Disease Prevention and Control / Communicable Diseases / Tuberculosis
Guidelines for Implementing Collaborative TB and HIV Programme Activities
(World Health Organization Stop TB Department and Department of HIV/AIDS, 2003)
Full Text (86 pp, PDF,
List of abbreviations
The dramatic spread of the HIV epidemic throughout sub-Saharan Africa in the past decades has been accompanied by up to a fourfold increase in the number of TB cases registered by national TB programmes (NTPs). The incidence of TB is also increasing in other HIV epidemic countries, where populations with HIV infection and TB overlap. Even those few countries with well-organised NTPs have an increase in TB cases. This suggests that TB control will not make much headway in HIV prevalent settings unless HIV control is also achieved. TB is a common, treatable HIV-related disease and a leading killer of PLHA. As a consequence of all these issues, there is a strong need for close collaboration between HIV/AIDS programmes and TB programmes. This is necessary to implement the World Health Organization-recommended DOTS strategy for TB control and to improve care for people with HIV and TB.
Statistics show that very few countries in sub-Saharan Africa are fully implementing the DOTS strategy, achieving country-wide coverage and global WHO targets of 70 % case detection rate and 85 % cure rate. However, these statistics to not take into account the increased TB mortality in high HIV prevalent populations to accurately determine the performance of a DOTS programme. Comprehensive TB and HIV care and prevention rely on full implementation of the DOTS strategy as part of wide-ranging HIV/AIDS care and prevention programme as well as collaborative TB and HIV programme activities. These activities must not only be acceptable, feasible and affordable but also be a part of a strengthened national health service. The emphasis on collaborative TB and HIV activities should be the logical progression of an effective national DOTS programme.
The main aim of the guidelines is to enable the central units of national TB and HIV/AIDS programmes to support districts to plan, coordinate and implement collaborative TB/HIV activities. The guidelines are intended for countries with either an overlapping TB and HIV epidemic or where there is an increasing HIV rate which may fuel the TB epidemic.
The WHO "Strategic Framework to Reduce the Burden of TB/HIV" provides the evidence base for these guidelines. The guidelines are designed to implement the interventions as described in this framework. The guidelines reflect lessons learned from TB/HIV field sites including ProTEST with experience from comprehensive TB/HIV health services and interventions.
The guidelines are structured in line with the main theme of putting these interventions into action: what to implement, how to implement it and by whom.
The health situation is urgent and requires a move away from small scale, often costly and time-limited pilot projects to phased implementation of collaborative TB/HIV activities. Phased implementation will build on experience learned form ProTEST pilot sites. Human and financial constraints make phased implementation necessary.
These guidelines recognise that TB/HIV care and support is a fast-moving field where evidence for fully informed decision-making is currently incomplete. A small number of countries have embarked on the early phases of collaborative activities, and lessons will continue to emerge from these sites. A report from the ongoing ProTEST sites (in Malawi, South Africa and Zambia), will sum up the lesson learned so far and will be available in early 2003.
However, analysis of national TB and HIV/AIDS programmes, and emerging experience from collaborative TB/HIV sites shows that there are many unexploited potential synergies between TB and HIV/AIDS programme objectives and activities. Therefore, these guidelines suggest ways forward for collaboration between HIV/AIDS and tuberculosis programmes for implementing TB/HIV joint activities in support of local health services. It is expected that this will generate further evidence to build on phased implementation of collaborative TB and HIV activities at a country level. These guidelines will be updated, as new evidence of efficiency, affordability, feasibility and cost-effectiveness of TB/HIV interventions becomes available.
These guidelines also show how necessary collaborative TB/HIV interventions are at different levels of the health care system. Interventions depend on the human and material resources available. The TB/HIV interventions are outlined for the home/community, primary and secondary levels. However, some interventions requiring specialist management at tertiary level are not described in these guidelines. Interventions applicable at primary and secondary levels of the health system are also applicable at tertiary level.
Many of the activities described in the following pages can be implemented by using the existing resources of district TB and HIV service providers and without new external financing. However, other activities will require greater human and financial resource investments. This document does not directly estimate the costs of interventions. Cost and cost-effective analysis of the existing pilot projects is currently being undertaken. However, tasks and steps required at national and district levels are described to enable establishing the cost of interventions and resources. In fact, national and district planners should estimate the cost of the interventions and evaluate the human resources required, as an essential component of a joint TB/HIV workplan.
These guidelines reinforce current medical understanding, that highly active antiretroviral treatment (HAART) has decreased TB incidence of people living with HIV/AIDS. However, the vast majority of the 40 million people living with HIV/AIDS in developing countries do not have access to HAART. It is hoped that these guidelines, in conjunction with WHO's publication, "Scaling up antiretroviral therapy in resource-limited settings-guidelines for a public health approach", will contribute to the development of models to deliver HAART, building on the collaboration between the HIV/AIDS and TB programmes.
The guidelines are comprehensive if not exhaustive, giving an overview of the range of activities that could be undertaken in high burden TB/HIV countries or where a rising prevalence of HIV might fuel TB. Although generic they can be adapted for regions and countries according to their own needs and resources.
The activities outlined include comprehensive care, prevention and support for adults living with HIV/AIDS. TB treatment and prevention forms one part of these activities. In recognition of this fact, these guidelines have been co-produced by the Stop TB Department and the Department of HIV-AIDS of WHO. This document has been developed in consultation with the Controlling Sexual Transmitted Infections Team in the Department of Reproductive Health and Research.
HIV-related TB remains overwhelming an adult infection. The number of people infected with HIV-related TB worldwide is of serious concern. Although child infection with either disease contributes little to the spread of either TB or HIV, it is strongly believed that children will benefit directly from the implementation of the activities described in these guidelines.