTEP) and the National AIDS Control Programme (NACP) have managed to collaborate effectively over the years – the India TB Report 2021 notes that more than 11 lakh PLHIVs have been initiated on TB preventive therapy since December 2016; and more than 90 percent of notified TB patients now know their HIV status which is a significant achievement.
However, there still exist areas that need further strengthening if we are to truly contain the double impact of TB-HIV. A key intervention will be to work toward a single delivery window for HIV-TB treatment/care services.
The India TB Report does clarify that single window TB and HIV services are being implemented through existing 587 antiretroviral therapy (ART) centers and these services are being scaled up increasingly.
But, considering India’s high TB incidence there is scope for greater push when it comes to more ART centers in high-priority states and districts across the country.
Another crucial programmatic dimension to bear in mind is how the private sector can be better leveraged.
Engaging the private sector becomes essential not only because of more effective HIV testing of TB patients, but also because of potentially more effective cascade of care.
The India TB Report, too, notes that one of the imminent objectives should be to improve HIV testing coverage among TB patients notified from the private sector in coordination with NTEP.
Discourse on the two diseases must not happen in silos and we must increasingly strive to analyze and address them in the context of the other, so that effective strategies can be developed to counter both.
As there is an uptick in sustained conversation around both diseases, awareness levels will increase around this life-threatening disease combination.
Accurate information always helps to make informed choices, and that’s always a major step toward addressing any public health issue.
The author, Prof (Dr) ROHIT SARIN is a Principal Consultant at the National Institute of TB & Respiratory Diseases (NITRD).