- The Washington Times - Wednesday, March 17, 2004

International public health officials winced in disbelief when they saw President Bush’s $2.8 billion request for combating AIDS next year in the most afflicted countries in Africa and the Caribbean.

Although Mr. Bush has been praised for pledging serious money to deal with HIV/AIDS, some say he is getting bad advice on the most efficient use of the funds if the goal is to save lives.

Specifically, the amount designated to combat infectious diseases was cut from $185 million to $139 million in 2005. Two such diseases — tuberculosis and malaria — are inexpensive and easy to cure but claim the lives of many HIV-positive patients.

“It is frustrating, very frustrating,” said Dr. Mario Raviglione, director of the Stop TB program at the World Health Organization (WHO). “There are 5,500 deaths a day from TB, but the focus is only on getting antiretroviral drugs to people with HIV.”

Dr. Raviglione, who made a short stop in Washington en route to Atlanta for a conference on infectious diseases at the Centers for Disease Control and Prevention, said that if a person is getting antiretroviral drugs but not being treated for TB, he stands a good chance of dying in six months.

“Even without antiretrovirals, if the patient’s TB is treated, you can extend life by two to five years,” he said. “A little extra money well invested, and you can get a lot.”

According to the WHO, tuberculosis, which can be cured with a $10 regimen of antibiotics, is the leading killer among those who are HIV positive. More than a third of the world’s 40 million people with HIV are infected with TB.

About 25,000 people a day — nearly 9 million a year, including those who are HIV positive — become sick with TB. Without treatment, many — especially those who are HIV positive — are likely to die from the disease.

Dr. Raviglione said that while tackling HIV is imperative, it is a losing battle unless eliminating TB is part of the battle plan. He said building lines of communication between HIV health care workers and TB health care workers would save lives.

“In the nations with the highest rates of HIV, between 60 percent and 80 percent of all those infected with TB are also HIV positive. Between 30 percent and 40 percent of all HIV-positive patients will get TB. We badly need interaction between these two communities,” he said.

According to a study by Results Educational Fund and the public health arm of the Open Society Institute, it would take about $53 million to treat all the TB/HIV-positive patients in the 14 countries covered by the Bush administration’s AIDS initiative. It would require an additional $200 million to treat all the TB patients in those impoverished nations.

Dr. Raviglione said it is common in African clinics to have one nurse dealing with HIV and another for TB, and that despite the overlap in the diseases, patients are rarely tested for both.

“If you can put together a system for getting antiretrovirals to AIDS patients, you could add TB drugs for a little cost,” he said.

According to WHO studies, about 264 million HIV-positive TB patients in the 14 countries targeted in Mr. Bush’s initiative are in the system, receiving directly observed treatments, but 264 million more have TB and may not know it.

“We need to strengthen HIV testing and TB testing. If our goal is to find HIV-positive patients and get them antiretroviral drugs, the best way to find them is to scale up TB programs. We are telling HIV programs to test for TB, and TB programs to test for HIV. Once you detect TB, you can do a lot of good for $10,” he said.

Dr. Raviglione said that an even bigger problem, and one that Washington doesn’t seem to grasp fully, is the issue of public health infrastructure in Africa. If the Bush administration spends $18 billion on drugs that are gone in five years, and availability and access to basic health care remain elusive, what will have been accomplished, Dr. Raviglione asked.

He said money is being allocated that way because TB has no strong lobby in Europe or the United States.

“TB is a disease of poverty and the developing world. The money is going toward [antiretrovirals] because there is a powerful gay community framing the issue. We need to convince the AIDS community that there is mutual advantage to working together,” he said.

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