Stopping the "Syndemic": HIV and TB Co-infection

A woman and child receive TB treatment.
A woman and child receive TB treatment.


An estimated 2 billion people – one-third of the global population – are infected with tuberculosis (TB). Each year, 8.7 million people develop TB disease and more than 1.4 million people die, devastating families and communities worldwide. It is one of top five causes of death among women of reproductive age and adult women aged 20 to 59 years, killing more than 500,000 women each year. It is also the leading cause of death in people living with HIV (PLHIV).

Although TB is a global problem, it is not evenly distributed around the world: 95 percent of all TB cases and 98 percent of all TB deaths occur in developing countries. In fact, only 22 high-burden countries (HBCs) (countries with large populations that can have large infection numbers), account for 80 percent of the world’s TB cases. Half of these countries are in Asia. On the other hand, the majority of countries with the very high TB prevalence rates (infection rates based off the total percentage of population, not the number of infections) are in Africa. Africa also has the highest rates of TB and HIV co-infection.

Esther a nurse at a TB clinic in Kayole, Kenya ensures that her facility always has medicine by practicing good record keeping h
Esther a nurse at a TB clinic in Kayole, Kenya ensures that her facility always has medicine by practicing good record keeping habits.
Yvonne Otieno/MSH

HIV and TB co-infection presents a special challenge. Of the approximately 34 million PLHIV, more than one-third are also infected with TB, and 25 percent of deaths attributed to HIV (430,000) are actually due to TB. The dual epidemics of TB and HIV are particularly pervasive in Africa, where HIV has been the most important contributing factor in the region’s increasing incidence of TB over the past two decades. In some countries in sub-Saharan Africa, up to 80 percent of individuals with active TB disease are also PLHIV. The dual epidemics are also of growing concern in Asia, where two-thirds of TB-infected individuals live and where TB now accounts for 40 percent of AIDS-related deaths. Eastern Europe and the former Soviet Union have the fastest growing HIV epidemics in the world, a factor further exacerbating the expanding problem of the multidrug-resistant (MDR) TB and extensively drug-resistant (XDR) TB epidemics in these regions.

Because of the significant risk to individuals and programs, addressing TB and HIV co-infection has been identified as a high priority for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and for HIV and TB country programs worldwide. In the 2012 PEPFAR Blueprint for an AIDS-Free Generation: Roadmap for Smart Investments [PDF, 2.8MB], the first action item is to “Target HIV-associated tuberculosis (TB) and reduce co-morbidity and mortality.”


USAID is addressing the ongoing crisis of TB and HIV by working with its partners to implement collaborative TB-HIV activities in accordance with the WHO Policy on Collaborative TB/HIV Activities:

Assist in establishing mechanisms for coordination of TB and HIV and AIDS activities and services

  • Supporting the development and maintenance of country coordinating bodies at all levels
  • Supporting surveillance of HIV prevalence among TB patients
  • Supporting joint TB-HIV planning, including the establishment of each program’s roles and responsibilities
  • Supporting monitoring and evaluation through development and collection of data, development of tools to capture data and optimization of programs based on evaluations

Decrease the burden of TB in PLHIV

“We cannot win the battle against AIDS if we do not also fight TB. TB is too often a death sentence for people with AIDS.”

— Nelson Mandela

  • Supporting intensified TB case finding through symptom screening and innovative community and private sector strategies, followed by prompt diagnosis through approved technologies and treatment
  • Improving TB infection control in health care and congregate settings through the development of infection control policies, plans and guidelines that include administrative, environmental and personal protection measures to reduce transmission
  • Introducing isoniazid prevention therapy to prevent progression from TB infection to active disease

Decrease the burden of HIV in individuals with active TB

  • Providing HIV testing and counseling to all individuals presenting for TB as an entry to continuum of HIV prevention, care and support and ensuring HIV care and support during and after TB treatment
  • Introducing HIV prevention methods
  • Expanding the consistent use of co-trimoxazole preventive therapy

Initiate early antiretroviral treatment for PLHIV with active TB disease to increase survival and improve quality of life


The U.S. Agency for International Development (USAID) works closely with host countries, U.S. Government sister agencies and international partners, including multilateral organizations (e.g., the World Health Organization and the Stop TB Partnership); funders (e.g., the Global Fund to Fight AIDS, Tuberculosis and Malaria); foundations (e.g., the Bill & Melinda Gates Foundation); technical agencies (e.g., the International Union Against Tuberculosis and Lung Disease and the KNCV Tuberculosis Foundation); and research organizations (e.g., the TB Alliance) to reduce the morbidity and mortality associated with TB and TB-HIV. The collective effort of these partners has led to accelerated diagnosis and treatment. It has also resulted in successful outcomes for individuals with TB and TB-HIV. Some recent outcomes include the following:

  • With its partners, USAID has supported the introduction and rollout of GeneXpert, a new diagnostic technology that facilitates faster and more accurate diagnosis of HIV-associated TB and drug-resistant TB
  • In FY 2012, 1.5 million people with TB were successfully treated in USAID TB priority countries. In addition, initiation of MDR-TB treatment in priority countries doubled (44,000) between FY 2011 and FY 2012
  • Since 1990, the global TB mortality rate has decreased by 41 percent and is on track to reach the global target of 50 percent reduction by 2015

However, the job is far from done, as evidenced by the estimated 8.7 million new TB cases and 1.4 million deaths each year, and the number of individuals with drug-resistant TB who have yet to be identified and receive appropriate treatment.

“The unmet need is extraordinary. Those who have not already been brought into (HIV) care and treatment services, the prevention services that have not been established, as well as treatment, and both prevention and treatment for tuberculosis and malaria – these needs still sit in front of us, and we are committed to working with them over the next 3 years and beyond.”

— Ambassador Eric Goosby

Last updated: February 02, 2016

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