Opportunities and challenges for HIV care in overlapping HIV and TB epidemics

Department of Medicine, University of California, San Francisco, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 07/2008; 300(4):423-30. DOI: 10.1001/jama.300.4.423
Source: PubMed


Tuberculosis (TB) and the emerging multidrug-resistant TB epidemic represent major challenges to human immunodeficiency virus (HIV) care and treatment programs in resource-limited settings. Tuberculosis is a major cause of mortality among patients with HIV and poses a risk throughout the course of HIV disease, even after successful initiation of antiretroviral therapy (ART). Progress in the implementation of activities directed at reducing TB burden in the HIV population lags far behind global targets. HIV programs designed for longitudinal care are ideally suited to implement TB control measures and have no option but to address TB vigorously to save patient lives, to safeguard the massive investment in HIV treatment, and to curb the global TB burden. We propose a framework of strategic actions for HIV care programs to optimally integrate TB into their services. The core activities of this framework include intensified TB case finding, treatment of TB, isoniazid preventive treatment, infection control, administration of ART, TB recording and reporting, and joint efforts of HIV and TB programs at the national and local levels.

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    • "Screening HIV patients for TB was another activity, but in 3 of the studies[7,8,12], it was not routinely done for all cases but only for those who reported symptoms. This is as opposed to the intensified case finding promoted because early diagnosis and treatment of TB is still an effective control strategy[21]. Challenges include the availability of sensitive screening tools and how often to screen[23]. Improving uptake in SSA requires that barriers to these TB/HIV activities are addressed and best practices are identified and replicated. "
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    ABSTRACT: Sub-Saharan Africa (SSA) has borne the greatest burden of the tuberculosis (TB) and HIV pandemics. In attempt to halt and reverse the situation, World Health Organization-inspired policies have been adopted by many countries. However, implementing these policies have seen limited success. And few studies have been conducted to ascertain the factors influencing interventions and their implementation. This review therefore sought to use comparative analysis to determine the activities implemented, service delivery models as well as the barriers and facilitators of TB/HIV integration in SSA. Many literatures were identified and selected based on a criteria. Narrative approach was then used to review the literature. Eight articles were identified based on different TB/HIV integration programmes across SSA. TB/HIV implemented interventions were HIV screening for TB patients, co-trimoxazole preventive therapy and antiretroviral therapy for eligible HIV positive patients. Three main service delivery models with varying levels of integration were identified: referral, partial integration and full integration model. Staff shortages, poor documentation, lack of resources, irregular supply of drugs, inadequate infrastructure were barriers whereas direct supervision, standardization and mutual adjustment were identified as facilitators of integration. TB/HIV integration in SSA is feasible but the uptake of interventions has been low due to barriers arising from the local policies and other contexts. Identified facilitators can therefore be used to promote TB/HIV integration.
    No preview · Article · Nov 2015 · Asian Pacific Journal of Tropical Disease
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    • "The WHO global TB control policy endorses the directly observed treatment short course (DOTS) strategy which relies on symptomatic individuals voluntarily seeking care at health facilities as the standard strategy for case findings [1]. While passive selfpresentation of patients advocated by the DOTS strategy was shown to improve TB case detection in some high-TB burden countries like Ethiopia, Peru and Vietnam [2] [3], doubts of its effectiveness, however, emerged with the rising human immunodeficiency virus (HIV) epidemic [4]. In recent years, the rate of TB case detection has stagnated, while the rate of decline in estimated TB incidence has been slower than expected [5] [6]. "
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    ABSTRACT: Background: Nigeria ranks 10th among 22 high TB burden countries with low TB case detection that relies on passive case finding. Although there is increasing body of evidence that active case finding (ACF) has improved TB case finding in urban slums in some parts of the world, this strategy had not been implemented in Nigeria despite the pervasiveness of urban slums in the country. Objective: To assess the yield and profile of TB in urban slums in Nigeria through ACF. Methods: A prospective, implementation study was conducted in three urban slums of southeastern Nigeria. Individuals with TB symptoms were identified through targeted screening using a standardized questionnaire and investigated further for TB. Descriptive and bivariate analyses were performed using SPSS. Results: Among 16,743 individuals screened for TB, 6361 (38.0%) were identified as TB suspects; 5894 suspects were evaluated for TB. TB was diagnosed in 1079 individuals, representing 6.4% of the screened population and 18.3% of those evaluated for TB. Of the 1079 cases found, 97.1% (n = 1084) had pulmonary TB (PTB), and majority (65%) had new smear-positive TB. Children (<15 years) accounted for 6.7% of the cases. Also, 22.6% (216) of the cases were HIV co-infected, among whom 55.1% (n = 119) were females. The average number of individuals needed to screen to find a case of TB was 16. Conclusions: There is high prevalence of TB in Nigeria slum population. Targeted screening of out-patients, TB contacts, and HIV-infected patients should be optimized for active TB case finding in Nigeria.
    Full-text · Article · Feb 2015 · International Journal of Mycobacteriology
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    • "Around the world, people living with HIV have a 20-fold higher risk than people without HIV of dying from tuberculosis (TB) [1]. Active TB disease can occur at any stage of HIV infection [2], [3] and, as such, routine screening for TB during HIV care provides important opportunities to prevent, diagnose, and promptly treat the disease. Given the vulnerability of people living with HIV, prevention is especially important. "
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    ABSTRACT: With the aim of integrating HIV and tuberculosis care in rural Kenya, a team of researchers, clinicians, and technologists used the human-centered design approach to facilitate design, development, and deployment processes of new patient-specific TB clinical decision support system for medical providers. In Kenya, approximately 1.6 million people are living with HIV and have a 20-times higher risk of dying of tuberculosis. Although tuberculosis prevention and treatment medication is widely available, proven to save lives, and prioritized by the World Health Organization, ensuring that it reaches the most vulnerable communities remains challenging. Human-centered design, used in the fields of industrial design and information technology for decades, is an approach to improving the effectiveness and impact of innovations that has been scarcely used in the health field. Using this approach, our team followed a 3-step process, involving mixed methods assessment to (1) understand the situation through the collection and analysis of site observation sessions and key informant interviews; (2) develop a new clinical decision support system through iterative prototyping, end-user engagement, and usability testing; and, (3) implement and evaluate the system across 24 clinics in rural West Kenya. Through the application of this approach, we found that human-centered design facilitated the process of digital innovation in a complex and resource-constrained context.
    Full-text · Article · Aug 2014 · PLoS ONE
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