Inside HRSA - July 2008 - Health Resources and Services Administration
 
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2008 Primary Health Care All-Grantee Meeting

HRSA Doctors Underscore Links Between HIV/AIDS and Tuberculosis

In stark language, two HRSA physicians warned health center providers of emerging trends in the prevalence patterns of certain “diseases of poverty” that could have dramatic consequences for their clinics.

Popular misconceptions that tuberculosis and HIV/AIDS largely have been brought under control have set the stage for new outbreaks, drug-resistant strains and co-morbidities -— multiple simultaneous infections, often in conjunction with drug or alcohol addiction.

“Things are different now than they were just two years ago,” Laura Cheever, M.D., deputy associate administrator for HRSA’s HIV/AIDS Bureau, told a rapt audience attending the 2008 Primary Health Care All-Grantee Meeting at the Gaylord Hotel and Resort. “While we have seen a dramatic decline in AIDS deaths since the early-90s — because of improvements in the maintenance medications patients are receiving — we have also seen a sharp increase in prevalence.”

The very drugs that are extending patients’ lives, she said, appear to have removed much of the fear factor associated with HIV and may be “emboldening others to return to high-risk behaviors.” At the same time, a new generation of younger gay men who had not yet come of age during the “early, dark days” of the epidemic may be less wary.

Exacerbating the problem, said CAPT Theresa Watkins-Bryant, M.D., senior medical advisor for HRSA’s Office of Minority Health and Health Disparities, is that HIV/AIDS has hit hardest in populations already beset by disproportionate rates of infection for hepatitis-C, gonorrhea, chlamydia — and drug-resistant tuberculosis. Of the 40,000-60,000 new cases of HIV diagnosed every year, 49 percent occur among African Americans.

“Black males are now seven times more likely to get infected than whites,” Dr. Cheever added, “which is a rate similar to that in African countries.”

The single largest cohort of HIV patients of all races continues to be men who have sex with men; but even among heterosexual patients who engage in little or no high-risk behavior, racial and ethnic minorities are infected at disproportionate rates. Approximately eight out of 10 children living with the virus in the U.S., for example, are black and Hispanic.

Dr. Cheever explained that new evidence strongly suggests this disparity is closely related to two co-factors: people tend to restrict sexual activity to members of their own race, and certain racial groups are less likely to have access to preventative health care.

 

CAPT Theresa Watkins-Bryant, MD
CAPT Theresa Watkins-Bryant, MD

So, even though studies show that infected adults are 68% less likely to pass on the virus if they know they are infected, the lack of early detection in medically underserved areas (MUAs) makes it difficult to break the chain of transmission.

Research has found that nearly seven out 10 black men who have sex with other men were not aware they were carrying an STD. And even though they tended to have fewer partners, their rates of infection and re-transmission were much higher on average, because a greater percentage of them lived in a MUA.

“We see heterosexual African American women infected with HIV who have not engaged in any high-risk behavior at all,” said Dr. Cheever. “They’re not IV drug users, and they may have only had two sexual partners in their entire lives. But they do tend to choose those partners from a population with a greater rate of infection and transmission (and less access to early detection), which is to say, African American males.”

The net effect is that the disease is passed around much more readily within a medically underserved population, because there’s “a much greater likelihood of people being unknowingly infected” and transmitting it to multiple partners, Dr. Cheever said.

One immediate reckoning for health care workers, she said, is that self-reported risk behavior by their patients is now considered a less reliable indicator of likely HIV exposure than previously thought — so much so that the U.S. Centers for Disease Control and Prevention now recommends voluntary universal testing for all patients ages 13-64 who come to a health center for treatment.

“If for no other reason than your own protection — from needle sticks, fluid transmission, what-have-you — these are things you need to know,” Dr. Cheever said.

CAPT Watkins-Bryant brought home the point by noting that tuberculosis is easily transmitted through coughing or sneezing, harder to detect, and increasingly occurs concurrent with HIV/AIDS in health professional shortage areas (HPSAs).

“Even in those states with relatively low rates of TB and HIV,” she told the grantees, “the place where these patients are most likely to present is at a HRSA-funded health center — your clinics.”

Further, as noted in a 2006 report from the CDC’s Advisory Council for the Elimination of Tuberculosis, many public health agencies relaxed their TB prevention programs as the prevalence of the disease dipped from a high of 18,000 patients in 1993 to 14,000 in 2007.

“So in addition to all that you do,” CAPT Watkins-Bryant said, “our health centers now play a vital role in public health surveillance in this instance. If we don’t look for tuberculosis in our patients — if we’re not thinking about it” — the likelihood of a general outbreak, particularly in densely populated urban areas, is much higher.

“I don’t want to sound alarmist, but the increased resistance of tuberculosis (to existing drugs) is something that we have to take very seriously, and we are concerned that our health center clinicians who may be seeing an HIV-positive patient who’s coughing or has flu-like symptoms may not necessarily be thinking, TB.”

And, as in the case of HIV/AIDS, the burdens of the disease fall disproportionately on racial minorities living in designated HPSAs. At present, CAPT Watkins-Bryant said, the likelihood of contracting tuberculosis is eight times higher for blacks than it is for whites.

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