Integration and Coordination: Tuberculosis

TB is the leading cause of death among individuals with HIV/AIDS in Africa. Of the more than 9.2 million new TB cases reported by WHO in 2007, an estimated 1.37 million are related to HIV. The prevalence of HIV infection among patients in TB clinical settings is extremely high. In addition, the emergence of multi-drug-resistant (MDR) and extensively drug-resistant (XDR) TB creates additional challenges in expanding HIV care and treatment. Given the overlap in patient populations and the susceptibility of PLWHA to TB infection, PEPFAR is expanding coordination with USG TB programming in the following ways:

Reducing the burden of TB in PLWHA through provision of routine screening, diagnosis, treatment, and prevention of TB among PLWHA

PLWHA have multiple interactions with the health care system, creating opportunities to monitor the progression of HIV-related illness and prevent, identify, and treat opportunistic infections like TB. To avoid additional morbidity and mortality, each person identified as HIV-positive through a PEPFAR-supported testing and counseling program should be screened for TB. Individuals already in HIV treatment or care programs should also receive routine TB screening. Coinfected clients will receive cotrimoxazole, ART, and TB treatment (including isoniazid prophylaxis in patients without active TB and, as applicable, treatment with anti-mycobacterial drugs). As effective successor TB treatments and improved diagnostics become available, PEPFAR will work with countries to incorporate them as appropriate. PEPFAR is also supporting efforts to prevent nosocomial transmission among highly susceptible individuals and health care workers.

Reducing the burden of HIV in persons with TB through provision of routine HIV testing and counseling and ensuring appropriate referrals to care

As HIV testing and counseling is the entry point for HIV care and treatment, PEPFAR supports scaling up provider- initiated testing and counseling in TB clinical settings. Although a large number of TB patients are identified as HIV-positive after being tested in TB clinic settings, many of these individuals do not receive HIV care and treatment. The referral and follow-up of patients from TB sites to HIV care and treatment sites will be strengthened. Doing so improves access and use of both HIV/TB services and broader health care services integrated as part of the GHI. These efforts will be tied to more aggressive efforts to identify and refer partners of PLWHA to testing and counseling.

Engaging in health systems strengthening through HIV/TB

The lack of an adequate and well-trained cadre of health care workers is a constant challenge in the effort to identify and serve coinfected populations. Innovative approaches that strengthen health systems overall can ameliorate this situation. For examples, task-shifting can increase capacity to provide needed services for HIV and TB testing and counseling. The foundation of successful TB diagnosis and treatment programs for PLWHA is a strong laboratory system that includes microscopy, TB culture, and drug-susceptibility testing (DST) capacity. As PEPFAR works with countries to engage in clinic renovation and reconstruction, it will support designs that allow for better infection control. With international partners, PEPFAR is also introducing new laboratory methodologies able to rapidly identify susceptible and resistant TB that are adaptable to low-resource settings.

Supporting coordination between HIV and TB programs

Technical assistance and capacity-building are essential to expand the ability of national HIV and TB programs to plan, implement, monitor and sustain collaborative activities. PEPFAR is supporting development of international and national policies, guidelines and operational tools, providing technical assistance to governments, and performing program evaluations. Key platform-strengthening approaches include a focus on monitoring and evaluation systems and laboratory and program surveillance, including for drug-resistant TB.

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