Tuberculosis and HIV: The need for a stronger and sustained collaboration against a deadly duo

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Nigeria ranks fourth among the 22 high-burden Tuberculosis (TB) countries in the world. The WHO 2015 Global report gave the estimated TB incidence rate at 322 per 100,000 population and the prevalence rate at 330 per 100,000 population. TB is synergistically affected by HIV. While HIV fuels the TB burden, TB is the commonest infection suffered by People Living with HIV (PLHIV). In 2015, an estimated 36.7 million people were said to be living with HIV in the world with 25.6 million living in sub-Saharan Africa. There were an estimated 2.1 million new HIV infections worldwide within this same period. Nigeria presently has about 3 million people living with HIV (PLWHIV), the second highest HIV disease burden in the world.

TB and HIV pose serious challenges to the Nigerian Health sector as well as other similar resource limited settings. About 40% of deaths in PLWHIV has been linked to TB. In recent years, an estimated 1.2 million PLWHIV have died from complications arising from TB. Thus the diagnosis of TB in this key group is crucial in the fight against HIV in Nigeria and world-wide. Presently, global efforts to fight TB and HIV require improved collaboration between programmes to ensure a holistic approach in dealing with the dual epidemic. Nigeria needs to urgently upscale efforts in preventing, diagnosing and treating TB to ensure success in the fight against both diseases. Healthcare workers need to be aware of the close link between HIV and TB and always exclude co-infection when assessing patients presenting with symptoms compatible with either or both disease conditions. Patients who have TB require immediate testing for HIV and those found to be positive must be started on treatment for HIV. In the same vein, persons diagnosed with HIV require screening for TB and a low threshold for clinical intervention.

The federal government is engaging closely with partners to ensure better collaboration at health facilities between TB and HIV programmes.  Presently in many facilities, both programmes function in parallel paths, rarely crossing each other, with the result being increased patient attrition and the risk of further disease transmission in the community. Successes recorded with TB/HIV collaboration at the national level has not been adequately replicated at the state and facility level. One of such successes arising from such high level collaboration is the recent installation of 185 GeneXpert machines by the National Agency for the Control of AIDS (NACA) in collaboration with the National TB and Leprosy Control Programme and KNCV TB Foundation to improve the diagnosis of TB among PLHIV as well as other priority groups at risk of TB. Also, the success of the TB/HIV Technical Working Group currently co-chaired by the NTBLCP and the National HIV/AIDS and STI Control Programme (NASCP), which incidentally are both organs of the Federal Ministry of Health has not been really replicated at the state level and even at the local/facility level. The result is the perceived lack of ownership and sustainability of both programmes at the state and local levels. With donor funding accounting for nearly 85%-90% of funding for both programmes, it is necessary that an integrated approach at state and local level be adopted to ensure sustainability and enhance stronger collaboration.

The availability and utility of molecular diagnostics using the GeneXpert machine is crucial to the success of the TB programme in Nigeria. The GeneXpert machine is a cartridge based test which can diagnose TB and also define susceptibility to rifampicin, a marker of multidrug resistant TB. At present, Nigeria has over 300 GeneXpert machines spread across the country and donated by various donor groups and agencies. Unfortunately, many of these machines are grossly underutilised and some require major repairs at significant cost to the host facility. Warranty certificates from the company (Cepheid) also come at quite a cost. In the long term, a robust strategy is required to improve country ownership of TB diagnostics as well as innovative funding models to ensure the long term sustainability of the TB programme. As the Federal Government partners with international donors to continue to deliver the bulk of the national TB programme, state governments should be supported and encouraged to commits funds towards the sustainable maintenance of these machines in both the short and long term.

In conclusion, TB and HIV control programmes are intrinsically-linked and have many things in common. Therefore a collaborative effort backed by a coherent and robust approach at national and sub-national levels by government and partners will go a long way towards tacking the deadly twin scourge and ensuring a healthy TB- and HIV free generation.

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