HIV-related TB deaths: impact of joined-up programmes in Estonia

The control of drug sensitive tuberculosis, multi-drug resistant tuberculosis and HIV is a serious public health challenge in Eastern Europe and Central Asia. Estonia has a rising HIV epidemic and a high prevalence of multi-drug resistant tuberculosis. What effect will simultaneous tuberculosis control and HIV harm reduction programmes have in Estonia?

Estonia is experiencing a rapidly escalating HIV epidemic among injecting drug users. The country now has the highest rate of new cases of HIV among former Soviet Union states. At the same time, tuberculosis (TB) cases have increased substantially. In 1998, Estonia’s multi-drug resistant tuberculosis (MDRTB) rate was among the highest in the world. Poor MDRTB control is of concern in areas where there is a rising HIV infection rate. HIV damages the body’s immune response and is a major risk factor for latent TB infection developing into active TB. The death rate among people with MDRTB is high, especially if they are also infected with HIV.

A study by Imperial College London’s Centre for Health Management, Hertfordshire University’s Business School, the London School of Hygiene and Tropical Medicine and World Health Organization examined the impact of joined-up HIV harm reduction and MDRTB control programmes in Estonia. The study explored the potential impact of different policy decisions for communicable disease control in Estonia over a projected 20-year period. It considered the effect of MDRTB control programmes and harm reduction programmes, which reduce needle sharing and injection frequency among injecting drug users, on cumulative HIV and AIDS, TB, and HIV related TB deaths.

The study made the following findings:

• If effective harm-reduction programmes are in place, HIV-related deaths will drop by an estimated 30 percent, but will double if they are ineffective.
• If effective MDRTB and HIV control is in place, TB deaths will decline by 54 percent, while MDRTB deaths will be reduced 15-fold and HIV-related TB deaths two-fold.
• Effective MDRTB control on its own will reduce TB deaths by only 22 percent.
• An effective harm-reduction programme run alongside a poor MDRTB control programme would reduce TB deaths by 34 percent, MDRTB deaths by 14 percent and HIV-related TB deaths by 56 percent.
• If harm reduction and MDRTB control programmes are neglected but drug sensitive tuberculosis (DSTB) is controlled well, there will be 50 percent more TB-related deaths than if all are addressed effectively.
• Deaths from TB are reduced more substantially by effective harm reduction programmes than effective MDRTB control.

If the emerging HIV and MDRTB epidemics are to be addressed effectively in post-Soviet countries such as Estonia, communicable disease policies must be changed substantially. The study recommends the following:

• Where there is high MDRTB prevalence and an immature HIV epidemic among injecting drug users, effective HIV harm reduction and DSTB/MDRTB control programmes must be set up simultaneously to prevent large numbers of deaths.
• In the early stages of an IDU-centred HIV epidemic, if too little attention is given to effective harm reduction, substantial deaths will occur even if good TB control is in place.
• A highly effective MDRTB treatment programme will have far less impact on cumulative TB-related deaths than when an effective HIV harm-reduction programme is in place.
• Continuing with and improving harm-reduction programmes is critical for reducing cumulative HIV-related TB deaths in situations such as Estonia.

Source(s):
‘Impact of Joined-up HIV Harm Reduction and Multidrug Resistant Tuberculosis Control Programmes in Estonia: System dynamics simulation model’, Health Policy 81, pages 207-217, by Rifat A Atun, Reda M Lebcir, Martin McKee, Jarno Habicht and Richard Coker, 2007

Funded by: UK Department for International Development (DFID) and Imperial College London

id21 Research Highlight: 19 December 2007

Further Information:
Rifat A Atun
Centre for Health Management
Tanaka Business School
Imperial College London
South Kensington Campus
London SW7 2AZ
UK

Tel: +44 (0) 207 5949160
Fax: +44 (0) 207 5945915
Contact the contributor: r.atun@imperial.ac.uk

Imperial College, London, UK

Other related links:
'Priorities for intervention: HIV, STIs and drug injecting in Central Asia'

'Hiding from the truth? The spread of HIV/AIDS in Eastern Europe'

'Responding to Russia's emerging tuberculosis epidemic'

'Setting the right health goals for Eastern Europe and Central Asia'

'Providing care in South Africa - lessons from TB/HIV pilot districts'

'Evidence from South Africa: joint TB/HIV programme activities are more cost-effective'

HIV/AIDS Guide on Eldis