Approaches to TB/HIV Integration

HIV Update No 9

February 2011

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Introduction

Tuberculosis (TB) is the single most important threat to persons living with HIV. A total of 1.7 million

people died from TB in 2009, including 380,000 people living with HIV, equal to 4700 deaths per day.

Not only is TB the largest cause of death amongst persons living with HIV AIDS, but it also has

important implications related to drug interactions and toxicity when a person is on both TB and HIV

medications. The risk of developing active TB from latent tuberculosis infection is increased 100-fold

in the setting of HIV infection. Furthermore even after a diagnosis of TB has been made, persons on

TB treatment may experience clinical deterioration due to immune reconstitution (technically referred

to as TB IRIS i.e. immune reconstitution inflammatory syndrome).

We must acknowledge that there has been some good progress in TB control globally. The

percentage of people successfully treated reached the highest level at 86% in 2008. In addition, more

than 41 million people have been successfully treated and more than 6 million lives saved from TB in

the last five years alone. However, this is a small proportion compared to the estimated number of TB

infections that occur annually, a significant proportion of which goes unreported and untreated,

resulting in thousands of TB related deaths.

In addition, the global disease burden caused by multidrug resistant (MDR) TB, a form of TB which is

difficult and expensive to treat and which fails to respond to standard first line drugs, is increasing.

Current estimates indicate that there are more than 400,000 MDR cases occurring annually and

150,000 deaths from MDR TB. It is therefore clear that the global burden of TB is high and that this

burden is especially high amongst persons living with HIV who are particularly vulnerable to TB due to

their weak immunity. The global burden of TB disease has been accelerated by the co-existence of

the HIV epidemic.

Why integrate?

The need to integrate TB and HIV is both urgent and logical, mainly due to the close interaction

between TB and HIV as well as the increasing and compelling evidence of the benefits of effective

integration. HIV and TB have many common features in terms of disease burden, epidemiological

contexts and the recommended strategic activities for their control, which include prevention of spread

of infection, case finding as well as treatment.

Summary

Tuberculosis is the most important cause of death amongst persons living with HIV. Consequently,

integration of TB and HIV is important because of the close linkages between the two diseases.

Integration of TB and HIV can be achieved using several approaches for collaborative activities at

different levels. Additionally, successful integration of TB and HIV is the first step in ensuring that

both TB and HIV responses are fully integrated into the wider health system. Although a number of

programmatic, infrastructural and human resource challenges remain, with commitment of all

stakeholders, successful integration is possible and will facilitate the achievement of the health

Millennium Development Goals.

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Also, and as noted above, TB has an important impact on people living with HIV. For instance, TB is

responsible for 23% of all HIV-related deaths in developing countries. Both TB and HIV control form

important indicators of Millennium Development Goal (MDG) number 6. The aim of MDG 6 is to

combat HIV, TB, Malaria and other infectious diseases. Consequently, addressing TB and HIV in an

integrated fashion is critical to achieving progress in this particular MDG.

In addition, there is strong evidence of benefits of TB HIV integration to both health systems (in terms

of improved cost efficiency and increased access to services) as well as clinical outcomes (in terms of

reduced deaths amongst HIV patients and greater cure rates amongst TB patients). Thus every effort

should be made to achieve some level of TB HIV integration.

It must however be noted that successful control of TB and HIV control depends on the presence of

effective health system functions e.g. vital registration, drug procurement, laboratories, human

resources, financing and so on. Consequently, integration of TB and HIV responses should also occur

within a wider agenda of integration of the two diseases i.e. HIV and TB, into the wider health system.

The World Health Organization and the Stop TB Partnership recommend collaborative activities

between TB and HIV at various levels, examples of which are alluded to in the following section.

What are the opportunities for integration?

HIV and TB can be integrated at various levels including global, national, sub-national (i.e. provincial

and district) facility as well as at the community level. TB integration into HIV programs can be

achieved through several approaches including advocacy, communication and social mobilization,

fostering partnerships, program planning and implementation as well as operational research.

1. National level

Scale up of TB and HIV collaborative activities may necessitate unification of the national TB and HIV

control programs (ideal but difficult), joint planning between the National TB and AIDS programs,

shared policies, strategies, training manuals etc. Emerging evidence shows that joint planning has

been done successfully in a number of high burden countries such as Kenya. In addition, cohort

analysis and Medical Information Systems should facilitate tracking of both the TB and HIV status of

patients. Providing basic TB and HIV training for all primary health workers, (including pre-service

training), is another critical step which ensures that every health worker is well versed with both TB

and HIV prevention and treatment skills. In order to facilitate integration at lower levels, patient flow in

facilities and referral pathways may need to be changed. In addition, regular TB and HIV registers

may need to be re-designed so that they capture TB screening, TB treatment and HIV testing etc,

depending on the context and availability of resources.

2. District and regional level

Further opportunities exist for integration of TB and HIV activities at the district level. District focal

persons (if in place) should be responsible for both TB and HIV service delivery, including

surveillance, monitoring and reporting rather than having two parallel and vertical systems for TB and

HIV.

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In practical terms this means that the existing TB or HIV coordinators or focal persons would assume

responsibility for both TB and HIV programs at the district level. In addition, tremendous progress

could be achieved if the programmatic coordination, planning, budgeting and resource allocation

could be decentralised to the district level.

3. Health facility level

There are numerous opportunities for integration of both TB and HIV disease responses in order to

ensure optimal utilization of resources as well as minimize the impact of both diseases on health

outcomes. This integration can be achieved at the programming level and ultimately at the service

provision level. Among other collaborative activities, the following offer unique opportunities for

integration and have some overlap with WHO-recommended TB / HIV collaborative activities:

1. Testing all TB patients for HIV

Since HIV testing is a key entry point to care,

confidential counselling and testing for HIV should

be offered to every TB patient and if possible at

every TB service delivery point. TB patients should

also be included in post-test support mechanisms

such as psychosocial support clubs, group

therapies and so on.

2. Screening all HIV patients for TB

HIV patients are at increased risk of TB due to their weak immune status. The incidence of TB

disease is particularly high amongst people living with HIV as compared to HIV negative persons. For

this reason, persons living with HIV should be screened regularly for TB, using simple screening

procedures as recommended by the World Health Organization or national TB programs. These may

include screening patients for chronic cough, night sweats, weight loss, previous history of contact

with a person on treatment for pulmonary TB, tuberculin skin sensitivity testing and so on. Early

diagnosis and treatment reduces the burden of TB disease at the population level.

3. Providing antiretroviral therapy early in patients with TB

Antiretroviral Therapy (ART) has been shown to dramatically reduce the incidence of TB amongst

persons living with HIV. Current evidence suggests that ART reduces the incidence of TB disease by

up to 80-90%. This is a huge benefit which should be made available to every eligible person living

with HIV. The WHO now recommends starting treatment at higher CD4 counts of 350.

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Isoniazid preventive therapy means

that a person without TB disease (but

who is at high risk) takes TB drugs

for a period of at least six months as

a preventive measure against

Tuberculosis.

This effectively means that a larger proportion of HIV patients

would benefit from a reduced risk of developing TB disease if

they started ART earlier in line with this particular

recommendation. Every eligible person living with HIV should

access antiretroviral drugs before their CD 4 count falls far

below 350.

4. Provision of Isoniazid Preventive Therapy for PLHIV

at high risk of TB

Isoniazid preventive therapy (IPT) increases the likelihood that a

HIV positive individual will remain free of TB disease.

Currently, the global uptake of IPT has been low, mainly due to

slow policy changes at national levels as well as the fear that

Isoniazid resistance could emerge as a result of widespread use

of IPT. The World Health Organization recommends provision of

IPT for 6 months to HIV persons at high risk of TB.

A recent trial conducted in Botswana by the US-based Centres

for Disease Control and Prevention showed that the residual

benefit of IPT can extend up to 36 months, and that this benefit

is largely restricted to persons with positive tuberculin tests.

Additional evidence shows that if ART is offered together with

IPT, it has an even greater protective benefit, meaning that

these two interventions can be combined to further reduce the

risk of TB disease amongst people living with HIV in settings

where there is high prevalence of both diseases.

5. Provision of Cotrimoxazole Prophylaxis Therapy to

HIV positive TB patients

Cotrimoxazole prophylaxis should be offered to persons living with HIV as per national guidelines,

including those on TB treatment. Cotrimoxazole is an important drug which reduces the risk of

opportunistic infections amongst persons living with HIV.

WHO Interim Policy on

Collaborative TB and HIV

Activities

A Establish mechanisms for

collaboration

A1 Joint coordination of TB HIV

at national regional, district and

local levels

A2 Surveillance of HIV amongst

TB patients

A3 Joint TB /HIV planning

A4 Monitoring & evaluation

B Decrease the burden of TB

in Persons living with HIV

B1 Intensified TB case finding

B2 IPT Implementation

B3 TB Infection control

C Decrease the burden of HIV

in tuberculosis patients

C1 Provide HIV testing and

counselling

C2 Introduce HIV prevention

C3 Cotrimoxazole prophylaxis

C4 HIV care and support

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In such situations, close clinical monitoring is required due to possible drug toxicities. Cotrimozaxole

prophylaxis is protective against a wide range of other bacterial infections including Q fever,

pneumocystis jeroveci pneumonia, as well as protozoa infections such as malaria.

6. Physical proximity of TB and HIV service delivery points

Often, the linkages between HIV and TB can be improved by close physical proximity of TB and HIV

service provision points. However it is important to remember that infection control is critical in such

situations because of the increased vulnerability of HIV patients to TB. Clear patient flow and referral

pathways at the health facility can often be beneficial in ensuring that there are no missed

opportunities in TB case detection as well as HIV testing and counselling. This can be achieved

through a number of models as shown below, depending on health system factors and resource

contexts.

Model 1: Cross referrals

between HIV and TB service

points

Model 2: Partial integration e.g.

TB and HIV services in the

same facility or synchronised

same day appointments

Model 3: provision of TB and

HIV services under the same

roof or same provider

TB and HIV services are

separate and TB patients and

the co-infected seek HIV testing

services, HIV care and

treatment support outside of the

TB clinic. TB/HIV services are

linked by a referral system. This

is the most common model in

many settings

Partial integration is achieved

by deliberate effort by health

professionals to ensure that

services can be delivered on

the same day.

TB and HIV services

(Counselling and testing for

HIV, ART, TB screening and

treatment) are provided in the

same room by the same staff.

4. Community level

The number of persons living with HIV is gradually increasing, partly due to the fact that the

availability of ART has prolonged the lives of people living with HIV, as well as the continuing

occurrence of new infections. Community health or extension workers need to be trained in both HIV

and TB. They need to be equipped with tools and skills to advocate for both TB and HIV responses.

TB HIV TB HIV BOTH

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Standardized short-course

anti-TB treatment is often

provided under direct and

supportive observation

(DOT) which helps to ensure

the right drugs are taken at

the right time for the full

duration of treatment.

Supportive observation can

be provided by the health

workers, designated family

members, community

resource persons or peers.

Intensified case finding, home based care, contact tracing, DOT follow up as well as defaulter tracing

for both ART and TB treatment should be performed by the same community health worker,

whenever possible. It is not necessary to have community health worker for TB and others for HIV. In

addition, support to patients on TB medications, Isoniazid Preventive Therapy, ART and

Cotrimoxazole Prophylaxis should be offered as an integrated package to both HIV and TB patients

including nutritional screening and support.

What is the Road map to achievement of MDG 6 TB and HIV indicators?

As the year 2015 approaches, every effort should be made to ensure that MDG 6 indicators including

a reduction in the burden of TB and HIV will be achieved. Integration of TB and HIV using several

approaches to include those suggested below offers a strategic roadmap towards this.

1. Advocacy communication and social mobilization

All stakeholders should scale up multi-disease advocacy

on TB and HIV. Civil society and treatment groups should

monitor their governments’ policies on TB and HIV

integration and advocate for change. Joint awareness-

raising for both TB and HIV including IEC materials and

campaigns are now urgently needed.

2. Program monitoring and evaluation and operational research

Joint program indicators for both TB and HIV should be emphasized and tracked consistently,

including program tools and registers which should track TB and HIV status, service uptake, retention

in care, adherence to treatment, Isoniazid Preventive Therapy and Cotrimoxazole Prophylaxis

Therapy. Monitoring and reporting TB treatment outcomes stratified according to HIV status especially

mortality as well as recording and reporting TB prevalence amongst HIV patients are valuable

indicators that could show the extent of integration in service provision. More collaborative operational

research and surveys are required to deal with emerging issues in HIV and TB. The important

message here is that programs should ensure that information on TB and HIV is systematically

collected, analysed and informs decision making at all levels.

3. Partnerships

Public-private partnerships continue to offer an additional platform through which private health

providers are sensitized about both TB and HIV prevention, care and treatment. Partnership with the

community has been shown to increases access and adherence to both TB and ART. Fostering

partnerships with other stakeholders including non-governmental organizations, government

institutions, pharmaceutical organizations and advocacy groups is important for successful

integration.

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What are the key determinants of success?

Epidemiological context, including HIV and TB prevalence, malnutrition, social economic factors,

geographical setting (rural versus urban), poverty and gender may influence success of integration. In

addition, the health system architecture, service availability, service access, health financing and

policy are important determinants of extent of integration. There are important programmatic,

infrastructural, and staffing challenges in many developing countries which may need to be addressed

within the wider health system in-order to facilitate TB / HIV integration. However, with strong

commitment from the political leaders, civil society, treatment advocacy groups and the community,

successful integration of TB and HIV can be achieved.

Conclusions

There is urgent need to put into place rigorous measures to integrate TB and HIV response globally,

which can be achieved at various levels and using a number of approaches. A number of

programmatic, infrastructural, and human resource challenges must be addressed through

strengthening the health systems. Communities can play an important role in supporting the

integration of TB into HIV programs by tackling stigma and discrimination, offering support to people

living with HIV and TB and strengthening community-based referrals, linkages and service provision

of both TB and HIV.

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Glossary of Terms and Abbreviations

1. AIDS: Acquired Immune Deficiency Syndrome

2. ART: Antiretroviral therapy which constitutes a combination of drugs from two or more classes

for HIV treatment

3. DOT: Directly observed therapy for Tuberculosis

4. HIV: Human immunodeficiency virus

5. IPT : Isoniazid preventive therapy is one of the key interventions recommended by WHO in

1998 to reduce the burden of TB in people living with HIV

6. MDG: Millennium development goals are eight international development goals that all 192

United Nations member states and at least 23 international organizations have agreed to

achieve by the year 2015.

7. MDR: Multi-drug resistant Tuberculosis is a particularly form of TB which is hard to treat which

is associated with resistance of Tuberculosis mycobacterium to multiply even in the presence of

TB drugs such as Rifampicin or Isoniazid.

8. PLHIV: People living with HIV

9. Q fever: Q fever is a zoonosis caused by Coxiella burnetii which can cause complications in

pregnancy.

10. TB : Tuberculosis, a contagious and airborne disease (mainly of the lungs) which is caused by

Tuberculosis mycobacterium

11. TB IRIS: Tuberculosis immune reconstitution inflammatory syndrome, which can lead to clinical

deterioration of a person on treatment for due to the improvement of the immune system.

12. WHO: World Health Organization

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References and recommended readings:

1. WHO Interim policy on collaborative HIV TB activities. 2004. WHO Geneva. Available at

http://www.who.int/hiv/pub/tb/en/Printed_version_interim-policy_2004.pdf

2. STOP TB Partnership. 2008 Global Plan to stop TB 2006-2015. Progress report 2006-2008.

Available at

http://www.stoptb.org/assets/documents/global/plan/The_global_plan_progress_report1.pdf

3. Friedland G, Harries A, Coetzee D Implementation issues in tuberculosis/HIV program

collaboration and integration: 3 case studies. J Infect Dis. 2007 Aug 15;196 Suppl 1:S114-23.

4. Gandhi NR, Moll AP, Lalloo U, Pawinski R, Zeller K, Moodley P, Meyer E, Friedland G;

Tugela Ferry Care and Research (TFCaRes) Collaboration.Successful integration of

tuberculosis and HIV treatment in rural South Africa: the Sizonq'oba study. J Acquir Immune

Defic Syndr. 2009 Jan 1;50(1):37-43.

5. Wandwalo E Kapalata N, Tarimo E Corrigan CB Morkve O Collaboration between the national

tuberculosis programme and a non-governmental organisation in TB/HIV care at a district

level: experience from Tanzania. Afr Health Sci. 2004 Aug;4(2):109-14.

6. Harris JB, Hatwiinda SM, Randels KM, Chi BH, Kancheya NG, Jham MA, Samungole KV,

Tambatamba BC, Cantrell RA, Levy JW, Kimerling ME, Reid SE Early lessons from the

integration of tuberculosis and HIV services in primary care centers in Lusaka, Zambia. Int J

Tuberc Lung Dis. 2008 Jul;12(7):773-9.

7. Conseil A, Mounier-Jack S, Coker R Integration of health systems and priority health

interventions: a case study of the integration of HIV and TB control programmes into the

general health system in Vietnam. Health Policy Plan. 2010 Nov;25 Suppl 1:i32-36.

8. Maher D Re-thinking global health sector efforts for HIV and tuberculosis epidemic control:

promoting integration of programme activities within a strengthened health system. BMC

Public Health. 2010 Jul 5;10:394.

9. Carcopino X, Raoult D, Bretelle F, Boubli L, Stein A. Managing Q fever during pregnancy: the

benefits of long-term cotrimoxazole therapy. Clin Infect Di.s 2007 Sep 1;45(5):548-55. Epub

2007 Jul 17.

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For further information please contact:

Gitau Mburu

Senior Advisor, HIV and Health Systems

e-mail address: gmburu@aidsalliance.org

Telephone:+44(0)1273 718929

International HIV/AIDS Alliance

(International secretariat)

Telephone: +44(0)1273 718900

Fax: +44(0)1273 718901

www.aidsalliance.org

Registered British charity number: 1038860