Abstract
BackgroundDespite widely acknowledged WHO guidelines for the integration of TB and HIV services, heavily burdened countries have been slow to implement these and thus significant missed opportunities have arisen.DiscussionThe individual-centred, rights-based paradigm of the SA National AIDS Policy, remains dissonant with the compelling public-health approach of TB control. The existence of independent and disconnected TB and HIV services results in a wastage of scarce health resources, an increased burden on patients' time and finances, and ignores evidence of patients' preference for an integrated service. The current situation translates into a web of unacceptable, ongoing missed opportunities such as failure to maximize collaborative disease surveillance, VCT, adherence support, infection control, and positive prevention. TB services present a readily identifiable cohort for HIV provider-initiated testing. Integrating HAART and DOTS will promote efficient usage of health workers' time and a more navigable experience for patients, ultimately ensuring increased TB treatment completion rates and MDR-TB prevention. As direct observation evolves into a more supportive, empowering experience for patients, adherence to both TB drugs and HAART will be bolstered. Little attention has been paid to the transmission of TB within HIV services. Low cost infection control interventions include: triaging patients, scheduling new and follow-up patients separately; well-ventilated, sheltered waiting rooms; and the use of personal respirators by patients and staff. A more patient-centred approach to TB care may be able to recruit the active participation of TB patients in positive prevention efforts, including maximizing personal infection control, limiting exposure of social contacts to TB during the intensive phase of treatment, advocating isoniazid prophylaxis within the home and patient-centred education efforts to reduce overall transmission. Several model programmes demonstrated synergy, in which the impact of the "whole" or integrated response was greater than the sum of the non-integrated parts.SummaryThe full potential of an integrated TB-HIV service has not been fully harvested. Missed opportunities discount existing efforts in both programmes, will perpetuate the burden of disease, and prevent major gains in future interventions. This paper outlines simple, readily-implementable strategies to narrow the gap and reclaim existing missed opportunities.
Highlights
Despite widely acknowledged WHO guidelines for the integration of TB and human immunodeficiency virus (HIV) services, heavily burdened countries have been slow to implement these and significant missed opportunities have arisen
A more patient-centred approach to TB care may be able to recruit the active participation of TB patients in positive prevention efforts, including maximizing personal infection control, limiting exposure of social contacts to TB during the intensive phase of treatment, advocating isoniazid prophylaxis within the home and patient-centred education efforts to reduce overall transmission
The opportunity presented by the continued scale-up of comprehensive HIV/AIDS care including HAART to simultaneously scale-up the integration of TB and HIV services should be fully exploited
Summary
Guiding Principles Two fundamental principles should guide efforts to construct an integrated complementary response. Areas of focus Several points along the continuum of comprehensive care present opportunities for applying the lessons learned between HIV and TB services (Table 1): With respect to HIV counselling and testing, TB services present a readily identifiable cohort for HIV provider-initiated testing (PIT) Service integration in this cohort will undoubtedly increase HIV screening for this high risk cohort. To enhance the uptake of counselling and testing, patients in the various waiting areas in our TB clinic receive simple key messages from health care workers on TB and HIV. At the adjoining HIV clinic, patients self-administer their HAART and receive adherence counselling at five strategic points in their care These sessions are used to familiarize patients with their diagnosis, the drug therapy they will be exposed to, relevant time-frames, the importance of adherence, and the consequences of non-adherence. The assessment of vulnerability in our context is a complex issue and undoubtedly requires a thorough evaluation of the pros and cons of facilitating such a disclosure to sexual partners of the patient
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