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JOINT HIV/TUBERCULOSIS INTERVENTIONS

What are they?

Joint HIV/Tuberculosis (TB) interventions seek to promote synergies between TB and HIV/AIDS prevention and care activities.

Why it is Important

  • About a third of the 40 million PLWHA worldwide at the end of 2001 are co-infected with Mycobacterium tuberculosis. The majority of these coinfected people are in resource constrained countries.
  • TB accounts for up to a third of AIDS deaths worldwide.
  • Escalating tuberculosis case rates over the past decade in many countries in sub-Saharan Africa and in parts of SE Asia (e.g. northern Thailand) are largely attributable to the HIV epidemic. Since the mid-1980s, in many African countries, including those with well-organised programmes, annual tuberculosis case notification rates have risen up to fourfold. Up to 70% of patients with sputum smear-positive pulmonary tuberculosis are HIV-positive in some countries in sub-Saharan Africa.
  • Since up to half of people living with HIV/AIDS (PLWHA) develop tuberculosis, and tuberculosis has an adverse effect on HIV progression, tuberculosis care and prevention should be priority concerns of HIV/AIDS programmes, and HIV/AIDS prevention and care should be priority concerns of TB programmes.

How it is done?

TB and HIV prevention and care interventions are mutually reinforcing. Interventions to tackle tuberculosis among HIV-infected people can occur in the home, community and hospital/clinic. Joint TB/HIV interventions seek to 1) prevent HIV infection, 2) prevent TB, 3) provide care for PLWHA and 4) provide care for people with TB. Many potentials for overlap will occur.

Examples of joint TB/HIV interventions include:

Home care

  • Include TB case detection and care in training of HIV/AIDS caregivers (family members, volunteers, and health care workers).
  • Prevent new cases of TB among PLWHA and their families with isoniazid preventive treatment when appropriate.
  • Establish referral mechanisms between HIV/AIDS home care programmes and TB clinics.

Community care

  • Provide information and education on TB and HIV to increase community awareness of both infections and their inter-relationship.
  • Intensify tuberculosis case finding in areas of high HIV prevalence, where there are effective local TB programmes achieving good rates of successful treatment.

Hospital/clinic care

  • Increase interventions for HIV care (e.g. testing and counselling, treatment of other opportunistic infections, ART) for TB patients co-infected with HIV.
  • Increase capacity of staff in all settings to provide comprehensive care (e.g. increase ability to provide care for HIV-related illness in TB clinics as well as ability of staff providing care for HIV/AIDS to include follow-up of TB patients.

Human Resources, Infrastructure and Supplies Needed

The need for additional human resources will depend on the staffing of existing HIV/AIDS, TB and general health care services. Given the scope of the TB and HIV/AIDS epidemics, additional staff will be needed in all high HIV prevalence countries if prevention and care activities for TB and HIV/AIDS are to be augmented. Existing staff may need to be trained or re-trained to ensure that joint interventions are realized.

Several requirements are necessary for countries to implement joint TB/HIV interventions. In addition to adequate staff and training, facilities and supplies will be required (e.g. testing and counselling sites, ARV therapy, condoms, medicines to treat HIV-related infections, etc.). Research to find out how best HIV/AIDS and tuberculosis programmes can work together will be important. Coordination of activities between the National HIV/AIDS Control Programme and National TB Programme will require policies to be developed within the Ministry of Health that can then be extended to the institutional and district level.

Once in place, policies that result in collaboration between HIV/AIDS and TB programmes have the potential to yield benefits for more effective and efficient training, drug supply, case detection and management, and surveillance.

Cost Information

It is clear that joint TB/HIV interventions will clearly require additional funding to improve both TB and HIV programme performance and coverage, increase testing and counselling, prevent mother to child transmission of HIV infection, provide community home based care for people living with HIV/AIDS and provide antiretroviral treatment. It should be emphasized however, that much can be done with existing resources. Collaborative activities are possible even at present funding levels and with the use of existing resources. Costs can be minimised by targeting preventive interventions to those at greatest risk and providing care to those most in need. As new services are developed they will benefit from an integrated approach.

Key References

  • World Health Organization. Strategic framework to decrease the burden of TB/HIV. WHO/CDS/TB/2002.296, WHO/HIV_AIDS/2002.2)
  • Gilks C, Katabira E, De Cock KM. The challenge of providing effective care for HIV/AIDS in Africa. AIDS 1997; 11 (suppl B): S99-S106.
  • Grant AD, Djomand G, De Cock KM. Natural history and spectrum of disease in adults with HIV/AIDS in Africa. AIDS 1997; 11 (suppl B): S43-S54.
  • Raviglione MC, Harries AD, Msiska R, Wilkinson D, Nunn P. Tuberculosis and HIV: current status in Africa. AIDS 1997; 11 (suppl B): S115-S123.
  • Dye C, Scheele S, Dolin P, et al. Global burden of tuberculosis. Estimated incidence, prevalence, and mortality by country. JAMA 1999; 282: 677-686.
  • World Health Organization. Global Tuberculosis Control. WHO Report 2002. Geneva, Switzerland. WHO/CDS/TB/2002.295.
  • World Health Organization. Preventive therapy against tuberculosis in people living with HIV. Weekly Epidemiological Record 1999; 74: 385-398.
  • Harries A, Maher D. TB/HIV: A Clinical Manual. WHO/TB/96.200.

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