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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. ●
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