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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Strengthening the Parts to Strengthen the Whole

It is important to acknowledge that it may not be possible to adopt a collaboration strategy in all settings in which HIV and TB epidemics overlap. One major barrier is the current situation that TB programs face, that is, their struggle to cope with rising caseloads driven by the HIV epidemic in the setting of insufficient structural and human resources. The additional responsibilities needed to address TB/HIV co-infection (such as on-site counselling and testing for HIV and effectively addressing issues of TB transmission and infection control) may not be feasible in already overburdened TB programs in certain settings. Similarly, national HIV programs are overwhelmed by current HIV treatment scale-up efforts and by the large number of patients seeking care and treatment. They face enormous challenges, including the need to train clinical staff, establish new laboratory services for patients with HIV and secure an uninterrupted supply of antiretroviral therapy. Finally, national TB and HIV programs in many countries may have limited authority to implement collaborative models of care, either at the national or local level.

Action to overcome these barriers is urgently needed. An infusion of resources to strengthen TB programs, on the same scale as those received by national HIV programs, is critical. These resources could be used to improve TB diagnostic capabilities, especially as they pertain to HIV-infected patients, and to expand the number of trained TB treatment providers and directly observed therapy supporters. As HIV programs establish their care and treatment programs, attention to issues of TB co-infection such as active TB case-finding, must be included, because TB represents one of the most common opportunistic infections that threatens the health of patients with HIV and carries a dangerous risk of transmission of both drug-susceptible and drug-resistant TB to others, particularly those with HIV infection.[4] Lastly, the World Health Organization has advocated the creation of national TB/HIV working groups, which would have the authority to oversee increased collaboration and integration of TB and HIV programs and services at both national and local levels.

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