Deaths from tuberculosis in sub-Saharan African countries with a high prevalence of HIV-1

Through the efforts of WHO and partners, nearly 50% of the global population and more than 60% of the African population now has access to a directly observed therapy (DOTS) tuberculosis programme.2 Tuberculosis programmes aim to prevent infection with Mycobacterium tuberculosis and reduce the burden of disease in the community by providing high quality care to individual patients who are the major source of transmission of the infectious agent. To achieve this aim, they should take responsibility for the outcome of such patients from the time of registration until treatment has been completed. If death occurs for any reason (for example death from HIV-related disease or road traffic accident) during the course of treatment, this would be regarded as a tuberculosis death. In countries with a high HIV-burden, many tuberculosis deaths will be a result of HIV infection, but recording these deaths as actual tuberculosis serves two purposes. It recognises the enormous difficulties experienced by resource-poor countries in establishing precise causes of death, and it may persuade responsible tuberculosis programmes to broaden their remit and to consider the implications of HIV infection. In some countries in sub-Saharan Africa, more than 70% of patients with tuberculosis are HIV-positive.3 Tuberculosis programmes in the region, including many of those which have adopted WHO's DOTS strategy, have recorded rising death rates in their patients during the last 15 years. This rise is leading to loss of credibility among health-care staff, patients, and the wider community. Reducing deaths from tuberculosis will require a strengthening of tuberculosis control efforts and research focused on improving the care of HIV-positive tuberculosis patients. We would like to discuss from the perspective of a tuberculosis-control programme the type of research we believe should be done if we are to begin making any headway in reducing deaths from tuberculosis in sub-Saharan Africa.