Tuberculosis and HIV--Needed: A New Paradigm for the Control and Management of Linked Epidemics

Simon J. Tsiouris, MD, MPH (corresponding author); Neel R. Gandhi, MD; Wafaa M. El-Sadr, MD, MPH; Gerald Friedland, MD

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In This Article

Current vs Alternative Care and Treatment Paradigms

Although increasing numbers of patients have both conditions, current national TB and HIV programs remain largely separate with varying levels of interaction and communication. This programmatic separation often extends through the entire health care system. While this characteristic is true of developed countries as well, the far greater resources available in developed settings can often compensate for this division and provide adequate care for co-infected patients. In resource-limited countries, however, this separation of programs results in care of co-infected patients that is often fragmented, uncoordinated, and unsuccessful. It is essential, in areas of high HIV prevalence and TB burden, that national TB and HIV programs collaborate and that care for TB/HIV co-infected individuals is integrated at the healthcare delivery level.

Encouragingly, because the leadership of these often separate TB and HIV programs is usually situated within the structure of National Ministries of Health, there is the opportunity for these latter institutions to play a critical role in establishing and strengthening a coordinated approach to both diseases thereby ensuring communication and collaboration between the 2 programs. Rwanda is an excellent example of such collaboration at the central, Ministry of Health level.[12] For effective service integration to take hold in a widespread manner at the healthcare delivery level, collaboration has to first exist at the national level. In some primary care settings, where resources are extremely limited and personnel even more so, TB/HIV collaboration and service integration does occur, but often in an unsupervised, unstructured, and therefore, suboptimal manner.

The figure depicts stylized representations of 2 different paradigms for interactions between HIV and TB programs and service delivery sites: the common current paradigm and a proposed alternative paradigm. The current common paradigm is characterized by separate and distinct programs with little coordination or overlap. The alternate paradigm emphasizes the need for increased communication, collaboration, and integration of services, in an effort to improve the care and treatment of TB/HIV co-infected patients.

Figure.

Common and alternative TB and HIV program paradigms. C&T = Counseling and Testing; DOT = Directly Observed Therapy; HIV = Human Immunodeficiency Virus; IPT = Isoniazid (INH) Preventive Therapy; LTBI = Latent Tuberculosis Infection; OI = Opportunistic Infection; Px = Prophylaxis; Rx = Treatment; TB = Tuberculosis

Achieving this alternative paradigm requires assessment of various models of collaboration and integration and their relevance to the specific setting. These models may range from maintenance of separate programs and services with enhanced communication and referral mechanisms between them to programs that partially or fully integrate the services they provide. A variety of models of collaboration and integration will be necessary to suit the diverse characteristics of a range of settings, for example, urban vs. rural, high vs. low TB incidence, high vs. low HIV prevalence. Answers to important question are needed such as: (1) at what level of prevalence of TB/HIV co-infection will integration be of most benefit, (2) how will population density affect the paradigm of collaboration and integration, and (3) how will the cost of implementing integration influence national decision-making? Ongoing efforts such as those of the National Institutes of Health-sponsored International epidemiologic Databases to Evaluate AIDS (IeDEA) study,[13] the Consortium to Respond Effectively to the AIDS/TB Epidemic (CREATE),[14] and the Zambia and South Africa Tuberculosis and AIDS reduction study (ZAMSTAR) may help answer some of these questions.

Some important progress toward increasing collaboration between HIV and TB programs and integrating services is underway. The World Health Organization (WHO) has formulated recommendations regarding collaboration and integration and has emphasized the importance of addressing TB/HIV co-infection in its new "Stop TB" strategy.[15,16] In Rwanda, screening for TB at enrolment into HIV care and treatment programs and at follow-up visits using simple symptom questionnaires is being implemented.[17] Additionally, some programs, most notably Malawi's, have already begun to adopt the public health-oriented strategies of TB care in newly developed HIV treatment programs.[18] National-level examples such as these can serve as models that other countries can adopt and implement.

Several individual projects assessing the feasibility of various collaborative and integrative efforts at the healthcare delivery level in urban and rural areas have been carried out or are ongoing. In Rwanda, integration of TB and HIV services at a district hospital increased HIV counselling and testing of TB patients and improved TB screening and case detection in HIV-infected individuals enrolled into care.[19] In rural KwaZulu-Natal, once-daily antiretroviral therapy for patients with HIV and TB is successfully being combined with the existing TB directly observed therapy program and is using community-based treatment supporters.[20] In Haiti, combined treatment of both TB and HIV has been shown to be effective both in rural settings using a community-based treatment model[21] and in urban settings using a clinic-based approach.[22] These different experiences in integration of TB and HIV care and treatment are highly encouraging while at the same time their examples highlight the technical, programmatic, staffing and scale-up challenges that remain and demonstrate that although broad program principles of TB/HIV collaboration and integration are essential, specific program components and designs will vary between and even within countries.[23]

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