About HIV and tuberculosis

The risk of developing tuberculosis (TB) is estimated to be between 20-37 times greater in people living with HIV than among those without HIV infection. In 2010, there were 8.8 million new cases of TB, of which 1.1 million were among people living with HIV. In response to demands from countries, WHO recommends 12 TB/HIV collaborative activities, including the Three I's for HIV/TB. The WHO HIV/AIDS and TB Departments and their partners, including community groups, work collaboratively on joint HIV/TB advocacy, policy development and implementation in countries. WHO also develops and promotes tools and guidelines to support countries in improving their TB/HIV collaborative action in order to achieve universal access to HIV and TB prevention, care and treatment services for all people in need. The main areas of our work are:

Three I's for HIV/TB

Key interventions to decrease the impact of TB on people living with HIV Key facts

Tuberculosis (TB) is the leading cause of HIV-related deaths worldwide. Of the 1.7 million people who died from TB in 2009, 400,000 (24%) were living with HIV. Additionally in 2009 there were 9.4 million new cases of TB, of which 1.2 (13%) were among people living with HIV. The risk of developing TB is estimated to be between 20-37 times greater in people living with HIV than among those without HV infection.

Key interventions
There is a strong scientific evidence base supporting that ART, by lowering a persons viral load and restoring the immune system, significantly reduces the impact of HIV and TB. WHO recommends earlier ART at <350 CD4 and the immediate initiation of ART for all TB patients irrespective of CD4 count.

The Three I's for HIV/TB

In addition to initiating earlier antiretroviral therapy (ART), WHO recommends the implementation of the Three I's for HIV/TB to reduce the burden of TB among people living with HIV:

Intensified TB case finding Isoniazid preventive therapy Infection control for TB.

As resource-constrained countries rapidly expand HIV services prevention, treatment and care of TB in people living with HIV is an urgent priority for both HIV/AIDS and TB programmes. WHO recommends that the Three I's for HIV/TB in addition to ART be part of a TB prevention package and that emphasize that they should be core components of HIV services with AIDS programmes and service providers taking the primary responsibility for the Three I's for HIV/TB.

Antiretroviral therapy for prevention ART lowers the concentration of HIV (also known as viral load) in the bloodstream and in genital secretions. Since viral load is the single greatest risk factor for all modes of HIV transmission, ART use decreases the risk that HIV will be transmitted from one person to another. Modelling efforts over the past decade have examined the effects of antiretroviral therapy on HIV and TB prevention with varying proof of concept that antiretroviral drugs decrease HIV transmission comes from the prevention of mother to child transmission of HIV. Guidance also exists on the use of antiretroviral drugs for post-exposure prophylaxis to prevent HIV acquisition in HIV negative individuals, and research is ongoing on their use for pre-exposure prophylaxis. More ART also has a substantial effect on prevention of HIV-associated tuberculosis. Studies have shown that ART reduces the risk of tuberculosis by 80-92%. When coupled with the Three Is for HIV/TB; isoniazid preventive therapy, tuberculosis infection control, and intensified case finding; ART provides programmes with an excellent opportunity at limiting morbidity and mortality associated with HIVassociated with tuberculosis. The 2010 WHO ART guidelines recommend treatment for people 350 CD4 cells and all patients with TB irrespective of CD4 count. Modelling efforts over the past decade have examined the effects of antiretroviral therapy on HIV and TB prevention with varying results depending on the assumptions used in the model. A model by scientists from WHO published in 2008 suggested that expanding antiretroviral therapy to people with CD4 cell count 350 mm3 and beyond could substantially reduce the growth of the epidemic. The findings also suggested that the benefits of the infections averted would outweigh the initial investments required. Documents and presentations on antiretroviral therapy in HIV and TB prevention.

Observational studies suggest that antiretroviral therapy reduces the sexual transmission of HIV in generalized epidemics, especially among sero-discordant couples. There is also growing evidence of the impact of ART on communitylevel HIV transmission, both, in generalized and concentrated epidemics including among injecting drug users. Most importantly ART is being provided as part of a package of prevention and treatment interventions and not in isolation.

Partnerships with civil society to scale up HIV/TB activities Read more on the 12 TB/HIV collaborative activities

Establish the mechanisms for collaboration

1. Ensure a coordinating body exists for effective TB/HIV collaboration at all levels To ensure TB and HIV services get to those who need them most 2. Conduct surveillance of HIV prevalance among TB patients and TB prevalance among HIV patients To understand the size of the problem 3. Carry out joint HIV/TB planning To coordinate the efforts of both programmes and make best use of resources 4. Conduct monitoring and evaluation To be sure we know that people are able to access the services they need

Decrease the burden of TB in people living with HIV

5. Establish intensified TB case-finding TB screening to find undiagnosed TB cases in people living with HIV 6. Introduce Isoniazid prevention therapy To prevent the progression of latent TB infection to active disease 7. Ensure TB infection control in health care and congregate settings To prevent anyone from catching TB while in a health facility or other congregate settings such as prisons

Decrease the burden of HIV in TB patients

8. Provide HIV testing and conselling To prevent anyone from catching TB while in a health facility or other congregate settings such as prisons

9. Introduce HIV prevention methods To ensure TB patients know how to prevent HIV, which will in turn reduce transmission of both HIV and TB

Decrease the burden for people living with HIV and TB

10. Introduce co-trimoxazole prevention therapy To reduce the the risk of people living with HIV and TB from dying during treatment 11. Ensure HIV and TB care and support To provide people living with HIV and TB with the care and support they need to manage their illness 12. Provide antiretroviral therapy To ensure that all people living with HIV and TB receive ART where appropriate - this will reduce their risk of death and improve their quality of life

Reduction of tuberculosis infection risk in people living with HIV through antiretroviral therapy
The online journal PLoS Medicine has published findings of a WHO-led meta-analysis revealing that antiretroviral therapy (ART) reduces the risk of tuberculosis (TB) infection by 65% in people living with HIV. This protective effect of ART against TB was seen irrespective of the CD4 counts at which people started taking antiretroviral treatment. These findings will inform the ongoing review of WHO guidance on when to start ART in people living with HIV and at risk of TB.