The rise and fall of tuberculosis in Malawi: associations with HIV infection and antiretroviral therapy

Abstract

ObjectivesSince 1985, Malawi has experienced a dual epidemic of HIV and tuberculosis (TB) which has been moderated recently by the advent of antiretroviral therapy (ART). The aim of this study was to describe the association over several decades between HIV/AIDS, the scale‐up of ART and TB case notifications.MethodsAggregate data were extracted from annual reports of the National TB Control Programme, the Ministry of Health HIV Department and the National Statistics Office. ART coverage was calculated using the total HIV population as denominator (derived from UNAIDS Spectrum software).ResultsIn 1970, there were no HIV‐infected persons but numbers had increased to a maximum of 1.18 million by 2014. HIV prevalence reached a maximum of 10.8% in 2000, thereafter decreasing to 7.5% by 2014. Numbers alive on ART increased from 2586 in 2003 to 536 527 (coverage 45.3%) by 2014. In 1985, there were 5286 TB cases which reached a maximum of 28 234 in 2003 and then decreased to 17 723 by 2014 (37% decline from 2003). There were increases in all types of new TB between 1998–2003 which then declined by 30% for extrapulmonary TB, by 37% for new smear‐positive PTB and by 50% for smear‐negative PTB. Previously treated TB cases reached a maximum of 3443 in 2003 and then declined by 42% by 2014.ConclusionThe rise and fall of TB in Malawi between 1985 and 2014 was strongly associated with HIV infection and ART scale‐up; this has implications for ending the TB epidemic in high HIV–TB burden countries.

Scale-up of ART in Malawi has reduced case notification rates in HIV-positive and HIV-negative tuberculosis

“…First, our initial reports from Malawi on the pronounced inverse correlation between the national scale-up of ART and national TB case notifications are confirmed. 10,12 As ART coverage increases, the absolute …”

“…[4][5][6][7] At the programme level, although PLHIV are often initiated late on ART and with low CD4 counts, studies from Malawi and Swaziland have shown that when high ART coverage rates are reached among HIV-infected populations, the TB case notification rate (CNR) decreases. [8][9][10][11][12] In a study from Malawi reporting data up to 2012, there was some preliminary evidence to suggest that while the declines in TB were most apparent in those with HIV infection, there might also be a decline in patients who were HIV-negative. 10 This led to suggestions that the overall decrease in HIV-associated TB in the community might have led to reduced community transmission of M. tuberculosis and thus fewer cases of TB in the non-HIV-infected population.…”

Early infant diagnosis and outcomes in HIV-exposed infants at a central and a district hospital, Northern Malawi

“…18 Health care is provided free of charge in the public sector throughout the whole country for all diseases. Since AIDS was first recognised in Malawi in 1985, 19 the country has suffered from a severe HIV/AIDS epidemic, with an HIV prevalence of 11% in the general population and 8% among pregnant women. 20,21 Total fertility is high, at 4.4 children per woman.…”

Ending tuberculosis by 2030: can we do it?

“…24 In the high HIV-TB burden setting of southern Africa, achieving universal access to ART should be effective in reducing TB incidence. 25 Implementing preventive treatment for latent tuberculous infection (LTBI) is necessary to reduce the number of people who develop active disease. However, this is hampered by technical problems, unresolved scientific uncertainties, and unclear service delivery approaches.…”