Some critics of the HIV/AIDS paradigm argue that "AIDS" is just a new label for many old diseases. This UNGASS report suggests that the presentations at the TB event came perilously close to supporting that view. UN General Assembly - Special Session on HIV/AIDS [UNGASS] New York - 25 to 27 June, 2001 TB - The forgotten companion of HIV Monday 25 June, 11.30 - 1pm UN Dag Hammarskjold Auditorium, New York This event took place on the first day of the UNGASS and was organised by the International Union Against Tuberculosis and Lung Disease. The main purpose of this event was to bring the links between tuberculosis (TB) and AIDS to the fore, and to highlight the often overlooked aetiological connection between these two diseases. The first presentation was given by Dr Lee Reichmann, Executive Director of the New Jersey Medical School National TB Center. His talk outlined the way in which HIV/AIDS and TB are inextricably linked, highlighting the following points: TB is the first manifestation of AIDS in 50% of cases in developing countries Around one third of HIV+ people have TB. There is a two-way relationship between the two conditions: HIV seropositivity increases the likelihood of reactivation of latent tuberculosis, and HIV positive people with tuberculosis have much higher viral loads (Goletti D et al, 1996). And when TB is cured in an HIV positive person the onset of AIDS can be delayed by several years. Unlike HIV/AIDS, a low cost cure already exists for TB. In light of these considerations it was hard to comprehend why tuberculosis had only been mentioned once in the UNGASS Declaration of Commitment on HIV/AIDS, and this was by way of reference to the Abuja summit, held in April 2001. One of the next speakers, Dr Jai Narain from the WHO Regional Office in New Delhi, India, focused the discussion on Asia where 40% of global notified TB cases originate. In addition, he reported that epidemiological patterns are changing in many parts of the region, and very often the prevalence of TB amongst HIV+ patients is increasing rapidly - over three-fold in the past 10 years in the case of Chiang Mai, in northern Thailand. Dr. Narain noted that in many areas where the need for HIV prevention and care schemes are now being recognised and implemented, there is seldom the same recognition and political will or resources to deal with the TB problem in the same areas. This is not to say that resources for TB and HIV/AIDS are necessarily in competition with each other. It was pointed out that there was a need for greater integration of TB and HIV/AIDS service delivery, for example those who have tested HIV+ should be referred to a DOTS (directly observed treatment schedule) centre where they could receive prophylaxis to prevent the onset of TB. There could also be joint advocacy and training efforts to reflect the inherent connection between the two conditions. An interesting case study of successful efforts to respond to these diseases in an integrated way came from Uganda and was described by Professor Omaswa, Director General of Ugandan Health Services. A community-based pilot study has been started in Kiboga. In the study, detection of tuberculosis cases takes place within the community, and the treatment of those identified with TB takes place in the home under the supervision of volunteers. This delivery system is overseen by a district level Director of Health Services and has proved to be a cost effective and sustainable means of TB prevention and care. The number of drop-outs from the pilot were very low and this increased success might be attributable to the strong level of community participation in the programme. The Global Fund on Health & HIV/AIDS, which has already received much attention in the corridors and halls of the Special Session, is intended to be used in the fight against the three biggest killer diseases: TB, HIV/AIDS and malaria, the latter of which results in 3 million deaths annually. Although the linkages between TB and HIV/AIDS are perhaps more self evident, they also exist between HIV and malaria. Dr Kakano from UNICEF described malaria as an opportunistic infection, which causes AIDS to become more severe and in turn seropositivity must be taken into account when administering dosages of anti-malarial drugs to patients. The messages taken away from this side event by UNGASS delegates were clear. We should not view HIV in isolation from other bedfellow diseases, and addressing TB issues especially should not be relegated to a side event at a meeting on HIV/AIDS, for example. To partition these two diseases as if they develop independently of each other ignores the reality of their mutual reinforcement, leads to sub-standard care and does not make for sound public health policy. HDN Key Correspondent Email: correspondets@hdnet.org Commentary: This "side event" to the UN General Assembly - Special Session on HIV/AIDS failed to address another issue: Tuberculosis and malaria are easily mistaken for AIDS. First: tuberculosis and malaria are known to cause false positive results on so-called HIV antibody tests. Secondly: in Africa, where AIDS is diagnosed clinically, "AIDS symptoms" are indistinguishable from the symptoms of tuberculosis, and many other illnesses that are widespread on the continent. Among the diseases common in underprivileged and impoverished communities that are known to cause false positive results are tuberculosis, malaria, hepatitis and leprosy (Burke, 1993; Challakeree, 1993; Johnson, 1998; Kashala, 1994; MacKenzie, 1992; Meyer, 1987). In fact, tuberculosis and malaria are the primary health threats in Africa; several million cases of tuberculosis and malaria are reported in Africa each year - more than all the AIDS cases reported in Africa since 1982 (WHO, 1998) *. * see Mark Craddock's comments on disease reporting in Africa. In Africa, the continent supposedly being decimated by HIV, HIV tests are rarely ever done, so the idea that all patients with AIDS in Africa are infected with HIV is based entirely on supposition. At a WHO conference in the Central African Republic in 1985, U.S. Centers for Disease Control (CDC) introduced the "Bangui Definition" of AIDS in Africa. The CDC officials later explained, "The definition was reached by consensus, based mostly on the delegates' experience in treating AIDS patients. It has proven a useful tool in determining the extent of the AIDS epidemic in Africa, especially in areas where no testing is available. Its major components were prolonged fevers (for a month or more), weight loss of 10% or greater, and prolonged diarrhea..."(McCormick & Fisher-Hock, 1995). In describing why they felt it was reasonable to adopt this extremely non-specific definition of AIDS, they wrote: If we could get everyone at the WHO meeting in Bangui to agree on a simple definition of what an AIDS case was in Africa, then, imperfect as the definition might be, we could actually start to count the cases. (McCormick & Fisher-Hoch 1995, page 189).In their haste to start counting, they seem to have overlooked that their "AIDS symptoms" are common results of malnutrition, advanced tuberculosis, and many other illnesses that are widespread in Africa. Where AIDS is diagnosed clinically, large numbers of AIDS patients test negative for HIV. As no HIV testing is required in Africa we have no idea how many AIDS cases there are HIV positive (De Cock, 1991; Gilks, 1991; Widy-Wirski, 1988). References  TORONTO
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