Tackling HIV and Tuberculosis:

the contribution to END TB

Anthony D Harries
The Union, Paris, France
London School of Hygiene & Tropical Medicine, UK

The END TB Strategy

INDICATORS

TARGETS
SDG 2030

Reduction in TB incidence rate

compared with 2015 (%)
Reduction in number of TB
compared with 2015 (%)

deaths

TB-affected families facing catastrophic costs

due to TB

END TB 2035

80%
(<20/100,000)

90%
(<10/100,000)

90%

95%

Zero

Zero

World Health Organization 2015

Over 75% of HIV-TB in sub-Saharan Africa

Global Tuberculosis Report 2016

Risk of TB in persons with

Mycobacterium tuberculosis
Not HIV Infected

HIV Infected

Life time risk = 5-15%

Annual risk = 5-15%

Risk of TB increases as the CD4 cell count decreases

Lawn SD et al, Int J Tuberc Lung Dis 2011; 15: 287-95

Tuberculosis incidence rates (cases / 100 person-years)

in HIV-infected patients prior to availability of antiretroviral therapy
in South Africa and Italy

Lawn SD et al. Int J Tuberc Lung Dis 2011; 15: 571 - 81

Antiretroviral therapy (ART)

suppresses HIV replication and
this leads to a gradual increase in
CD4 cell counts
These increased CD4 cell counts
protect against Tuberculosis

Effect of ART on TB Incidence Rates:

systematic review and meta-analysis
TB IRR 0.35 [0.28-0.44] for all baseline CD4 counts

Adapted from Suthar AB et al, PLOS Medicine 2012; 9: e1001270

Zimbabwe: ART scale up and TB case notification rates

ART
scale
up

TB case
notification
rate

Takarinda et
al, Public
Health
Action 2016

Correlation between ART coverage and TB case notification rates

in Malawi

HIV-Infected on ART
Updated CD4
(cells/uL)

TB rate
(per 100 PY)

100

25.5

101-200

11.2

201-300

7.9

301-500

5.0

501-700

4.1

> 700

2.7

HIV-Uninfected
TB rate (per 100 PY)
0.62

Isoniazid Preventive Therapy [IPT]

Reduces overall TB
risk by 33% in PLHIV
Protective effect in
those with positive
tuberculin skin test
(TST) where risk
reduction is 64%
(Akolo et al 2010)

Synergistic benefit of adding

IPT to ART
37% reduction in TB using ART and IPT
compared with ART alone
[Rangaka et al, Lancet 2014; 384: 682-690]

36% - 60% reduction in TB using ART and

IPT compared with ART alone
[TEMPRANO ANRS study, NEJM 2015; 373: 808 822]

Conclusion:
In people living with HIV
ART is protective - better overall protection at
high CD4 counts
IPT adds to this protection in high HIV-TB
burden settings e.g., Southern Africa
Duration of IPT probably indefinite
ART and IPT to people living with HIV will reduce TB
incidence and indirectly will reduce TB mortality

HIV care for HIV-TB patients

TB patient registered and treated with anti-TB drugs
Provider initiated HIV testing and counselling
[PITC]
If HIV- seropositive
Start cotrimoxazole preventive therapy (CPT)as soon as possible
[25% - 46% mortality reduction]

Start antiretroviral therapy (ART) as soon as possible

[64% - 95% mortality reduction]

HIV Testing and care in TB patients in Malawi:

progress every 2 years
MALAWI

2004

2006

2008

2010

2012

TB patients

26136

26659

25688

22536

20463

HIV tested

26%

66%

84%

88%

93%

HIV positive

72%

66%

63%

64%

59%

Start CPT

97%

98%

96%

94%

88%

Start ART

<10%

38%

38%

54%

81%

Source: Malawi NTP

TB treatment outcomes in patients with new

smear-positive PTB at national level
Year

Treatment Success

Death

Other

2002

71%

19%

10%

2004

71%

16%

13%

2006

79%

13%

8%

2008

85%

8%

7%

2010

88%

8%

4%

Source: Malawi NTP

In Conclusion: in
TB patients diagnosed with HIV
Start ART as soon as possible
Start CPT as soon as possible

ART and CPT given to patients with HIV-TB will reduce TB

mortality and by preventing recurrent TB will reduce TB-incidence