TUBERCULOSIS AND HIV-EXECUTIVE SUMMARY.pdf

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extracted text: CI/CIDSE Conference on Tuberculosis and HIV
The Challenge of Cure and Care
9th till 11th of March 1999, Wuerzburg, Germany

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Edited by
Medical Mission Institute
Unit for Health Services and HIV/AIDS
Salvatorstrasse 22
D-97074 Wuerzburg, Germany
Tel:
+ 49 931 804850Fax: +49 9318048525.
Email: mi.health@mail.uni-wuerzburg.de

"Table oe Qcfi'j'EMs
l.

TB and HIV, the Challenge for Church Mission of Healing....................................................... 3

2.

Involvement of CARITAS and CIDSE organisations in TB and HIV..................................... 4

3.

The Magnitude of the Problem........................................................................................................... 4

4.

Important Medical Aspects of Tuberculosis.................................................................................... 6

5.

Interactions between TB and HIV Programmes............................................................................ 7

6.

Practice and Potential for Community Care Organisations....................................................... 7

7.

Points Raised in the Presentations..................................................................................................... 8

8.

Resume of the Conference on TB and HIVIAIDS...................................................................... 11

9.

Summary of the Outcome of the Working Groups...................................................................... 12

10.

Annexes.................................................................................................................................................. 13

i

i. TB and HIV, the Challenge
for the Church’s Mission of

TB and HIV/AIDS are problems which are not
just additive, but augment the negative effects
which each problem imposes on the human
family. The HIV epidemic spurs the spread of
TB and increases the TB risk for the whole
population. For example, in Malawi the number
of TB cases increased from 5300 in 1985 to just
over 20 000 in 1996, of which about 60% are
attributable to HIV. One third of the world-wide
increase in the incidence of TB in the last five
years can be attributed to HIV. The World Health
Organisation (WHO) By the end of the century,
an estimated 15 percent of TB cases will be
attributed to HIV. estimates that, by the end of
the century, HIV infection will annually cause
nearly 1.5 million cases ofTB diseasethat would
not have occurred otherwise. TB is the leading
cause of death among people who are living with
HIV. It accounts for almost one-third of AIDS
deaths world-wide, 40 percent of AIDS deaths
in Africa and in Asia. Of nearly 31 million people
world-wide who were HIV-positive in 1997,
around one-third were believed to be infected
with TB. In 1993, WHO took an unprecedented
step and declared TB a global emergency, so great
was the concern about the modern TB epidemic.

Healing
The growing epidemic of human immune
deficiency virus (HIV) has breathed new life into
an old enemy - Tuberculosis (TB). In both
developing and industrialised countries, TB has
re-emerged as a serious health problem since the
early eighties. Upto 70 percent of young adults in
developing countries and fast developing countries
are infected with Mycobacterium Tuberculosis, the
germ causing the disease. They all carry a risk of
getting ill during their lifetime. TB kills more
youth and adults than any other infectious disease
in the world today. It is a big killer comparable to
malaria, diarrhoea or HIV/AIDS. More than
100.000 children die of TB each year.
The increase in the last two decades can partly
be attributed to the following general factors, the
growing migration from countries or settings
where TB is common, the transmission of TB in
situations of crowding (e.g. health care facilities,
correctional facilities or shelters for the homeless,
community housing), a deterioration of the health
care infrastructure and the HIV/AIDS pandemic.

Since the late sixties, concepts of efficient TB
control programmes have been outlined. There
is no doubt that a number of interventions are
known by which TB patients can be cured and
the epidemic can be controlled. At the end of the
second decade of the global spread of HIV, many
lessons have also been learned with regard to
HIV, in particular how to assure prevention and
care for the infected and affected. Just to mention
a few: there is blood transfusion safety, IEC
(information, education, communication),
prevention and control of sexual transmitted
infections, treatment of opportunistic infections,
voluntary testing, counselling and home based
care. There is no doubt that causal factors for
TB and HIV are linked. Therefore, there is an
urgent need to work out synergistic strategies.

As more specific causes of the world-wide
increase in TB mainly related to the health sector.
experts also identified non-compliance with
control programmes, inadequate diagnosis and
treatment, ambulatory and self-administered
treatment as contributing to the problem. This
may lead to situations where TB becomes
incurable, in particular when drug resistant
species of the TB germ are causing the infection.
Figure 1: Global Spread of Drug resistant
Forms of Tuberculosis

The Church feels challenged by its mission to
address the issue, that ‘despite the fact that tools
for curingTB exist’, they do not reach the people
most in need. Further questions can be raised,
such as, “What are the causes and the impact of
the TB and HIV pandemic on societies and the

3

work of the Church? What are her role and her
responsibilities in respect of the socio-medical
services she is offering? In which way should
they be developed in the future, to be able to give
both a relevant as well a significant response?”

2,

The Involvement of
CARITAS and CIDSE
Organisations in TB and HIV

Caritas Internationalis (CI) has 154 national
member organisations throughout the world. The
se are engaged in relief, development and social
work. CIDSE has a membership of 16 agencies in
the more affluent countries of the world. These
organisations fund development projects in
countries of the South. What the two networks have
in common is that they are both rooted in the Ro
man Catholic Church. Both are committed to the
preferential option for the poor and both have been
active in the field of HIV/AIDS for many years.

Being rooted in the Catholic Church determines
the way of approaching HIV and TB. The Church's
vision which has emerged from the Second Vatican
Council is to take the essential tasks rooted in the
Gospel - leaching, healing and social service and to think of them in terms of a Church at the
service of society as a whole. Therefore, nothing
which affects human life is alien to the Church
and its agencies - including illnesses which touch
on the double taboos of sex and death. The
preferential option for the poor means that, in the
words of the Holy Father in the Jubilee Letter.
‘Tertio Millennio Adveniente’, we must "raise our
voices on behalf of all the poor of the world",
particularly the most excluded and those at the
lines of rapture in society, because that is where
Christ is and where His Church must be.
By taking this option for the poor seriously. Cl
founded a Working Group on HIV/AIDS more
than 10 years ago, and later founded an AIDS
Funding Network Group (AFNG) which includes
CIDSE agencies in order to co-ordinate the
response of partner agencies in the North with
the challenges of AIDS in the South.

In October 1996, the AFNG discussed the
necessity of reflecting on appropriate concepts

regarding support of projects in relation to TB
and HIV. Two general observations were made.
First of all. TB largely determined the health
needs of beneficiaries of those projects and
secondly, in very many settings the referral of
patients with TB to appropriate health service
structures posed a huge problem. According to
experiences in several projects, the co-effects of
TB and HIV threatened the success of
programmes and led to the setting up of parallel
structures competing for scarce resources.
In further discussions, it became clear that the
support and funding guidelines for programmes
with a TB component varied widely among the
said organisations. There was, for instance, no
consensus on criteria for minimal quality
assurance of projects. It was therefore decided to
study the dimensions of the problem and the
constraints mentioned during a 3-day conference.
Rev. Dr. Jon Fuller. SJ, Ms. Colette Niclausse and
Dr. Klcmens Ochel as members of the CI AIDS
Task Force and delegates in the AFNG formed
the organising committee. The Medical Mission
Institute in Wuerzburg was asked to host the venue.
Caritas and CIDSE organisations from the North
provided the resources and invited their partners
from developing and fast developing countries.
The 90 participants came from 36 countries, half
of them from the ‘South’ and Eastern Europe.

The conference-“TB and HIV-The Challenge
of Cure and Care” - aimed at contributing to a
more adequate and improved response in the
context of the Church’s development aid and the
Christian mission of healing. Through
presentations by experts in the field of TB and
HIV. the sharing of concrete project experience
and support policies of donor organisations, the
commitment of CI/C1DSE organisations and
their partners to future TB and HIV work was to
be enhanced.

3.

The Magnitude of the
Problem

The historical development of the HIV epidemic
has been well documented e.g. by the United
Nations co-sponsored programme on HIV/AIDS
(UNAIDS). It issues regular updates on

The TB germ, M. Tuberculosis, is highly prevalent
tn much of the developing world and in poor ur
ban parts of industrialised countries. In these
communities, people typically become infected in
childhood, but a healthy immune system usually
keeps the infection in check. In the past, before
Ute era of HIV, only 5 to 15% “carriers" of TB
bacilli ever developed active tuberculosis. TB
germs are spread through the air from patients with
active pulmonary' tuberculosis. For people living
with HIV and TB. the risk of developing active
TB is 30 to 50 fold higher than for people infected
with TB alone. Over the next four years, the spread
of HIV will result in more than 3 million newTB
cases among both HIV-positive and HIV-negati
ve people.

prevalences for each country and for various
population groups. Latin America saw early cases
in the eighties and rates have risen gradually
since. Africa has rapidly become the continent
with the highest prevalences and the peak of the
epidemic has drifted southwards over time. Asia
remains the most frightening prospect for the
future; the epidemic arrived a little later than in
Africa but has risen in a few countries and the
population is so large that small percentage
increases mean that huge numbers of people are
affected. While two thirds of the 33 million
people with HIV live in sub-Saharan Africa, the
epidemiology of HIV is characterised by its focal
nature (State; end of 1998). Thus, within the subSaharan region, there is a more than 10 fold
difference between countries, and. within
countries there is often considerable variation
between provinces or between rural and urban
areas. Even within one city there may be
considerable variation between apparently
similar residential areas.

Three million people throughout the world die
of TB annually, one third of them in Asia. The
highest mortality rates have been documented in
Africa where 91-100 persons per 100,000 die of
TB. That means that every twentieth death is
caused by TB. TB is the cause of 7% of all deaths
in developing countries. It is assumed that 26%
of TB deaths in adults could be prevented.

With regard toTB, two billion people are infected
with TB bacilli world-wide. More than four
million persons are estimated to become infected
with both TB and HIV per year, of whom 80%
are living in developing countries. While the
epidemiology of HIV is focal in nature, TB is
more evenly distributed across the poorer
countries of the world. More than half the global
burden of TB occurs in four highly populous
countries: India. China, Indonesia and
Bangladesh.

The average prevalence of TB infection in
countries of sub-Saharan Africa is reported to be
40-50% in the age group 15 to 49 years. Rele
vant studies in Uganda, Rwanda and in the
Republic of the Congo (formerly Zaire) reveal
an infection rate of 60 to 100% in adults among
the above-mentioned age groups. Incidence
(number of new cases per year) as well as
prevalence (number of cases alive at any time)
of TB show a five to ten times higher figure in
developing countries compared to industrial ones
and are continuing to rise. A doubling of figures
was found in Uganda within a period of 4 years.
Although factors like war, poverty, malnutrition,
overpopulation and alcoholism are important in
the promotion ofTB, the spread of HIV infection
is the most important risk factor in developing
countries. It is said that HIV infection resulted
in an additional 150,000 TB deaths in Africa
alone during 1990. The number of sputum nega
tive cases is rising. In Africa, 20% of TB cases
in the HIV infected are sputum negative, and in
Asia it is said to be one quarter of all cases. This
is important because diagnosis and treatment of
those patients are very difficult.

Annually, nine million people fall ill with active
TB, two million in Africa alone. Nearly 3 million
TB cases per year occur in South-east Asia per
year, and over a quarter of a million TB in Eastern
Europe. It is estimated that at least 8% of all TB
cases world-wide show a connection to HIV
infection. Of the 15.3 million people estimated
to be infected with HIV and Mycobacterium
Tuberculosis at the end of 1997. 11.7 million (76
percent) lived in sub-Saharan Africa. HIV
infection accelerates the development of active
TB and its course. Active TB increases the
morbidity and fatality of HIV infected persons.
The incidence of TB is expected to rise from 10.2
million cases by the year 2000 to 12 million by
2005.

5

4.

The emergence of strains of Mycobacterium
Tuberculosis that are resistant to antimycobacterial agents is a world-wide problem.
The WHO and the International Union Against
TB and Lung Diseases (IUATLD) have
established a global project of drug resistance
surveillance that is based on standard
epidemiological methods and quality control
through an extensive network of reference
laboratories. The highest rates of multi-drugresistant TB have been reported in Nepal (48%),
Gujarat State, India (33,8%), New York City
(30,1%), Bolivia (15,3%) and Korea (14,5%),
Only sporadic data from countries in the Eastern
European region are available, but case studies
in congregate settings in the Baltic States and
Russia have produced frightening results. MDRTB is caused by inconsistent or partial treatment,
e.g. when patients do not take all their medicines
regularly for the required period because they
start to feel better, when doctors and health
workers prescribe the wrong drugs or the wrong
combination of drugs, or when the drug supply
is unreliable.

Important medical Aspects
of TB

TB is a contagious disease, which spreads
through the air. Only people who are sick with
pulmonary TB are infectious. Tubercle bacilli can
only be made visible in sputum smears under the
microscope by acid fast staining. Therefore, other
names are used such as acid fast bacilli (AFB)
for Mycobacterium Tuberculosis or “smear po
sitive" or “sputum positive” cases for patients.
When infectious people cough, sneeze, talk or
spit, they propel TB germs known as bacilli into
the air. A person needs only to inhale one of these
to be infected. The probability that TB will be
transmitted depends on the infectiousness of the
person with tuberculosis, an environment in
which exposure occurs, and the duration of the
exposure. Persons of the highest risk of becoming
infected with Mycobacterium Tuberculosis are
close contacts, particularly children. Infection
rates usually range from 21 % to 23 % for the
contacts of infectious TB-patients. HIV infected
persons with TB disease are not considered more
infectious than non-HIV-infected persons with
TB disease, although HIV-infected patients are
more vulnerable to becoming infected with TB
and to developing tuberculosis after exposure to
TB than are non HIV-infected persons. Left
untreated, each person with active TB will infect
on average between 10 and 15 people in each
year. But people infected with TB will not
necessarily develop the disease. The immune
system ‘walls off’theTB bacilli which, protected
by a thick waxy coat, can lie dormant for years
and years. If someone’s immune system is
weakened, the chances of getting sick are greater.
Some medical conditions increase the risk that
TB-infection will progress to disease. The risk
is approximately three times greater among
diabetics and up to more than one hundred times
greater among people with HIV-infection. Other
predisposing conditions include substance abuse
(esp. drug injection), recent infection with M.
TB (within the past two years), findings sugge
stive of previous TB (in a person who received
inadequate or no treatment), prolonged
corticosteroid therapy, cancer of the head and
neck, renal diseases, chronic malabsorption
syndromes and low body weight.

Figure 2: Fate of Cases of Pulmonary
Tuberculosis under various Treatment Pro
grammes

Source: Styblo, 1986

From a public health perspective, poorly
supervised and incomplete treatment of TB is
worse than no treatment at all. When people fail
to complete standard treatment regimens or are
given the wrong treatment, they may remain
infectious at the time that the bacilli in their lungs
develop resistance to anti-TB drugs. People
infected by them will have the same drug
resistant strain. Drug-resistant TB is more
difficult and more expensive to treat, and more
likely to be fatal. In industrialised countries, TB

6

treatment costs around US 52,000 per patient,
but rises more than 100-fold to up to US $250,000
per patient with MDR-TB. Up to 50 million
people may actually be infected with drug
resistant TB. There is no cure affordable to
developing countries for some multidrug
resistant (MDR) strains, defined as resistant to
the two most important drugs, isoniazid and
rifampicin.

5,

The health sector reform, which is currently taking
place in low or middle income countries following
the implementation of structural adjustment
programmes, advocates the use of rational
measures aimed at increasing efficiency of health
services. However, the negative effects on natio
nal TB control programmes in many countries
underline that cuts in governments’ social budgets
have had the effect of favouring the development
of the private medical and pharmaceutical sector,
rather than rationalising the choice of priorities.
The emphasis on cost recovery in basic health
services is penalising the poorest groups, most
vulnerable also forTB and HIV.

Interactions between TB
and HIV Programmes

When the estimates of adult HIV prevalence are
plotted against the Global TB Programme’s
estimated TB incidence for African countries, a
striking relationship can be seen. None of the
countries severely affected by HIV have been
successful in keeping TB rates down. In these
countries, 60-70% of TB cases are also infected
with HIV. In countries with severe HIV
epidemics, it is not possible to control TB without
controlling HIV.

6,

Practice and Potential for
Community Care
Organisations

In developing and fast developing countries there
is a need to explore new ways of providing care
for TB patients based on community
participation. Community participation is a
process by which individuals and families
assume responsibility for their own and their
communities’ health and welfare, and develop
the capacity to contribute to their and the
community’s development. Providing care for
TB patients in the community with the aim to
contribute to their cure has the potential to reduce
patient load on hospitals and health centres,
decrease costs to patients and their families,
improve adherence by making treatment more
accessible, and reduces the risk of nosocomial
transmission to health care workers and other
patients.

HIV has adversely affected TB control
programmes both directly (through increases in
the number of patients to take care of and by
making diagnosis more difficult), but also
indirectly through its negative effect on health
seeking behaviour and on the interaction between
patient and provider at the health services. The
control of TB in areas with a high prevalence of
HIV infection is therefore, to a considerable
degree, dependant on the success of the HIV
control programme.

TB diagnosis and treatment are vital components
of any HIV care program. Considerable
opportunities exist for synergy between TB and
HIV programmes. The decentralisation and
increasing autonomy of districts that the health
sector reform is bringing to many countries
should be used as an opportunity to enhance the
concerted management of the dual epidemics.
Possible actions include: training; community
care; IEC manuals and guidelines; advocacy;
surveillance; collaboration with NGOs; social
mobilisation.

However, it is not an approach which can be
applied easily. According to a study by WHO in
1997, the provision of TB care offered by
community based organisations fell short of
internationally recommended standards in most
of the community care organisations assessed.
Obstacles were identified that undermined the
provision of adequate care: the charitable and
compassionate attitude to provide moral support
and palliation for an incurable disease, as well
as the lack of knowledge and the fear of TB, and
the failure to recognise its clinical and
7

TB. in particular the necessity to cure patients.
The counter effects of well meant, but inefficient
treatment not respecting medical standards, is
disastrous not only for the individual but for the
community, particularly by aggravating the
epidemic and the suffering of humans.
According to him. solutions to existing
difficulties lie mainly in a mobilisation of
manpower and resources, both in industrialised
and developing countries, to implement the
Directly Observed Therapy strategy (DOTs)
recommended by WHO. In industrialised
countries, political commitment to assure
effective treatment to all who need it. should be
renewed, some specialised clinics should be
maintained where they are needed, the search
for new drugs should be actively supported and
adequate measures taken to limit the diffusion
of resistant tubercle bacilli. In developing
countries, all influential personalities including
public health managers and politicians should
understand that successful completion of
therapy - in other words the cure of patients is the responsibility of the provider who
undertakes to treat TB patients, and that
chemotherapy can be successful only within the
framework of the overall clinical and social
management of patients and their contacts. The
absolute need for a regular supply of drugs and
lor the patients to really swallow all prescribed
drugs at an adequate dosage should be re
emphasised in all settings. The use of combined
drug formulations is strongly recommended as
well as the use of drugs included in blister packs.
The DOTs strategy recommended by WHO and
all experts in the world should be applied
because its live components are the minimal
prerequisites for a successful intervention
against TB. These five components are the
following:
• government commitment
• case detection by microscopy
• short-course chemotherapy administered free
of charge, under close control (of course, the
way to organise the control depends upon the
local facilities and may involve different
partners)
• regular drug supply
establishment and maintenance of monitoring
mechanisms of case detection and treatment
outcomes.

epidemiological importance for HIV/AIDS
patients. Further problems which arise with the
use of community health workers are
sustainability and high turnover. Ways must be
found to address the following issues:
• the establishing of close co-operation between
national TB control programmes at district
level, hospitals, health centres, and community
care organisations;
• the development of training methods and
materials for community health workers;
• training of community health workers in order
to achieve a high level of motivation and
efficiency:
• the development of a supervision system of
community health workers;
• the use of a national TB control programme
system of registration, recording and reporting
by community care organisations;
• ensuring the availability of transport for na
tional TB control programme staff who
supervise community health workers;
• the delivery, storage and supply of drugs.

7.

Points Raised in the
Presentations

Peter Godfrey-Faussett, Researcher from the
London School of Tropical Medicine and Hy
giene and External Consultant for WHO and
UNAIDS, addressed the issues of differences and
synergism between the two pandemics of TB and
HIV. He pointed out what should be the
responsibilities of and expectations from church
organisations with respect to:
• social mobilisation.
• political engagement,
• development of a long-term vision,
• complementation or strengthening of
government structures as well as the need to
collaborate with the latter,
• sharing between organisation of lessons
learned in community based work,
• promotion of technical principles.
Jacques H. Grossel. from the Faculty of
Medicine, working in the Hospital Pitie
Salpetriere in Paris and Consultant for WHO
and IUATLD, spoke about medical aspects of
8

Pierre Chaulet. former professor of TB and Lung
Diseases, Algiers University. Algeria, and a
Consultant for WHO and IUATLD, presented
issues around socio-political aspects of the health
sector in developing and fast developing
countries, in particular outcomes of structural
adjustment programmes and the health sector
relorm. He did his utmost to argue about
reviewing the uncritical, unbalanced and
incoherent integration of TB and HIV control on
primary level. A well designed programme is not
expensive to run - approximately $1 US per
capita ol population per year in developing
countries, depending on the drug regimens used,
principally due to differences in salaries. He
concluded that the promotion of lung health,
among it the control of TB. is a collective
responsibility, shared by the state, NGOs and
religious communities, the population and the
health professionals of each country. For the
health professionals involved in tuberculosis and
lung diseases, this responsibility is particularly
burdensome. According to him, between the
approaches of the World Bank and ‘Mother
Theresa', there is a whole social space to fill in
order to organise, and if necessary invent, new
institutional forms of national solidarity and in
ternational co-operation.

in a previous or present life, promiscuity.
trespassing of sexual taboos. These beliefs create
a double stigma for the patient, as (s)he is
believed to deserve the disease. Women are hit
especially hard by the accusation of sexual
looseness, as in many, if not all societies sexual
norms are much stricter for females than for
males. Even parents may withdraw from a HIV
positive adolescent or turn angry because of the
double shame brought on the family. Adults can
cope better than adolescents with such
accusations by putting the blame on others
(witchcraft is a possible explanation for any
misfortune). Fully participatory and community
based approaches of ‘information, education
communication (IEC)' activities are needed to
work on a solution.
Mara Rossi. AIDS Co-ordinator, Ndola Diocese,
Zambia, presented the programme of her diocese
as a specific example of the Church’s response.
She started by saying that the Church's mission
is none other than that of Jesus, to “preach the
good news to the poor, proclaiming freedom for
prisoners and recovery of sight for the blind.
releasing the oppressed and proclaiming the year
of the Lord's favour". The fact that people with
H1V/A1DS or TB ask fundamental questions
related to God and heaven, life and death.
forgiveness and condemnation, salvation and
eternity, underlines that we have to deal not only
with medical problems, but also with social.
psychological and spiritual/moral issues. They
present themselves not only on the level of the
individual, but also on many others like the
families, the societies and even on the interna
tional level of justice and equity. Greater
involvement to respond to these issues is needed
not only from lay people, but also from the clergy.
Finally, she stressed that the Church is already
taking a leading role in asking for debt relief and
denouncing the existing world disparity, which
is at the roots of the pandemics of TB and HIV/
AIDS. This task of being voice of the voiceless
should be intensified and shared by all Christi
ans and people of good will.

Corlien M. Varkevisser, Public Health
Consultant. Royal Tropical Institute Amsterdam,
reported on her socio-medical and
anthropological studies in respect to TB. HIV/
AIDS and leprosy. The major part of her
presentation dealt with stigma. It can be defined
as 'an attribute, an undesirable state of difference
that discredits or disqualifies the individual from
full social acceptance'. This undesirable
difference can be physical, or social, or both.
Despite the fact that there are counter forces in
society that might mitigate stigma (parents do
not easily drop a child, children, especially
daughters, do not easily drop a parent) husband
- wife relationships are more fragile, as these
relationships can be dissolved when one of the
partners is affected by any of the above
mentioned diseases. This increases social
vulnerability and leads to settings of risk
behaviour. This is reinforced by some community
perceptions about possible causes of stigmatising
diseases: punishment of God for sin committed

Jon Fuller, SJ. Assistant Clinical Professor of
Medicine. Boston University School of Medicine
and Assistant Director. Adult Clinical AIDS Pro
gram. Boston Medical Centre, gave the keynote
9

address on ethical issues in the treatment of TB.
He strongly argued for a more elaborated way of
theological thinking in that respect. He said that
there are two major themes in catholic ethical
tradition which have contributed to the specific
manner of proceeding. The two principles are
gradualism and the toleration or counselling of
lesser evil: the psychological perspective is that
of heroic generosity. The principle of gradualism
which has been developed especially in the area
of individual pastoral care is based upon the
recognition that as humans we are always in
process as we grow towards greater holiness,
maturity and personal integration. It supports
encouraging those in need of our care to take
whatever next small step is possible as they move
towards a larger, long-term goal. In respect to
the second principle, the Catholic Church has a
long tradition of ethical analysis of the question
of whether it is permissible to support an activity
that is admittedly morally wrong if doing so
could avoid an even more gravely wrong
activity. An example for this may be seen in the
legalisation and regulation of prostitution and
might be seen as a forebear to the legalisation
of certain kinds of drug use to prevent their
association with organised crime and enormous
black markets. This moral-ethical teaching leads
to the art of doing what is possible, of
recognising that all the resources that we would
like to have at hand may not be there and under
such circumstances we do what we can. At least
giving someone a piece of bread is better than
not being able to give them anything at all, that
providing pain relief and simple measures of
hygiene may not save someone’s life but they
can provide a dignified setting in which to die.
Members of the Church are conditioned to do
what ever is possible, even though that may not
be very much. Fuller pointed out that in respect
to treatment of TB the generosity and zeal to
do something must be tempered by a
consideration of the impact of our efforts not
just on an individual, but on the common good
and the public health. We have been trained that
something is better than nothing, but in this
circumstance we are shocked to realise that
nothing is better than something. Even though
brief but incomplete treatment may benefit an
individual at least temporarily, in the long run
if we are really concerned about the community,

10

non-treatment of TB is better than inadequate
treatment. He drew the conclusion that the
ethical and even spiritual lesson that has to be
learned from HIV and TB is not generosity, but
humility: to recognise our poverty if our
resources are not adequate and to face the
difficult ethical question of withholding therapy
unless and until donors and partners can
guarantee the structure to complete therapy.
Decision - makers in church programmes need
to consider a contract for donor agencies and
partners in the South not to engage in TB
therapy unless and until it will be done properly.
This problem is also mirrored in the AIDS
epidemic since the introduction of specific,
antiviral therapies. Finally, while reflecting on
volunteerism especially by people in developing
countries, he questions, what it means to ask
people to volunteer their time if -as a result their children will eat less, or will not be able
to have their school fees paid? Ethical issues
arise from the fact that “you in the North are
accustomed to volunteering from your surplus,
but those from the South have volunteered from
the little that they had to live on.”

Other presentations dealt with case studies from
programmes in Cambodia, Uganda and East Ti
mor, or outlined the point of view of CI/CIDSE
organisations in the North. Staff from the German
Leprosy Relief Association and the Medical Mis
sion Institute provided talks on lessons learned
in respect to operating TB control programmes,
supervision of laboratory facilities, aspects ofTB
control in prison and appropriate means of
prevention of TB transmission in health care
settings.
An indication that this conference was making a
difference compared to other medical
conferences was a session devoted to a
theological reflection. Fr. Enda McDonagh, St.
Patrick College, Maynooth, Ireland, and Member
of Caritas Intemationalis HIV/AIDS Taskforce,
reflected on the proceedings of the conference
by taking the stands of a theologian. He started
by saying that it was something of a shock, when
we thought that TB had been finally wiped out,
to find it coming back and to find it in this deadly
combination with HIV/AIDS, a kind of a dual
death blow as it were. This requests our

commitment and for each of us there are diffe
rent causes for involvement. If we are to think of
2000 years of Christianity, we must think that
there were 2000 years of these kinds of
commitments and causes. In particular, the idea
of development, of development of the whole
person and of the whole human community is
something that comes naturally to people who
believe in one God. who believe that God is a
loving God, who believe in one human family,
who believe that the human family was created
for fulfilment by the one God, that our
commitment to development comes naturally, or
should come naturally. In the particular situation
in which we are when focusing on health care,
we see that the healing work itself is deeply
rooted in our understanding of God’s relations
with humanity. God’s commitment to the healing
and transformation of humanity and the world
was Jesus’ mission, Jesus’ commitment, Jesus’
cause. He created a new human community by
attending first of ail to the ill. to the hungry, to
the so-called sinners, to the excluded, to the poor.
But one of the essential features really was, that
he established a community of equals. This was
part of the thrust of the strategy of God becoming
one, of Jesus seeking out the deprived and the
excluded so there would be no doubt about the
equality of relationship or partnership that would
be established. If we stress the need to co-operate,
it means that we co-operate with one another and
we co-operate in the service of the different
dimensions of each community and each person,
so that this kind of integral vision of the person
and integral service of the person is typified now
by bringing together TB and HIV/AIDS. This
is part of the kind of bonding which involves
inclusivity, participation in the area we are
talking about, and it is the bonding that was
established between God and humanity,
between God and creation, at the price of the
life and death of Jesus Christ. The God who
bonded with us and with creation is now
enabling us to bond with the people in this kind
of distress and the people who would serve
them. We must be aware that there is a resource
of love and healing that we will need to attend
to. But it is that alertness to the final mystery of
these particular people - and the mystery of
sustaining them and healing them, of
transforming them - that seems to give a furt
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her and richer quality to how we respond to
people with HIV/AIDS or TB. As we do that,
we come into that presence and power of the
mystery we call God. There are risks involved,
like transmission of the TB germ while caring
for patients. These are risks that have to be
shared and risks that have to be reduced. The
risk, that God has taken by his incarnation, is
part of what enables us to move out of ourselves.

8.

Resume of the Conference
ON TB AND HIV/AIDS

There is no doubt that both the TB and the HIV/
AIDS pandemic pose a challenge to the specific
mission of the Christian Churches. But before
coming to concrete responses, the general context,
which will be present in the future, can be
summarised as follows: all people involved will
continuously be confronted with a lack of com
mitment, which is due to basic obstacles such as,
• lack of good epidemiological data on each of
the dual epidemics
• lack of professional consensus about costeffective approaches to TB control, STD
control and HIV containment and
• reluctance to monitor effectiveness (coverage
and outcome) of ongoing TB and HIV/AIDS
programmes.
HIV and TB programmes till now usually
function separately from each other. Both
infections have a mutually enhancing impact on
each other e.g. in the natural history of the disease
and thus on the respective control programmes:
• All programmes have to deal with an increased
number of patients.
• Problems arise in respect of diagnosis.
• Treatment becomes more complicated.
• Despite all efforts, morbidity and mortality
will increase.
• Stigma will be experienced by a wider group
of people. This affects health seeking
behaviour and the adherence to treatment
adversely.
• The risk of nosocomial and institutional
transmission has a negative impact on staff
motivation.

resolutions at the end. These can be summarised
as follows:
• Representatives
from
participating
organisations should present the results to re
levant bodies of the Church e.g. the Pontifical
Council for Health Care Workers, and request
that it should be distributed to all Bishops’
Conferences in the world and also to all
Catholic health institutions.
• CI/CIDSE organisations should designate a
representative international body to be
responsible for the follow-up of the
conference.
• Cl/CIDSE should have a working group on
TB/H1V/AIDS in order to publicise the
outcome of the conference. It should be put
into the Caritas work plan at the General
Assembly.
• The Working Group should bring together
both decision makers and donors.
• The Working Group should elaborate a draft
policy and an agenda for future action.
• The Working Group for Action should also
be responsible for advocacy.
• They should follow-up on priority areas in
regard to performance by bi-laterals, multi
laterals and NGOs.
• CI/CIDSE organisations need to organise
more training courses for the health workers
about these two matters.
• CI/CIDSE organisations need to draft a
development plan to support solutions for
basic problems (like lab. drug supplies, etc.)
or basic health needs.
• CI/CIDSE should have a representative at
WHO as an advocate for health issues;
• CI/CIDSE should campaign for more
equitable policies on health and development
• More efficient advocacy is also necessary
concerning the effects of globalization and
structural adjustment on the health of the poor,
particular in respect to TB and HIV.
• Support of the Jubilee 2000 debt relief
campaign should be supported.

Diagnosis and cure of TB should be a concern in
any case of symptomatic HIV infection. Despite
all constraints, considerable opportunities for
synergy between TB and HIV programmes do
exist. Decentralisation and the increasing
autonomy of districts which health sector reform
is bringing to many countries should be used as
an opportunity to enhance the concerted
management of the dual epidemics. Possible
actions include: training; community care: IEC
manuals and guidelines: advocacy: surveillance;
collaboration with NGOs; and social
mobilisation.
Real progress in controlling TB and providing
care for HIV can only be achieved with a dual
strategy targeting both epidemics: TB control
and HIV prevention. This will first require
gathering the resources needed for action. The
continuum of care model, nowadays developed
in ‘AIDS home based care programmes’ can
assure comprehensiveness, integration,
continuity and accessibility of care.
Strengthening of this model and its components
at all levels can make cure possible in many
settings which are out of reach for vertical
programmes. However, community involvement
is not a ‘magic bullet’and does not lead easily to
success. Shortcomings may arise from the
charitable and compassionate attitude to provide
moral support and palliation for an incurable
disease, the lack of knowledge, the fear of TB
and the failure to recognise its clinical and
epidemiological importance for HIV/AIDS
patients.

9.

Summary of the Outcome of
the Working Groups

To facilitate mutual sharing of experiences and
to achieve common viewpoints, working groups
have been organised during the conference. They
worked on specific questions and formulated

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io. Annexes
Table 1: Slate of performance of national TB control programmes

Countries with
Countries which made
successful
important progress
TB Control Programs
in TB Control

Countries with
Very poor performance of TB Control
Low income countries

Middle income countries

• Ethiopia
• Afghanistan
• India
• Myanmar (Burma)
• Nigeria
• Pakistan
• Sudan
• Uganda

• Bangladesh
• Brazil
• Peru
• Indonesia
• Vietnam
• Iran
• Mexico
• Philippines
• Russian Confederation
• South African Republic
• Thailand

• Armenia
• Cambodia
• Cuba
• Malawi
• Morocco
• Mongolia
• Nicaragua
• Oman
• Slowenia

Figure 3:

TB Epidemiology: si global view

WHO; 1997

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ELEr/IEl ITS OE All A'GEl WA T'O ACTIOEE
• Two representatives — one from a northern country and one from a southern country should
present the results of the conference to the Pontifical Council for Health Care and request that
it should be distributed to all Bishops’ Conferences in the world and also to all Catholic health

institutions
• CI/CIDSE organisations need to designate an international body to be responsible for the
follow-up of the conference
• Reservation: In doing the above we are concerned that a balance of power be maintained
which allows partners to fully participate in the process
• CI/CIDSE should have a working group on TB/HIV/AIDS in order to publicise the outcome
of the conference. It should be put into the Caritas work plan at the General Assembly
• Working Group for both deciders and donors
• The proposed working group should elaborate a draft policy and an agenda for action
• Working group for action plan making and for advocacy
• Select specific areas for priority attention until the year 2000
• Follow-up on these priority areas in regard to performance by bi-laterals, multi-laterals and
implementing NGOs
• Workshop to establish co-ordination between deciders and other partners like NGO’s and
Church’s institutions

• CI/CIDSE organisations need to organise training courses of the health workers about these
two matters
• CI/CIDSE organisations need to draft a development plan to support basic health problems
(lab, drug supplies) or basic health needs

• Improve communication between grass roots and international bodies regarding important
aspects of implementation and experiences
• CI/CIDSE should have a representative at WHO to advocate for health issues and also CI/
CIDSE should promote people as applicators in developing countries
• CI/CIDSE should campaign for more equitable policies on health and development
• Advocacy concerning the effects of globalization and structure adjustment on the health of
the poor, particular T/H
• Support of the Jubilee 2000 debt relief campaign.

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