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The Power of Activism: TB vs. HIV

You know it was a long flight when the passenger next to you grew five o’clock shadow through the course of it. But when my feet met the tarmac and I felt South Africa’s chill winter wind enliven my senses, 20 hours could have been ten or two or nothing at all. After one more flight, a euphoric night’s sleep and a breakneck taxi ride, on Saturday morning I arrived at the medical school and took my seat in a stadium-style lecture hall among 150 of the world’s leading HIV/AIDS and tuberculosis researchers—including the truly eminent Francoise Barré-Sinoussi, Nobel laureate and discoverer of HIV. On the meeting’s docket: jump-starting a global research agenda aimed at reversing the TB-HIV co-epidemic. I’m not a medical researcher myself, but as a policy researcher and global health advocate I took part to learn, to network, and to build support for the recommendations found in ACTION's newest report, Living With HIV, Dying of TB: A Critique of the Response of Global AIDS Donors To the Co-epidemic.

The time and place for a gathering like this couldn’t have been more appropriate: July 18, Nelson Mandela’s birthday, in Cape Town. It was in Polkmoor Prison on the outskirts of this city where, in 1988, while being forced to serve what was then a life sentence for sabotage and treason, Mandela developed tuberculosis. He was hospitalized for six weeks before being transferred to Victor Verster Prison, where he spent over a year before he was released in 1990. Mandela spoke his most famous words from a dock in 1964, when he called for the realization of a democratic and free society for people everywhere. For TB advocates, he spoke his second-most famous words 40 years later at a press conference in Bangkok, where he asserted, "We are all here because of our commitment to fighting AIDS. But we cannot win the battle against AIDS if we do not also fight TB.”

According to the World Health Organization, almost 1.4 million people with HIV developed tuberculosis in 2007 — eighty percent of whom live in Africa. More than half of people in Africa who die of TB are co-infected with HIV. The epidemics on the continent have converged, yet too often the people responsible for fighting both diseases continue to work independently. What’s more is the research driving the development of new tools to diagnose, treat and prevent TB has languished over the past thirty years, with not a single new TB drug developed since the advent of HIV/AIDS. Why?

According to Dr. Anthony Fauci, director of the U.S. National Institutes of Health, much of the blame must go to "complacency"-- the absence of TB activism over the past several decades. In his opening presentation, Dr. Fauci contrasted the recent history of HIV and TB research, demonstrating the extent to which TB research has lagged behind that for HIV/AIDS. He credited activism with being the driving force behind HIV/AIDS research, leading NIH to invest US$39 billion cumulatively in R&D since the early 1980s. These resources have generated over 200,000 published studies, leading to more tools to diagnose and treat HIV than are available for the rest of the viral diseases combined. In just a few decades, activism transformed HIV/AIDS from a new disease — with no history, no treatment and no cure — to what’s now become a chronic illness for those living in wealthy countries. Indeed, most people in need of treatment still lack access, and a vaccine continues to elude us. But, taken on its own merits, the rapid development of a broad armamentarium of HIV/AIDS drugs and diagnostics is a human accomplishment unprecedented in the history of medicine.

Not so for TB: complacency has left the world with a TB vaccine that’s 88 years old, a standard diagnostic that predates the automobile, and no new drug to hit market in over 40 years. While TB research has recently seen an increase in funding, with a number of promising tools in the pipeline, we’re just playing catch-up. Moreover, as ACTION’s report shows, global HIV/AIDS donors have not yet caught on to the fact that TB and HIV/AIDS must be met with an integrated attack in those parts of the world where rates of both diseases are highest. Perversely, the roll-out of antiretroviral drugs and other types of care for those with HIV, without a simultaneous response to TB and without improving infection control, has actually enabled TB’s spread in healthcare settings among those whose ravaged immune systems leave them most vulnerable. Even placing technology barriers aside, what is known is simply not being done.

To change this will require not only more advocates, but that advocates demand more. A look to the brief history of HIV/AIDS activism shows what’s possible.