What Works for Women and Girls

10A. Preventing, Detecting and Treating CriticalCo-Infections: TuberculosisTuberculosis (TB) is the leading cause of death among people with HIV globally, accountingfor almost 25% of all HIV deaths in 2008 (WHO, 2009i). The risk of acquiring TB is 20 to 37times greater among people living with HIV than in the general population.In some countries in sub-Saharan Africa, up to 80% of“TB continues to be the leadingcause of death among peopleliving with HIV”(UNAIDS, 2009e: 3).HIV Infection Fuels TB Epidemicspeople living with TB are also living with HIV. Sub-SaharanAfrica continues to account for the majority of people livingwith HIV and TB in the world with about 78% of the estimatedtotal people living with HIV and TB in 2008. SouthEast Asia, mainly India, accounts for 13% of the remainingcases.Rates of HIV and TB co-infection have increased dramatically in a short span of time. Therehas been a doubling of TB cases associated with the HIV epidemic in sub-Saharan Africa(Heymann et al., 1999). When the HIV epidemic is in an expansive phase, HIV and TBco-infection rates also increase rapidly. For example, HIV seroprevalence among TB casesin Chiang Mai, Thailand increased from 5% in 1989 to 40% in 1992, along with the rapidlygrowing HIV epidemic (Payanandana et al., 1995 cited in Raviglione et al., 1996; Kharsanyet al. 2006). However, at this time, in countries such as India or China where there is a highlevel of TB, there is less TB/HIV co-infection (WHO, 2009i). “The risk of TB increases withadvancing immunodeficiency, so as the HIV epidemic in a community matures, the burden ofHIV-associated TB may be expected to increase, even after the prevalence of HIV infection hasstabilized” (Lawn et al., 2006: 1046).TB Is a Serious Risk for Those Living with HIVNot everyone exposed to TB has active disease. A person with latent TB infection, or LTBI, hasbeen infected with the TB bacillus but has an immune system sufficiently intact to control theinfection and will not permit the bacillus to cause disease. A person with LTBI is not ill and is notinfectious. TB becomes a much more serious problem for someone with HIV. When a personinfected with the TB bacillus cannot control the infection because of a compromised immunesystem, the bacillus is able to multiply so that there are millions of TB bacilli that then causedisease. A person with active TB disease becomes sick and is considered infectious to others.HIV-positive individuals who are latently infected with TB are between 2 to 10 times morelikely to progress to active TB disease than their HIV-negative counterparts (Murray, 1990 quotedin Holmes et al, 1998). People whose immune systems have deteriorated due to advanced HIVdisease are at greatly increased risk of developing active TB disease from a previously contained268 CHAPTER 10 PREVENTING, DETECTING AND TREATING CRITICAL CO-INFECTIONS