Picture the daily routine of nurse Bongani Khumalo. He goes from village to village and household to household across Lubombo, a rural district in the kingdom of Swaziland. All of his patients are living with HIV. Many are also sick with tuberculosis. Most are hungry. Those who have not yet received treatment are so weak that they are unable to provide for their families. "Every day I have to meet the challenge of helping my clients to survive," he says.
Conditions in Lubombo mirror that of Swaziland as a whole, which has the highest rate of HIV/AIDS in the world and concurrently, one of the highest rates of TB. The situation is so dire that in March Swaziland's prime minister declared TB a national emergency. One in six or seven people are living with HIV and one in 10 have TB.
It's a dangerous mix, since people living with HIV are up to 30 times more likely to become ill with TB than those without HIV infection. They are also far more likely to die of TB, which currently precipitates one in four AIDS deaths.
Khumalo and his colleagues at the Cabrini Ministries Health Centre are confronting this disaster in a way that should serve as a model for health systems everywhere. They do this by following a tried and tested method.
In Bongani Khumalo's words, here is how it works. "We provide HIV testing and counseling for everyone, and we also check for TB in every case. Anyone who tests positive for HIV and also has TB starts TB treatment immediately. Then after two weeks the person begins antiretroviral therapy. Because people living with HIV are at risk of catching TB in our area, those who are not sick with TB are given isoniazid, a medicine that prevents TB."
The results, Khumalo says, are nothing short of miraculous. After several weeks of treatment, his patients are often transformed. "It is so wonderful to see them smiling, singing, feeling well. Most of them have no signs of any illness."
A scientific model recently produced through a joint effort by the Stop TB Partnership, World Health Organization (WHO), and UNAIDS shows that if this recipe can be built on and scaled up worldwide, one million TB deaths among people living with HIV -- which could be prevented, since TB is curable -- will be averted between now and 2015.
To produce these results on a wide scale, in countries where HIV and TB are prevalent, screening programs will need to provide testing for both infections every three years to everyone in the population. Any person living with HIV who needs TB treatment -- or treatment to prevent TB -- will need to get it promptly.
People living with HIV are far less likely to become ill with and die of TB if they begin antiretroviral therapy before their immune systems begin serious decline. ART should be started early, as WHO and UNAIDS recommend. People who are HIV-positive and diagnosed with TB should start ART regardless of the status of their immune system.
These objectives cannot be met in countries where the programs providing HIV care operate in isolation from those providing TB care. Every country seeking to prevent deaths from TB among people living with HIV needs to drive integration of its HIV and TB programs.
Government health programs have already shown how quickly they can move when the political will is there. Between 2006 and 2009, most of the ten countries with the highest number of deaths from HIV-associated TB more than doubled their rates of HIV testing in TB clinics. This is an important first step to providing life-saving care.
This week for the first time the TB issue will be on the agenda at the United Nations General Assembly's High-Level Meeting on AIDS. This is another important step, but it will take bold leadership to make the next one. At present few public health programs have the policy of screening for TB wherever HIV testing is offered. If that does not change, people with HIV -- even those receiving ART -- will continue to die of TB. Two million -- the equivalent of one quarter of the population of New York City -- will die by 2015 if we continue on our present course.
We live in a time of unprecedented hope for the 33.3 million people living with HIV worldwide. ART offers the promise of a full and fulfilling life. Now people living with HIV can raise their families, work and pursue their dreams. We cannot stand by and watch as TB -- which can cost as little as $100 for treatment and cure -- steals those dreams. We must act, and act now.