www.aidsalliance.org Supporting community action on AIDS in developing countries
Integrating TB and HIV programmes: putting Lessons learnt into Practice TB infection is very common, with roughly one third of the world’s population infected with latent (inactive or silent) TB. There are about 9 million new cases of TB every year and about 2 million deaths. There is an urgent priority to address HIV and TB together: • TB infections have a disproportionate effect on the lives of people living with HIV, for whom TB is the most common opportunistic infection and cause of death. Over the years, the HIV epidemic has eroded many of the gains in TB control. • In people who have HIV, the risk of reactivation of latent TB increases dramatically. Without HIV, the chances of reactivation are 5–15% over a lifetime; with HIV the chances become 5–15% each year. Thus people with HIV are particularly at risk from TB disease. • There is an urgent need to address HIV and TB together because the risks of TB re-infection and drug-resistant TB are also much higher in those whose immune systems are weakened by HIV. • An estimated 10% of all cases of TB disease are co-infected with HIV globally.
How can TB be integrated with HIV services? Model 1: Cross referrals between HIV and TB service points
TB
HIV
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.
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Model 2: Partial integration e.g. synchronised appointments
TB
HIV
Partial integration is achieved by deliberate effort by health professionals to ensure that or some (but not all) components of TB/HIV services can be delivered on the same day, within the same facility.* * Adapted from Chifundo et al. 2010
Model 3: Provision of TB and HIV services under the same roof/by the same staff
BOTH
TB and HIV services (counselling and testing for HIV, provision of ART, TB screening and treatment) are provided in the same room by the same staff (under the same roof).
REMEMBER! Reasons to integrate TB and HIV programmes • The two diseases often exist in the same person (or geographic region). • They both require the diagnosis and treatment of the other to achieve the best results from the treatment. • They both rely on a good drug supply. • Both treatments must be taken carefully for a long time. • Poor adherence can lead to drug resistance. • A huge additional burden is placed on both the patient and the health system if such similar diseases are treated by different people and at different locations, leading to fragmented care, cost-inefficiencies and poor continuum of care.
How to make referrals at the community level Referring organisation (health facility or community-based organisation)
Receiving organisation (provider)
Directory • Consult • Find provider
1. Screen and make referral after screening
REFERRAL FORM • Fill out Part A with patient particulars • Give to the client
M FOR RAL s to R REFE t take ien • Cl vider pro
CLIENT TRACKING FORM • Fill out • Place in client file referral register • Complete • Update REFERRAL FORM • Fill out Part B with the relevant results and findings
3. Follow up and link patient to other services
REFERRAL FORM • Review form returned by receiving organisation or client CLIENT TRACKING FORM • Update referral register • Complete • Update
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referral register • Complete • Update
2. Receive client
Integrated TB/HIV programming intrinsic to organisation Knowledge of: • TB and HIV • health-seeking behaviour of clients • stigma and discrimination around TB and HIV • policies and guidelines for TB/HIV and the role of CBOs • services available for TB and TB/HIV • referral systems
Linkages or partnerships with: • the NAP and/or the NTP • coordinating bodies • health facilities and/or local points of care
Collaborative TB/HIV activities
Capacity to: • establish good governance and clear mandates • establish referral systems • manage effectively: > human resources (including volunteers) > recruitment and retention strategies > incentives and enablers > planning and M&E > resource mobilisation > referral services • provide TB/HIV services • provide or access TA for TB/HIV
Mechanisms of collaboration for TB/HIV are: • present and functioning at all levels • offer opportunities for broad representation
Policies and guidelines on: • community TB care, TB/HIV and HIV • engagement of civil society • M&E and supervision
Capacity of national or state programmes and technical partners to: • work effectively with CBOs • provide TA, training and supervision • provide or develop jointly IEC materials • know the status of basic TB and HIV services and their accessibility • be knowledgeable about CBOs and their potential roles
extrinsic to organisation Critical objectives of an integrated TB/HIV programme 4 Promote partnerships and resource efficiency between TB and HIV 4 Advocate at the national and sub-national level for TB/HIV integration 4 Promote community awareness and action on TB/HIV 4 Address risks and vulnerabilities of specific vulnerable groups and marginalised populations 4 Reduce TB disease in people living with HIV 4 Reduce HIV disease in TB patients 4 Tackle stigma and discrimination 4 Bring about policy change at different levels to facilitate TB/HIV integration
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EXAMPLES OF COMMUNITY-BASED ACTIVITIES WHICH PROMOTE THE INTEGRATION OF TB INTO HIV PROGRAMMES 4 Community-based screening of TB symptoms (using simple verbal or written questionnaire) 4 Community-based sputum collection 4 Referrals for HIV patients for TB screening 4 Contact tracing of household contacts of TB patients 4 Tracking lost-to-follow up TB patients 4 Community-based isoniazid preventive therapy 4 TB infection control activities (hygiene, cough etiquette, MDR centres, etc.) 4 Providing TB treatment 4 Referring TB cases for treatment elsewhere 4 Community-based support for TB treatment adherence (e.g. DOTS) 4 Nutritional support for TB patients 4 Posters or educational materials with either TB or both TB/HIV messages 4 Community-based advocacy for TB or TB/HIV (e.g. to combat TB stigma) 4 BCC activities for TB/HIV 4 Providing HIV testing for TB patients
Community education Š The Alliance
About the Alliance THE ALLIANCE GOOD PRACTICE PROGRAMMING STANDARDS FOR TB GOOD PRACTICE STANDARD 1
Our organisation has in place a local TB strategy that supports the integration of TB and HIV activities.
GOOD PRACTICE STANDARD 2
Our organisation ensures that all people living with HIV have access to TB screening, and either Isoniazid preventive therapy or full TB treatment as appropriate.
GOOD PRACTICE STANDARD 3
Our organisation ensures that all people offered HIV testing are made aware of TB infection.
GOOD PRACTICE STANDARD 4
Our organisation provides information on HIV or refers TB patients for HIV counselling and testing.
GOOD PRACTICE STANDARD 5
Our organisation has in place an infection control policy to reduce the risk of TB transmission to people living with HIV.
GOOD PRACTICE STANDARD 6
Our organisation has in place strategies to address both TB- and HIV-related stigma.
GOOD PRACTICE STANDARD 7
Our organisation works with local TB organisations and our TB work is informed by the national TB programme.
For more information contact: Gitau Mburu Senior Advisor, Health Systems and Services gmburu@aidsalliance.org
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Renato Pinto Senior Advisor, Technical Cooperation Unit rpinto@aidsalliance.org
Established in 1993, the International HIV/AIDS Alliance (the Alliance) is a global alliance of nationally-based organisations working to support community action on AIDS in developing countries. To date we have provided support to organisations from more than 40 developing countries for over 3,000 projects, reaching some of the poorest and most vulnerable communities with HIV prevention, care and support, and improved access to HIV treatment. The full Alliance good practice HIV programming standards for a range of technical areas can be found at: www.aidsalliance.org/ Publicationsdetails.aspx?Id=451
International HIV/AIDS Alliance (International secretariat) Preece House, 91–101 Davigdor Road, Hove, BN3 1RE, UK Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901