Dual Epidemics: Tuberculosis and Human Immunodeficiency Virus (HIV) in sub-Saharan

Africa

Andrew Ely

School of Public Health, University of Maryland

FMSC 110S: Families and Global Health

Dr. Maring

November 19, 2020

"I pledge on my honor that I have not given or received any unauthorized assistance on this

assessment." - Andrew Ely

Introduction

Widely considered a disease of the past for those living in developed countries like the

United States, tuberculosis still runs rampant in areas of the world, with the most problematic

hotspot persisting in the sub-Saharan regions of Africa. While it is not thought of as a current

problem by many in the developed world, tuberculosis still holds one of the highest death counts

from an infectious disease. According to Jacobsen (2019) in 2015, there were an estimated

1,789,000 worldwide deaths from tuberculosis. Of those, an estimated 210,000, a staggering value

of 12%, were children aged 0-14 years of age. While there are several regions across the globe that

are hit heavily from tuberculosis, sub-Saharan Africa is one of the most affected regions. Jacobsen

(2019) shows that in 2016 there was over 200 new cases per 100,000 residents of sub-Saharan

Africa, a prevalence tied with only southeast Asia for the highest case rate in the world. While

tuberculosis does affect individuals worldwide, the bigger issue in Africa is the struggle to treat

tuberculosis patients who are also suffering from human immunodeficiency virus, or HIV.

Although there are many health crises currently plaguing the Africa continent, the presence of

more than one health crisis does not detract from the severity of any single one or even combination

of them.

Background

While tuberculosis rates worldwide are falling by about 2% every year (WHO), Africa is

still a region that is perennially burdened by tuberculosis infection. In 2016, an estimated 2.5

million people contracted symptomatic tuberculosis in Africa, which accounted for 25% of cases

worldwide (WHO). Not everybody who is infected with the disease will show symptoms. In fact,

only about 10% of those living with tuberculosis bacteria will fall ill in their lifetime, but those

infected with HIV are far more likely to develop symptoms and possibly die. According to WHO,
34% of individuals living with HIV were also infected with tuberculosis, and about 35% of all

deaths among HIV-positive individuals can be attributed to tuberculosis infection. HIV attacks the

immune system of affected individuals, which makes their body less able to fight off the bacteria

that cause the tuberculosis infection. It also makes infection worse as the bacteria is able to

multiply to the number required for pathogenesis (causing sickness, often characterized by the

symptomatic stage). When the body is unable to fight off infection, it becomes far more dangerous

to get any type of infection, and the danger of living with tuberculosis is only increased. Because

HIV on its own is a dangerous condition to be living with, the fact that tuberculosis is responsible

for 35% of deaths of HIV-infected individuals is a significant number that shows there is a serious

health crisis in Africa that needs to be responded to.

While tuberculosis victimizes around the world with the largest number of cases actually

being reported in India, the primary concern with tuberculosis in Africa is the huge prevalence of

HIV affliction as well. HIV exacerbates the symptoms of tuberculosis, making the disease far more

deadly as it suppresses the immune system’s response. This causes the infection to become

symptomatic at far higher rates than usual and makes tuberculosis a far more dangerous disease

than on its own. In fact, the WHO estimates that about one third of the world's population is

infected with a latent (asymptomatic, non-transmissible) tuberculosis infection, but much fewer

actually develop symptoms. According to WHO, HIV positive individuals are 20-30 times more

likely to develop symptoms from a tuberculosis infection. Because HIV infection is so common in

this area, the rate of symptomatic tuberculosis is incredibly high and that causes an increased

number of deaths that can be attributed to the disease.

Significance

While tuberculosis may not be on the radar for many who do not directly look for it, the

United Nations and many other international health programs are well aware of the issue. Recently,

the UN developed a list of seventeen goals that urge the member countries to achieve several

milestones related to health and economic development by 2030, such as ending poverty and

promoting well-being. These Sustainable Development Goals are designed to reduce inequality

worldwide and promote global health and peace. Several member countries of the United Nations

have committed to a Leave No One Behind pledge, which is designed to prioritize the countries

that are farthest behind on these goals (United Nations). On its list of SDGs, the United Nations

addresses good health and well-being, as well as reduced inequalities between countries in two of

its goals (Jacobsen, 2019). Individuals infected with tuberculosis as well as living with HIV are

far from living a healthy life as they are ailed by two significant health detriments. Tuberculosis is

directly mentioned as a subsection of goal three, showing that the United Nations recognizes the

problems that this bacterium continues to cause. Additionally, tuberculosis and HIV rates in Africa

are far from equitable with most of the rest of the world, save a few select countries in Asia.

Although Africa may not have the most cases of symptomatic tuberculosis across the world, the

rate of infection of both tuberculosis and HIV is unmatched. If the United Nations is truly

committed to accomplishing each and every single one of the seventeen sustainable development

goals that have been laid out, they will certainly have to address the dual crisis of tuberculosis and

HIV rates in sub-Saharan Africa. Moreover, the Leave No One Behind pledge member countries

should recognize the sub-Saharan region of Africa as somewhat behind other countries in their

fight against tuberculosis and HIV and focus their intervention efforts in that area.
 While HIV and tuberculosis are both devastating to the infected individual, the results of

these diseases are far more wide-reaching than just the individual level. Often times when an

individual becomes sick, the community around them all take some responsibility in caring for

them, whether it be direct care, bringing food to the family, or just acting as a pillar of emotional

support to help the individual through the tough time. According to the Centers for Disease Control

and Prevention, tuberculosis of the lungs is highly contagious through the air when an infected

individual coughs or even speaks. Although, other sites of tuberculosis infection such as the kidney

or spine are generally not contagious. Therefore, the sick individual's mesosystem should be

cautious, as if family or other community members are in close proximity with an infected

individual, there is a strong possibility that it will continue to spread throughout the area. This

would infect and endanger more people, especially with the prevalence of HIV infection in these

regions. The effects of diseases like this can extend around the world, and this was an interesting

topic of discussion in the recent panel for the Global Public Health Colloquium. Because

tuberculosis, as well as many other diseases, are still primarily a problem in underdeveloped

countries, it creates a stigma or perpetuates a stereotype for many living in more developed

countries that are not burdened by these diseases. The regional disparities could reinforce the idea,

whether intentional or unintentional, that individuals living in these countries are inherently

"diseased" or "unhealthy." These stereotypes and prejudices are extremely problematic and only

worsen the regional health disparities as people might look down on the burdened areas and assume

that they cannot be helped, and instead choose to divert their attention to other issues. This serves

to shrink the effect that the macrosystem has on health in the region, as there will be less outside

help from other organizations made available to these regions.

 Tuberculosis worldwide does not get enough attention. It is rarely covered in the news, and

because it is no longer prevalent in more developed countries like the United States, people

generally do not think about the fact that it still runs rampant in many areas of the world. The most

problematic area, by far, is sub-Saharan Africa due to the rate of HIV infection. Despite accounting

for around just 14% of the world's population, this region carries the burden of 70% of HIV

infection worldwide (Kharsany & Karim, 2016). Because HIV weakens the immune system

substantially, individuals who contract tuberculosis have a much harder time fighting off infection

than HIV negative individuals. The lackluster immune response causes a higher rate of

symptomatic tuberculosis, as well as eventually fatal tuberculosis due to the lack of availability of

antibiotics and other treatments. There are several antibiotics that have been found effective in

treating tuberculosis, however access to these and other forms of healthcare in more

underdeveloped rural regions is far lower than it needs to be to gain control of this health crisis. If

there was an increase in worldwide attention, more organizations might be more inclined to invest

in larger interventions that can begin to chip away at this public health issue.

Current Effort

While there are many interventions that attempt to deal with tuberculosis, most are short-

term, one-time, expensive solutions that tend to revolve around increasing the availability of

medication. A recent study and small-scale intervention focused on the effects of increasing access

to educated health workers in an area burdened by heavy health inequities. The researchers

conducted a study in two districts of the Kwa-Zulu Natal region of South Africa with the goal of

determining the effectiveness of a two-day training session for Community Health Workers

(referred to as CHWs) (Plowright, et. al, 2018). CHWs were targeted because they are integral to

the health of communities in Africa, however they generally receive little training and that
deficiency is often ignored by other forms of interventions. In South Africa specifically, CHWs

make significant contributions towards fighting HIV and AIDS and tuberculosis by providing

continuous care and support that helps patients stick to long-term care schedules. The number of

CHWs in Africa is rapidly increasing because of the successes of similar programs in other

generally rural areas such as Asia and South America (Plowright, et. al, 2018).

The team focused in on the region of Kwa-Zulu because the area already had an extensive

CHW program that was working to ameliorate multiple health issues in the region. Additionally,

the partner organization for the project, Sizabantu (a non-government health organization), had a

strong presence in the area with a history of successful health interventions. The secured foothold

allowed the researchers to reach out to potential participants, as well as build confidence in the

validity of the program. This strategy worked, and the researchers were able to involve sixty-eight

CHWs from two different districts in the study (Plowright, et. al, 2018).

The researchers used pre-tests that measured the knowledge and confidence of the CHWs

in clinical skills as well as post-tests on knowledge and confidence to measure the effectiveness of

their intervention. To develop these questions and the training curriculum, the researches consulted

with other CHWs not involved in the study to get a better idea of the needs of their target

population. At the conclusion of the training, the participants were also given a survey to measure

satisfaction with the training they received and their opinion on the program as a whole. The

researchers made sure to obtain ethical approval for the intervention from multiple institutions and

kept individuals who responded to the tests and surveys anonymous to prevent bias and protect

privacy (Plowright, et. al, 2018).

Throughout the study there was full participation from the CHWs with none of the workers

leaving the program early. There was a close to half and half gender split with a broad range of
ages to give a stronger sense of how this program works for different demographics. The

researchers found that after the training, there was a statistically significant improvement in scores

on the test across the entire range of topics for all of the groups that trained separately. They also

determined that there was a negative relationship between original test score and final test score.

This means that individuals who had a higher pre-test score had similar final test scores to

individuals who had a lower pre-test score, showing that the training was accessible to all of the

CHWs, not just those with extensive prior knowledge (Plowright, et. al, 2018).

This shows the impact that both the exosystem and the mesosystem can have on

individuals. The exosystem, in this case the education program aimed at the CHWs, was shown to

be incredibly effective. The knowledge gain from the short training session was very promising

for a larger scale, and a ramping up of the exosystem could be extremely beneficial to the

individuals in the community. This exosystem directly translates to an improvement of the

mesosystem, which in this case are the CHWs working in the area. Their training could translate

to a vastly increased quality of care for sick individuals, improving yet another level of the social-

ecological model.

As promising as the findings from this study were, there are a few shortcomings to the

design that need to be discussed. The first issue is the way that participants were selected. All of

the participants were volunteers, which could skew the results as those who wanted to increase

their knowledge were likely those who wanted to participate. If CHWs who felt they did not need

the training or simply did not want it were forced to participate, the benefits would likely be lower.

There would still be some knowledge gains, but it would potentially be a much lower yield than

the interested individuals. Additionally, implementing this intervention on a larger scale than this

small sample size could present some problems. More participants would mean larger class sizes
and less beneficial one-on-one instruction time, decreasing knowledge retention. There is also no

data available on the effect that the trainings had on actual patient safety, or the effectiveness or

satisfaction of care provided after the new trainings. This is a primary unaddressed aspect of the

program, as if the knowledge gains do not translate into an increased level of care, it would an

ineffective method of intervention overall. Finally, finding the resources to implement this training

program on a large scale would be difficult, and finding time to train every, or at least most, CHWs

would present a logistical problem. Because of all of the uncertainties left in the air with this

intervention, more data and studies are needed before it can be rolled out on a larger scale across

the entire region (Plowright, et. al, 2018).

Discussion

The results presented from the research on the effects of a quick, two-day training session

in South Africa is very promising for future interventions in the area. While I was looking for

interventions, this stood out as different to me as it focused on educating healthcare workers on

how to deal with different diseases, with a special focus area on the two most problematic of the

region, being tuberculosis and HIV and AIDS. Instead of figuring out how to increase the supply

of medications, which is a very costly method, this study focused on a much cheaper, more viable

alternative that looked to improve medical literacy and overall care. This seems to be a much

longer-term solution as instead of a one-time shipment of expensive medication, it looks to

improve healthcare and access in the area and increase access to knowledgeable medical

professionals in the form of CHWs. This also addresses some of the inequity in the worldwide

burden of tuberculosis and HIV and AIDS by focusing on making care far more available and

higher quality to the region that is one of the hardest hit in the world. In a subsection of their third

Sustainable Development Goal, the United Nations directly mentions their efforts to eliminate the
tuberculosis and HIV epidemics by 2030. While this does seem far away, ten years is a very short

amount of time to drastically reduce the prevalence of a single disease worldwide, let alone two

that have consistently been problematic for such a long time. While ten years out does seem to be

an unrealistic timeline, that doesn't mean efforts should not be made as though it was a deadline.

If efforts slow down because people see it as an unattainable goal, then the issue will never be

addressed. Global health organizations should see the 2030 goal as a deadline and use the short

time frame to motivate them into action, something that has seemed somewhat scarce in the region

so far. Interventions in Africa have been relatively ineffective so far, but the low cost and high

yield of the study on the short training course shows promise as a viable method for dealing with

the prominent health crises, as well as any that may arise in the future.

Conclusion

While it is not a problem often thought about in developed countries, tuberculosis still

ravages certain areas of the world today. However, the study described earlier provides some hope

in the area of interventions that are feasible and effective at helping the health crises. While there

are still questions up in the air about the effectiveness of an intervention like this on a larger scale

than what was studied, the low cost and high educational yield is inspiring. While education alone

will likely not be enough to erase the health inequities in sub-Saharan Africa, it is an inexpensive

good start that lays a solid framework for improved overall health for the future of the region.
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