Fighting TB With HIV Will Reduce TB Burden & Children Must Not Be Left Behind

Eric Bond, EGPAF

HIV is a major driver of the TB epidemic in many countries.

While progress in the fight against HIV and AIDS has been steady over the years, the challenge of TB-HIV co-infection remains, especially among children. In 2015 tuberculosis (TB) ranked as the world’s deadliest infectious disease, currently causing the death of 1.5 million people per year. Every year around 10 million people develop TB; 1 million of them are children under the age of 14. Only 64% of these children are properly diagnosed due to lack of adequate technologies, low awareness and failing health systems. Every four minutes a child dies of TB. Approximately 10 million children are left orphaned because of TB every year.

Regionally, more than half of TB patients in South Africa and 70 percent of TB patients in Swaziland and Lesotho are co-infected with HIV. 

Combined HIV and TB infection is detrimental to the life of the patient. Each speeds disease progress of the other and if not identified and treated early and effectively, the TB-HIV co-infection is fatal.  

Although TB is curable, it is the leading cause of death for HIV positive people globally. At least one-third of people living with HIV worldwide in 2015 were infected with TB. The need to integrate TB in HIV programs and HIV in TB programs is therefore crucial. 

Children are the most vulnerable and often lag behind adults in accessing quality and comprehensive TB care and treatment. 

Diagnosing TB in Children 

While it’s estimated that there are over 1 million cases of pediatric TB each year, only around a third are treated. Without diagnosis, many of those children will die. 

TB is mainly diagnosed by checking the TB bacteria in sputum through microscopy.  

Unfortunately, diagnosis of TB in children is difficult. Very young children often cannot produce sputum for testing. Even when a sample is taken for microscopy, the quantity of TB bacteria in samples from children is often lower than in adults, making TB more difficult to detect.  

Many children, especially younger children or HIV-infected children develop forms of TB outside of the lungs, which are harder to diagnose as they rely on more complex sample collection techniques.  

While samples that are easier to collect in children, such as stool may provider greater accuracy for diagnosing TB, we are still a long way from the perfect microbiologic diagnostic test.  Increased support for research is urgently needed.

Children with TB must be identified quickly and put on treatment before they become extremely ill.  

A new DNA-based molecular near point-of-care diagnostic testing, GeneXpert has improved sensitivity over older and more commonly used diagnostic techniques. The test detects TB infection in patients and also determines if a patient’s TB bacterium is resistant to a common TB drug, rifampicin. Use of GeneXpert is recommended by the World Health Organization (WHO) as the first test for pediatric TB suspects. Unfortunately, availability and uptake of GeneXpert for pediatric TB testing is still limited in many sub-Saharan African countries.  

Countries should recommend GeneXpert for TB as the first line diagnostic in their national guidelines to ensure greater access to the technology.

Preventing TB in Children 

Latent tuberculosis, also called latent tuberculosis infection (LTBI) occurs when a patient is infected with  tuberculosis bacteria, but does not have active tuberculosis. Diagnosis and treatment of people with latent TB is an important part of controlling this disease. 

The source of TB infection for children is usually an adult in their household who has active TB.

Regular, low cost preventive medication exists to prevent cases of TB in children at risk of contracting TB, as well as adults with HIV. WHO recommends isoniazid preventive therapy (IPT) for children under 5 years old who are household contacts of individuals with active TB. WHO also recommends IPT for all HIV positive adults who are unlikely to have active TB, to protect them from TB.

Availability of IPT in correct doses for children is a major challenge. New formulations such as dispersible isoniazid are expected to enter the market in the next year and will ensure easier treatment for children with latent TB treatment. 

Treating Children with TB 

Dosage of anti-TB medication for children with TB has been a longtime challenge. Until recently, no child-friendly formulations were available and treatment for children with TB was a complex process. Children were required to take a cocktail of drugs - a single fixed dose combination with additional single tables of individual drugs, some of which were split to achieve the recommended dose for a child’s weight. For children who cannot swallow pills these medicines would also need to be crushed and mixed with water, resulting in bad-tasting slurries.  

A new and improved dispersible first-line fixed-dose combination for treatment of pediatric TB is now available in palatable fruit flavors. Developed by the TB Alliance, this new formulation is easier to administer as it is rapidly dispersible and easier for children to take. It is critical that countries adapt to this new formulation.  

Plans are underway for Southern African countries to roll-out the fixed dose combination.  

Although multi-drug resistant TB (MDRTB) is a growing issue in areas including Eastern Africa, there are no child formulations of second-line TB drugs. Development of such formulations is needed to help save lives when there is risk of children acquiring MDR TB from adults.  

HIV is a major driver of the TB epidemic in many countries. To ultimately help reduce TB in both children and adults, it is imperative that the East African community heed WHO's recommendation to begin antiretroviral treatment as soon after HIV diagnosis as possible, and to support efforts to prevent and treat HIV in children adolescents and young women by UNAIDS, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and others under a new call to action, Start Free, Stay Free, AIDS Free. While challenges remain, we have a clear opportunity to meet them and to finally reduce the burden of childhood TB.