Approaches to TB/HIV Integration HIV Update No 9
February 2011
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.
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.
2
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. 3
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.
4
This effectively means that a larger proportion of HIV patients would benefit from a reduced risk of developing TB disease if
WHO
Interim
Policy
on
they
started
ART
earlier
in
line
with
this
particular
Collaborative TB and HIV
recommendation. Every eligible person living with HIV should
Activities
access antiretroviral drugs before their CD 4 count falls far below 350. 4.
A Establish mechanisms for
Provision of Isoniazid Preventive Therapy for PLHIV
at high risk of TB
collaboration Isoniazid preventive therapy (IPT) increases the likelihood that a
A1 Joint coordination of TB HIV
HIV positive individual will remain free of TB disease.
at national regional, district and local levels 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.
A2 Surveillance of HIV amongst TB patients A3 Joint TB /HIV planning A4 Monitoring & evaluation
B Decrease the burden of TB
Currently, the global uptake of IPT has been low, mainly due to
in Persons living with HIV
slow policy changes at national levels as well as the fear that
B1 Intensified TB case finding B2 IPT Implementation
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.
B3 TB Infection control A recent trial conducted in Botswana by the US-based Centres for Disease Control and Prevention showed that the residual
C Decrease the burden of HIV in tuberculosis patients C1 Provide HIV testing and counselling C2 Introduce HIV prevention
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.
C3 Cotrimoxazole prophylaxis C4 HIV care and support
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. 5
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
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
Model 2: Partial integration e.g. TB and HIV services in the same facility or synchronised same day appointments
TB
HIV
Partial integration is achieved by deliberate effort by health professionals to ensure that services can be delivered on the same day.
Model 3: provision of TB and HIV services under the same roof or same provider
BOTH
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.
6
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 awarenessraising for both TB and HIV including IEC materials and campaigns are now urgently needed.
2. Program monitoring and evaluation and operational research
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.
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.
7
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.
8
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
9
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.
10
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
11