About 25% of tuberculosis deaths occur among HIV-positive people

About one-quarter of tuberculosis-related deaths involve an HIV-positive person, twice as high as previous estimates, according to the Global Tuberculosis Control Report 2009, which the World Health Organization released Tuesday to coincide with World TB Day, the Wall Street Journal reports.

The report found a total of 9.3 million new TB cases in 2007, 1.4 million of which occurred in people living with HIV/AIDS (Goldstein, Wall Street Journal, 3/25). These new estimates from WHO do not reflect an increase HIV/TB coinfections or in TB deaths among HIV patients, rather "better analyses, better data and better methodology," Kevin De Cock, HIV/AIDS director at WHO, said (MacInnis, Reuters, 3/24). In addition, "stepped-up HIV testing among TB patients has revealed cases of HIV that previously went undetected," the Journal reports. In previous reports, WHO used data on HIV/TB coinfection from 15 countries; however, the new report includes data from 64 countries, several of which are in sub-Saharan Africa, the Journal reports. The report noted that improved data are needed to "increase the reliability of these estimates" (Wall Street Journal, 3/25).

TB incidence decreased from 142 new cases in 2004 to 139 cases in 2007 (Brown, Washington Post, 3/25). According to the report, 55% of recorded TB cases occurred in Asia in 2007, while 31% occurred in Africa. India had the highest number of recorded cases at two million, followed by China with 1.3 million and Indonesia with 530,000 (Brooks, AP/Google.com, 3/24).

There were about 1.3 million TB deaths among HIV-negative people and about 456,000 among HIV-positive people in 2007, the report said. TB was the No. 1 cause of death among people living with HIV/AIDS in 2007 (Washington Post, 3/25). Health officials noted that HIV-positive people are about 20 times more likely to develop TB than HIV-negative people in countries with high HIV prevalence and are between 26 and 37 times more likely to develop TB in countries with lower HIV prevalence (AP/Google.com, 3/24).

The report found a "sharp increase" in the number of HIV tests that are administered to people with TB, particularly in Africa. About 4% of TB patients in Africa were tested for HIV in 2004, compared with 37% in 2007. In several countries, more than 75% of TB patients received an HIV test, according to the report (WHO release, 3/24). Although efforts to address HIV/TB coinfection have improved, the report noted that such efforts are inadequate in many developing countries. De Cock noted that only one in seven HIV-positive people receive preventive treatment for TB. In addition, more than one-third of TB cases worldwide are undiagnosed, increasing the risk of transmission, the report said (AFP/Google.com, 3/24). The report recommended that HIV-positive people receive TB screenings and medications to reduce their risk of developing the disease.

The report also found an increase in drug-resistant strains of TB in recent years. According to the report, more than 500,000 people worldwide have been diagnosed with multi-drug resistant TB (Reuters, 3/24). Fewer than 1% of people with MDR-TB were receiving WHO-recommended treatment in 2007 (WHO release, 3/24). In addition, at least one case of extensively drug-resistant TB has been reported in 55 countries and territories worldwide, the report said. XDR-TB is resistant to two of the most potent first-line treatments and at least two of the classes of second-line drugs. Mario Raviglione, director of WHO's Stop TB Department, added that the actual prevalence of XDR-TB likely is higher because many developing countries do not conduct tests to determine the extent of drug-resistance in TB patients (Reuters, 3/24).

The report also documented concern over funding in the current economic downturn, noting that 94 countries that account for 93% of all TB cases worldwide have a funding shortfall of $1.5 billion to meet the targets in the Global Plan To Stop TB 2006-2015 (WHO release, 3/24). Michel Kazatchkine -- executive director of the Global Fund To Fight AIDS, TB and Malaria -- estimated that the shortfall will increase to at least $4 billion by 2010. "The [economic] crisis is severely affecting developing nations, but countries should realize health costs are an investment for development and not just a strain on budgets," Kazatchkine said (AP/Google.com, 3/24). United Nations Secretary-General Ban Ki-moon welcomed funding commitments made by governments, nongovernmental organizations, foundations, the private sector, academia and researchers to meet the United Nations Millennium Development Goals' target of reversing the spread of the disease by 2015. "In this time of economic crisis, we must protect investments in global health, particularly to protect the most vulnerable," Ban said (U.N. News Service, 3/24).

Health officials from the 27 countries that account for 85% of MDR-TB cases worldwide -- including Bangladesh, China, India, Russia and South Africa -- are expected to meet next week in Beijing to discuss efforts to address drug-resistant TB, AFP/Google.com reports (AFP/Google.com, 3/24).

Reaction

The report's findings "point to an urgent need to find, prevent and treat TB in people living with HIV and to test for HIV in all patients with TB in order to provide prevention, treatment and care," WHO Director-General Margaret Chan said, adding, "Countries can only do that through stronger collaborative programs and stronger health systems that address both diseases." Michel Sidibe, executive director of UNAIDS, said, "We have to stop people living with HIV from dying of TB." He added, "Universal access to HIV prevention, treatment, care and support must include TB prevention, diagnosis and treatment" (WHO release, 3/24). Wafaa El-Sadr, a professor of medicine and epidemiology at Columbia University, said the report's findings "demonstrat[e] that one cannot think of tackling or controlling the TB epidemic globally without thinking of how we're going to do it in HIV-infected populations" (Wall Street Journal, 3/25).

Ban said the "rate of decline" in TB incidence is "far too slow," adding that unless the global health community "accelerate[s] action, the numbers of those falling ill will continue to grow" (U.N. News Service, 3/24). In addition, the "scale-up of interventions to deal with MDR-TB is not at the pace we would like to see and is far from the targets that have been established," Raviglione said. He added that TB incidence is decreasing by "less than 1% per year, which will get us to potentially eliminate TB in a very distant future: we are talking centuries if not a millennia in a way" (AFP/Google.com, 3/24).

The report is available online.