For Indonesia, World Tuberculosis Day, which falls on March 24, is an event of great relevance due to the fact that the country ranks fifth on the list of 22 high-burden Tuberculosis (TB) countries in the world.
According to the World Health Organization’s (WHO) Global Tuberculosis Control Report in 2012, an estimated 528,063 new TB cases or approximately 256 cases per 100,000 of the population were found in Indonesia in 2010. Based on WHO disability-adjusted life-year (DALY) calculations, TB alone is responsible for 6.3 percent of the total disease burden in Indonesia, almost twice the figure in Southeast Asia.
In addition, as in many other developing countries, coinfection or co-morbidity of TB and HIV is a common phenonemenon in Indonesia. Put differently, in many places in developing and low-income countries, including Indonesia, the TB epidemic has become intertwined with the HIV epidemic. On the one hand, HIV infection greatly increases the risk of TB infection; on the other hand, TB infection exacerbates the suffering of people living with HIV. Therefore, the current world TB commemoration once again empahasizes the urgent need to combat not just TB but also TB-HIV coinfection.
The Health Ministry states that as of March 2012 there were 20,564 reported cases of people living with HIV in the country. Considering the tendency of underreporting of HIV cases in Indonesia, the Indonesian National AIDS Commission (2010) estimates the number of people living with HIV and AIDS in the country ranges from 200,000 to 270,000. The United Nations Joint Commission on AIDS (UNAIDS) has identified a shift of HIV epidemics in Indonesia since early 2000 from “low prevalence” to “concentrated prevalence”, implying that HIV prevalence is less than 1 percent in the general population but more than 5 percent among vulnerable groups such as injecting drug users, female sex workers and their clients, as well as homosexuals.
TB-HIV coinfection is common among these HIV high-risk groups, In addition, it is noteworthy that these high-risk groups tend to be socially and economically marginalized. They usually suffer from the so called cluster of disadvantages e.g. generally having low educational attainment, low levels of skill and employability, low levels of income, low food and nutrition intake, low levels of physical fitness and immunity, and live with poor housing and sanitation.
Moreover, many of them are involved in high-risk behavior such as smoking, alcohol and drug abuse, as well as high-risk sexual practices. In these circumstances, it is not surprising that many of them are susceptible to infectious diseases, including TB and HIV.
Abundant studies indicate that because of their social and economic marginalization the presence of ignorance, lay beliefs and misconceptions about TB and TB/HIV coinfection are common among these high-risk groups. These beliefs and misconceptions influence their health-seeking behavior and frequently hinder their access to adequate treatment.
Moreover, the stigma and discrimination commonly attached to TB and HIV as well as to people living with TB and HIV further exacerbates their suffering and hinders their access to adequate medical treatment. As an example, the level of adherence to TB medication among the members of the above groups who suffer from TB is so low as to render them susceptible to TB multi-drug resistance.
Numerous studies indicate that to control TB-HIV coinfection, concerted efforts (not limited to biomedical and public health interventions) are needed. In other words, while educating people, particularly vulnerable groups, about the risks and the ways to prevent TB and HIV infection is necessary, it is not sufficient to reduce TB-HIV coinfection if they continue to live with high-risk factors such as poor housing, poor sanitation and poor nutrition.
An increasing number of studies maintain that there is a strong link between poverty, economic inequality and TB, HIV and TB-HIV coinfections. On the one hand, poverty and economic inequality lead to people living with TB-related high-risk factors (poor housing, poor sanitation and poor nutrition) as well as indulging in HIV-related high-risk behavior (having multiple sex partners, low levels of condom use and the sharing of needles and other injecting equipment).TB and HIV coinfection further exacerbate poverty, economic inequality, individual as well as social suffering among the members of these vulnerable groups.
Therefore, concerted efforts in the forms of increased access by vulnerable groups to knowledge and prevention skills, access to TB-HIV medication as well as social and economic interventions to improve access to sufficient educational attainment, employability, income, housing and nutrition are urgently needed. However, many of the above requirements are beyond the control of health authorities.
Thus, active engagement by multiple government agencies, not limited to the health sector, as well as the involvement of the community and civil society is crucial.
The writer is a lecturer and researcher at the department of health promotion, faculty of public health, Hasanuddin University, Makassar.