E-Note # 39: Guidance to the Field on Strengthening Collaboration Between TB AND HIV/AIDS Services

In sub-Saharan Africa today, the co-infections of tuberculosis and HIV/AIDS are severely impacting economic development, and posing complex new challenges to already overburdened and poorly managed primary health care systems and social services. Not only does the African Region have the highest HIV burden with 25.3 million cases of a total of 36.1 million worldwide; but also TB is the most common opportunistic infection associated with AIDS. In addition, TB is the cause of death in 40% of AIDS patients. In Africa, HIV is the single most important factor determining the increased incidence of TB in the last ten years.

HIV fuels the tuberculosis epidemic in several important ways. HIV promotes progression to active tuberculosis in people with recently acquired TB ^[i] and is the most powerful risk factor for reactivation of latent TB infection (previously acquired infection which had never developed into disease).ii The annual risk of developing tuberculosis in a person living with HIV/AIDS (PLWHA), who is co-infected with Mycobacterium tuberculosis ranges from 5-15%; compared to a 10% lifetime risk in those who are not HIV-infected. ^[ii] HIV also increases the incidence of recurrent tuberculosis. The increasing prevalence of tuberculosis cases in PLWHAs poses an increased risk of TB transmission to the general community, as well as the HIV-infected population.

As can be seen from this data, the escalating sub-Saharan African TB case rates for the past decade are largely attributable to the HIV epidemic. Since the mid-1980s, annual TB case notification rates have risen up to fourfold in many African countries, including those with well-run TB programs. There are now some countries in sub-Saharan Africa where up to 70% of patients with active (sputum smear-positive) pulmonary TB are HIV positive. ^[iii] Tuberculosis appears to have an adverse effect on HIV progression. Some studies show that the host immune response to M. tuberculosis enhances HIV replication and might accelerate the natural progression of HIV infection to AIDS. ^[iv]

Since HIV drives the tuberculosis epidemic, prevention of HIV should be a priority for the control of tuberculosis. Conversely, tuberculosis care and prevention should be a priority concern for HIV/AIDS programs. Both programs must be made “user friendly” in order that co-infected patients are made aware of their dual illnesses, and able to obtain the treatment and support they need, in the most efficient way. This guidance is not about integrating programs, but about finding pragmatic and effective ways to collaborate to mitigate the impact of these diseases on the lives of people dually infected and affected by HIV and TB.

Guiding Principles For Strengthening TB and HIV/AIDS Services

• Facilitate dialogue between the National Tuberculosis Program (NTP) and the National AIDS Control Program that focuses on developing avenues for effective collaboration between the programs.
• Determine if DOTS strategy is offered nation-wide or only in selected pilot areas. If DOTS does not extend nationally, explore ways to assist the NTP to increase coverage areas and/or strengthen certain program components.
• Assist the TB and AIDS programs conjointly to develop minimum standard Care and Support guidelines for the home/community level, primary care level (health center), secondary care level (district hospital), and tertiary care (referral hospital).

Appropriate HIV/AIDS Care encompasses a range of support services from screening and diagnostics; counseling and psychosocial support; community education and participation; prophylaxis and treatment of opportunistic infections; management of sexually transmitted infections (STI), reduction of mother to child transmission (MTCT); pain and palliative care; and antiretroviral therapy.

This document highlights the treatment and prophylaxis of the opportunistic infection with the greatest consequences for HIV-infected individuals- tuberculosis! Missions may want to particularly consider using operations research to evaluate the impact of providing TB care and preventive services through Voluntary Counseling and Testing (VCT) Centers. (see Table below).

Prioritized TB/ HIV/AIDS Interventions By Level Of Health Care

AFR/SD/ID, G/PHN and our partners are ready to assist missions in the design of interventions to build collaboration between the TB and HIV/AIDS programs. Please let us know when and what types of technical support you may require. Contact information for more assistance is listed below.

Dr. Connie Davis
Infectious Diseases Advisor
AFR/SD/HRD
Email: cdavis@afr-sd.org
Tel: (202) 219-0474

[i] DiPerri G, Cruciani M, Danzi MH, et al. Nosocomial epidemic of active tuberculosis in HIV infected patients.

ii Rieder HL, Cauthen GM, Comstock GW, Snider DE, Epidemiology of tuberculosis in the United States. Epidemiologic Reviews 1989; 11: 79-98

[iii] Raviglione MC, Harries AD, Msiska R, Wilkinson D, Nunn P., Tuberculosis and HIV: current status in Africa. AIDS 1997; 11 (suppl B): S115-S123

[iv] Del Amo J., Malin AS, Pozniak A, De Cock KM, Does tuberculosis accelerate the progression of HIV disease? Evidence from basic science and epidemiology. AIDS 1999; 13:1151-1158

1 The delivery of TB treatment at the community level through directly observed treatment by a variety of community level staff from CHWs to traditional healers.

2 VCT Plus- the delivery of a wide range of prevention and care services using counseling and testing as the entry point to identify the PLWHA. In this case, TB care and prevention services are offered.

3 IPT- isoniazid preventive therapy provides protection to PLWH against the risk of developing tuberculosis from either recent, or reactivation of latent, TB infection. IPT requires a patient to have easy access to the clinic, able to adhere to a six month daily course, and able to be monitored for signs and symptoms of active disease or drug toxicity.