Research Consortium Receives $44.7 Million Gates Foundation Grant to Evaluate New Strategies to Fight HIV-Related Tuberculosis

BANGKOK – At the XV International AIDS Conference in Bangkok today, the Bill & Melinda Gates Foundation announced a $44.7 million grant to support the Consortium to Respond Effectively to the AIDS-TB Epidemic (CREATE), which will conduct research on urgently needed strategies to control TB in communities with high HIV infection rates. CREATE is led by the Johns Hopkins Center for Tuberculosis Research, and includes researchers and health policy experts in Africa, South America, Europe, and the U.S.

Because HIV weakens the immune system, people with HIV are especially vulnerable to TB, and TB rates have increased significantly in countries with high HIV prevalence. In sub-Saharan Africa, two-thirds of TB patients are co-infected with HIV, and of the estimated 1.6 million deaths caused by TB annually, one quarter occur among people living with HIV/AIDS. TB is now the leading killer of people with HIV worldwide.

"We cannot successfully fight HIV/AIDS without also fighting TB, which has emerged as the leading killer of HIV-positive people," said Helene Gayle, MD, MPH, director of the HIV, TB, and Reproductive Health program at the Gates Foundation. "We’ve seen a devastating resurgence of TB in developing countries hit hard by HIV/AIDS, and to control it, it is essential that creative new strategies like those CREATE is pursuing are identified and quickly put into practice."
 
"TB and HIV form a lethal combination, each amplifying  the other’s progress," said Richard Chaisson, MD, Professor of Medicine at Johns Hopkins University and principal investigator of CREATE. "By studying the impact of promising new strategies, we hope to inform critical health policy decisions in countries confronting TB and HIV."

The current strategy for managing TB in developing countries, called directly observed therapy short course (DOTS), can help ensure high TB cure rates, but its reach is limited – DOTS relies on patients to seek treatment themselves and targets only those with active TB, not those with latent infection. In communities with high HIV rates, TB rates have risen dramatically even where DOTS is available.

The grant announced today will support research on two potential interventions: improved case finding and isoniazid preventive therapy (IPT). CREATE researchers will determine the cost-effectiveness and feasibility of these interventions in communities hard hit by TB-HIV co-infection:

• Improved case finding relies on community-based education and expanded TB diagnosis programs to identify people with active TB who would otherwise go undiagnosed, so they can be treated before they infect others.
  
• IPT employs the antibiotic isoniazid to prevent those who are infected with latent TB from developing the active form of the disease. Previous research has shown that IPT can be more than 85% effective in reducing an individual’s risk of developing active TB, but the impact of widespread IPT usage on an ongoing TB epidemic has  not been determined.

CREATE will use the grant announced today to conduct three large-scale community studies over seven years in Africa and South America:

• Zambia and South Africa: This study will evaluate the impact of a targeted package of IPT and improved case finding in Zambia and South Africa. The study will conduct school- and community-based TB education campaigns to help people recognize active TB cases, and intensify existing TB diagnosis programs. Researchers also will determine the benefits of providing IPT to all members of a household where a TB patient lives, to prevent further transmission of the disease.
  
• South Africa: This study will examine the impact of IPT on TB among South African gold miners, a population with a latent TB infection rate of more than 90% and high rates of HIV infection and a respiratory disease called silicosis, two of the strongest risk factors for progression to active TB. Preliminary data and mathematical modeling suggests that providing community-wide IPT for both HIV-positive and HIV-negative miners  may dramatically reduce TB disease rates.
  
• Brazil: This  study will deliver IPT to HIV-positive patients in Rio de Janeiro who are co-infected with TB and have access to antiretroviral (ARV) therapy through Brazil’s national HIV treatment program. Researchers have found that widespread use of ARV treatment in Rio de Janeiro led to a decline in TB/HIV deaths, but had no impact on overall active TB rates. This study will determine if adding IPT to existing ARV treatment will reduce active TB rates, which would help slow the spread of TB.

Throughout the course of the studies, CREATE’s policy and advocacy team, which includes representatives from the World Health Organization and the Stop TB Partnership, will work to ensure that research findings are quickly disseminated to public health officials and translated into new, more effective TB control strategies.

Dr. Gayle emphasized that while CREATE’s research could lead to important progress on controlling the joint epidemics, additional resources and increased collaboration among the TB and HIV communities are urgently needed to support further research and expand access to appropriate interventions.

"Anyone who is concerned about HIV/AIDS must also be concerned about TB, because the two diseases go hand in hand," said Dr. Gayle. "I’m optimistic that researchers, policymakers, and funders around the world will recognize the need to alleviate the tremendous burden of these linked epidemics."

Institutions participating in CREATE include the Johns Hopkins University Center for Tuberculosis Research, the London School of Hygiene and Tropical Medicine, Aurum Health Research in South Africa, the University of Zambia, South Africa’s Stellenbosch University, the Municipal Health Secretariat of Rio de Janeiro, the World Health Organization, and the U.S. Centers for Disease Control and Prevention.