Highly Active Antiretroviral Therapy and Tuberculosis Control in Africa: Synergies and Potential

By Harries, Anthony D.; Hargreaves, Nicola J. et al. | Bulletin of the World Health Organization, June 2002 | Go to article overview

Highly Active Antiretroviral Therapy and Tuberculosis Control in Africa: Synergies and Potential


Harries, Anthony D., Hargreaves, Nicola J., Chimzizi, Rehab, Salaniponi, Felix M., Bulletin of the World Health Organization


Voir page 468 le resume en francais. En la pagina 468 figura un resumen en espanol.

Introduction

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is the modern world's principal pandemic. It has claimed 22 million lives and created 13 million orphans (1). Sub-Saharan Africa bears the brunt of the catastrophe. In this region with less than 10% of the world's population there are 25.3 million people with HIV/ AIDS, i.e. 70% of all cases globally. In 2000 there were 3.8 million new HIV infections in sub-Saharan Africa and 2.4 million people with HIV/AIDS died, representing 80% of all deaths attributable to AIDS.

AIDS kills young adults in their most productive years, depriving the region of the skills and knowledge that are essential for economic development. Because of AIDS, large numbers of children have to be brought up by their grandparents. Many orphans cannot attend school, surfer from poverty and malnutrition, and are drawn into crime, violence, and commercial sex. AIDS retards development and may create conditions conducive to political instability.

In 1999 there were estimated to be 8.4 million new cases of TB in the world (2). Sub-Saharan Africa is the region most severely affected by this disease (3). HIV fuels the tuberculosis (TB) epidemic: nearly three-quarters of people infected with both HIV and Myobaterium tuberculosis live in sub-Saharan Africa (3). WHO predicts that by 2005 there will be 3.4 million TB cases in Africa (2).

Efforts to control HIV/AIDS and TB in sub-Saharan Africa

HIV/AIDS control efforts Control efforts have largely centred on prevention. Strategies for reducing the sexual transmission of HIV have focused on condom usage, treating sexually transmitted infections, and reducing unsafe sexual behaviour. In hospitals, donated blood is screened for HIV, reducing but hot eliminating the risk of transmitting HIV during transfusions (4).

Voluntary counselling and HIV testing have been advocated as a golden opportunity for educating and bringing about behavioural change. However, nearly 90% of infected people in Africa do not know their HIV serostatus (5). Among the many reasons for this are a general shortage of accessible voluntary counselling and HIV testing services, counselling of poor quality, poor uptake of voluntary counselling and HIV testing, and denial of the HIV/AIDS problem by both individuals and communities. Until now there has been a lack of understanding among policy-makers and health care providers that voluntary counselling and HIV testing and prevention should be linked to care. For the majority of people with HIV-related disease in Africa, only poor-quality clinical care and inadequate resources are available for treating serious opportunistic infections and tumours, e.g. Kaposi's sarcoma. There is almost no routine use of prophylaxis against opportunistic infections and virtually no access to antiretroviral drugs. Thus there is little incentive for people to ask for their HIV serostams to be determined.

The aspect of care most likely to benefit an individual with HIV/AIDS is highly active antiretroviral therapy (HAART). Furthermore, there is evidence that lowering the viral load with HAART may reduce the likelihood of transmitting HIV to others (6). In industrialized countries, HAART has dramatically improved the survival of patients living with HIV/AIDS. Indeed, it has transformed AIDS from a fatal disease into a potentially treatable and chronic condition. HAART is the standard care for all patients with HIV-related disease in these countries. In contrast, only some 25 000 of Africa's 25 million HIV-positive individuals receive antiretroviral therapy of any kind. Many of these patients receive the drugs in a chaotic and unregulated manner in the private sector, with grave implications for the rapid development of drug resistance (7). The main reasons given for lack of availability of this therapy have been the high cost of the drugs and the perceived inability of the health infrastructure in Africa to manage the complexities of HAART. …

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