Integrating Tuberculosis into Your HIV/AIDS Programs is a Low-Cost, High-Return Next Step

By Joan R. Magee

Contrary to its image in the West, tuberculosis is not a disease of another era. The TB epidemic claims two million lives each year, taking a devastating toll on the most vulnerable populations.

The deadly synergy between HIV and TB is unmistakable-accelerated in people with weakened immune systems, TB is responsible for half of all deaths among people living with HIV/AIDS.

Yet while business has made significant strides in the fight against HIV/AIDS, efforts to tackle TB-and the lethal combination of the two, known as co-infection-have lagged, according to the Coalition's 2008 assessment, The State of Business and HIV/AIDS, TB and Malaria. The resources and leadership simply aren't sufficient to turn the tide on TB.

But business is well-positioned to take action against tuberculosis. Companies already fighting HIV/AIDS in the workplace or the community are finding that they can integrate TB into their HIV/AIDS programs, achieving big results with a relatively low investment. Effectively, these companies are turning the deadly synergies between the two diseases into tools with which to fight them.

Challenges and Opportunities

"Many think of tuberculosis as a disease of the past century," says Peter Piot, former executive director of UNAIDS and current director of the Institute for Global Health at Imperial College London. "A walk through community health centers and hospitals of Sub- Saharan Africa is an eye opener on the comeback of this old disease and its deadly synergy with HIV."

Latent TB, which is the infection's non-deadly form, is more likely to become lethally active in people living with AIDS due to their weakened immune system. Compounding this deadly co-action is the fact that one-third of the population of the entire planet is currently infected with latent TB.

But the very synergies that make HIV and TB so deadly together can be made to work against the diseases-the same workplace and mass education models, testing vehicles and treatment programs that businesses have developed to fight HIV/AIDS can be easily and affordably adapted for use against TB. What's more, many of those components are already designed to target the highest-risk group for TB infection- people living with HIV/AIDS.

"Let's not treat tuberculosis as ‘business as usual,' and create synergies in endemic countries to keep our workforce healthy and promote, with local governments, sound TB and HIV/AIDS policies," says Dr. Patrizia Carlevaro, head of international aid at Eli Lilly and Company.

Finding and leveraging those connections between HIV/AIDS and TB programs is not only sound medical practice, but sound business practice as well. Although TB treatment is relatively cheap when compared to HIV treatment-costing around $20 per patient-the logistical costs of implementing a TB intervention are still high. In tough economic times, many private-sector health programs can't anticipate big budget increases, meaning that new TB interventions will need to focus on keeping logistics costs down.

"Business has the potential to contribute to the fight against TB with minimal cost and effort," says Jorge Sampaio, UN special envoy to Stop TB and former president of Portugal. "Many of the companies already engaged in the fight against HIV/AIDS have the necessary platforms in place to begin fighting TB. By integrating TB into HIV/AIDS programs, businesses can have a significant impact and they can do it cost-effectively."

The kind of programmatic synergy Sampaio describes includes the integration of TB into corporate nondiscrimination policies, education, testing and treatment programs and high-level advocacy.

As with HIV/AIDS, TB stigma hinders those with symptoms from seeking testing and treatment. Corporate nondiscrimination policies are critical to mitigating that stigma in the workplace and encouraging more people to seek out testing and treatment.

The very platforms developed to educate and engage employees or community members about HIV/AIDS-peer education programs, group information sessions and mass awareness campaigns, just to name a few-can be leveraged against TB. For example, companies in endemic regions often have internal health and wellness champions who are trained to educate their co-workers on HIV/AIDS. Integrating basic TB components into the training process- such as how to identify TB symptoms and where to seek TB screening-is one simple, yet impactful way to get the word out about TB.

Educational vehicles that are already targeting those who are living with HIV/AIDS-such as antiretroviral treatment awareness campaigns-are particularly valuable, since they provide a direct line to the audience at the highest risk for TB infection.

Perhaps one of the most important roles that business can play is to create an enabling environment that promotes TB treatment adherence. Incomplete treatment is responsible for the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of TB, which are striking across the globe with deadly force. Promoting treatment adherence is a joint responsibility among patients, medical staff and business.

Business can support employees and their families to complete their full regimens by providing free treatment in house at little cost to the company. Reinforcing both HIV and TB treatment through existing platforms helps to improve treatment adherence among HIV-positive employees already on antibiotic or antiretroviral (ARV) therapy. Those business TB programs that don't have the resources to provide treatment in-house should provide time off and transportation for their employees to receive their daily treatment at off-site clinics through public-sector programs.

The links between HIV/AIDS and TB couldn't be clearer to Dr. Brian Chicksen, director of AngloGold Health Services, a division of mining corporation AngloGold Ashanti. His company has taken early action to integrate its HIV/AIDS and TB workplace programs.

"You must manage the two diseases together because you cannot have an effective HIV program without an effective TB control program," says Chicksen.

AngloGold Ashanti recently began integrating a number of TB services into the general health program for its 50,000 employees across Africa, including the provision of TB education, screening and treatment. The company has seen immediate results from this exhaustive effort: After only one year, the number of new TB infections among employees dropped by 20 percent.

The impact of tuberculosis on business is severe. Each year it is responsible for a reduction in the annual incomes of the world's poorest communities of $16 billion, according to the World Economic Forum. In some countries, the decrease in productivity due to TB equals seven percent of GDP. Much like HIV/AIDS, TB among the workforce leads to increased absenteeism, high health insurance costs and lowered productivity.

"Business needs to be aware that TB-particularly when combined with HIV/AIDS-is a major problem that claims millions of lives each year," says Sampaio. "Companies need to know that just like HIV/AIDS, TB will negatively affect their employees, their consumers and their bottom line if it isn't taken seriously. The potential long-term benefits in helping to improve the health of consumers in emerging markets for their future growth are huge."

The Power of Collaboration

"There's a lot of knowledge out there among Stop TB partners about how to run an effective TB intervention, and even how to integrate TB into HIV/AIDS programs, among both businesses and non-corporate partners," says Irene Koek, chief of the Infectious Disease Division of USAID and chair of the Stop TB Partnership Coordinating Board. "Companies need to tap into that expertise, just as they do with HIV/AIDS, to maximize the value of their investments and avoid reinventing the wheel."

The least cost-effective way a company can approach TB is to take a go-it-alone approach. That's why the Coalition will be hosting three TB roundtables in South Africa in 2009, helping companies share knowledge and build-out new TB programs or improve existing ones. The roundtables will also help mobilize more experienced companies to support TB initiatives within the small and medium enterprises in their supply chains and around the community.

But collaboration at the highest levels is also needed to effectively support on-the-ground efforts against TB and HIV/AIDS. The Coalition and the Stop TB Partnership brought together business, public health and government leaders last June for a leaders' forum on HIV-TB co-infection at the United Nations Secretariat. High-level participants at the meeting reached an overwhelming consensus that a more centralized approach to preventing, testing, and treating TB and HIV patients is necessary.

"Real progress can only be made through the commitment of all the related stakeholders, including governments, NGOs and the international community, as well as the private sector. We can only achieve sustainable improvements by working together," says Matti J. Ojanen, director of international affairs and public policy for AstraZeneca. "We also need sustainable financing from governments, commitment from other stakeholders and recognition of the private sector's role in coming up with a solution."

Eli Lilly and Company has been a leading private-sector partner, contributing $70 million to global TB efforts through collaborations with Médecins San Frontières (MSF) and the World Health Organization to provide discounted MDR TB treatment to those in need.

"This pandemic kills close to two million people every year, and is the leading cause of death among HIV/AIDS victims in some parts of the world like in sub-Saharan Africa," says Carlevaro. "They can be saved through effective treatments which are now available and affordable to all those in need."

• The Three I’s: Learn about WHO’s guidelines for tackling HIV and TB together
• Best Practices: View case studies from companies that have effectively tackled TB
• Managing HIV and TB: Read Stop TB’s guide to managing both diseases in the workplace
• Get Involved: See upcoming roundtables, teleconferences and meetings on TB
• Global Partnership: Learn more about Eli Lilly’s high-impact MDR-TB partnerships
• XDR-TB.org: See photos from the front lines of the fight against drug-resistant TB