Critical Interventions: Tuberculosis and HIV/AIDS

Tuberculosis (TB), an airborne disease, is the leading cause of death among people who are HIV-positive. Approximately one-third of the nearly 40 million people living with HIV/AIDS are also infected with TB. In areas such as sub-Saharan Africa, up to half of AIDS-related deaths are caused by TB. Of those people living with HIV/AIDS with latent TB infection, approximately 10 percent per year develop active TB. It is vital to treat people with TB to prevent illness and death, as well as to prevent the spread of TB to others.

The U.S. President's Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR) supports national TB and HIV/AIDS programs that integrate HIV prevention, treatment and care activities into TB services, including support for TB care and treatment.

The priorities for HIV/ TB interventions are:

• Routine screening for TB disease;
• HIV counseling and testing for clients at TB facilities;
• Diagnosis and treatment of people living with HIV/AIDS with active TB using DOTS; and
• Ensuring that cross-referrals are made for TB patients to adequate care and treatment for HIV/AIDS, including antiretroviral treatment and cotrimoxazole.

Action Today, A Foundation for Tomorrow: The Emergency Plan supported TB care and treatment for approximately 369,000 people living with HIV/AIDS in the focus countries during FY 2005.   The U.S. Government is the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria, contributing one-third of the Fund's resources. The Global Fund finances essential HIV and TB programs in resource-limited settings.

The Emergency Plan also supports the development of laboratory infrastructure for the diagnosis of opportunistic infections, including TB. Support for diagnostic laboratories is focused on a public health approach that includes the development of tiered laboratory networks linked through an external quality assurance system.

Because of the high rate of co-morbidity between TB and HIV/AIDS, the U.S. Government urges counseling and testing facilities to screen for signs of TB, and offer HIV counseling, testing and referral for TB diagnosis and treatment. Diagnostic HIV testing and counseling of TB patients allows those who test HIV-positive to be referred for HIV/AIDS treatment and other services. PEPFAR supports development of a comprehensive curriculum and training materials to improve TB/HIV surveillance in TB clinics. The U.S. Government has developed two basic preventive care packages, including one for adults and one for children aged 0-14 born to HIV-infected mothers. These packages support national HIV/AIDS strategies and are for use by U.S. Government in-country staff and implementing partners. They outline interventions, including TB screening and TB treatment therapies, target the primary causes of HIV-related illness and death.

The Emergency Plan at Work

The following are a few examples of how the Emergency Plan is working under national strategies and in partnership with host nations to support TB services for people living with HIV/AIDS:

• In Ethiopia, Fenote Tesfa Project, a private sector program, provides employees with access to TB care and treatment at their company's clinic. Prior to the Fenote Tesfa Project, few Ethiopian parastatal clinics provided TB treatment. In October 2004, the Fenote Tesfa Project initiated a workplace HIV/TB program. Healthcare professionals now receive training on TB and HIV management in collaboration with the Ethiopian Ministry of Health. One beneficiary of the program explained: When I was told that my problem is TB, I was thinking about the referrals and the expenses I may have to incur to go daily to a health center to get treatment. But [my doctor] told me that the service is available onsite at the clinic, and thanks to the [Fenote Tesfa] Project, I have already started taking my drug on the day I was diagnosed. I am following my course here at the workplace receiving counseling by my own company medical doctor.?
   
• In Vietnam, the U.S. Government supports efforts to establish HIV diagnostic counseling and testing in TB clinics and improve screening of TB and referral to TB services among HIV-positive persons. The U.S. Government developed protocols for TB/HIV, which were approved by the Ministry of Health of Vietnam, along with a program needs assessment completed by the Vietnam National TB Program. Training materials on HIV diagnostic counseling and testing in TB programs were developed and have been translated, reviewed and approved by the Vietnam National TB Program.
   
• In Uganda, The AIDS Support Organization (TASO) is providing comprehensive, holistic care using a clinic- and home-based model of service delivery. To meet the care needs of isolated communities, TASO has integrated prevention, care and treatment services. TASO's efforts are providing outlying populations with comprehensive clinical care. TASO's integrated care package includes screening for active TB and treatment for TB/HIV co-infection. By providing treatment for HIV-positive patients with TB disease and with latent TB infection, TASO has helped improve overall health among program beneficiaries and reduce mortality rates.
   
• In Guyana, the U.S. Government and an Emergency Plan partner have been actively engaged in a Guyanese Ministry of Health initiative to improve TB and TB/HIV care. The PEPFAR partner organization's activities have focused on improvement in TB laboratory capacity, diagnosis, and clinical care. In addition, they are assisting the Ministry of Health with the revision of their five-year strategic plan for TB.
   
• In Kenya, the Eastern Deanery of the Nairobi Catholic Diocese has provided health care through seven clinics in the eastern slums of Nairobi since the early 1990s. In 2001, integrated HIV and TB services were established in these clinics. Initially, TB patients were referred to freestanding counseling and testing centers; however, only one-in-eight patients referred for counseling and testing actually sought testing. With Emergency Plan support, the program began in 2004 to routinely offer on-site HIV counseling and testing to all outpatients believed to have TB. Nurses now conduct testing, using simple HIV rapid tests done in the patient's presence. Of the 1,917 patients offered HIV counseling and testing over 19 months, 85 percent accepted treatment during their initial clinic visit and nearly all of those who came for a follow-up due to active TB eventually accepted testing.

Resources: The U.S. Government TB/HIV Technical Working Group, in collaboration with the World Health Organization, has developed a curriculum and training package entitled Routine Diagnostic Counseling and Testing in TB Clinical Settings: A Trainer's Manual to help TB and HIV/AIDS Control Programs initiate and rapidly scale-up HIV counseling and testing of TB patients. This manual will soon be available at www.cdc.gov/gap. For Emergency Plan TB/HIV-related technical assistance, please contact the Technical Workgroup co-chairs, Bess Miller (bimiller@cdc.gov) or Amy Bloom (abloom@usaid.gov). The U.S. Government TB/HIV Technical Working Group has also developed, in collaboration with the World Health Organization, an addendum to the 1999 WHO Guidelines for the Prevention of TB in Health Care Facilities in Resource Limited Settings entitled TB Infection Control in the Era of Expanding HIV Care and Treatment. This document includes training materials for health care workers and a sample infection control plan. This manual will soon be available at www.cdc.gov/gap.