Human immunodeficiency virus (HIV) care and treatment programs in resource-limited settings must aggressively address tuberculosis (TB) and the emerging multidrug-resistant TB epidemic to save patient lives and to curb the global TB burden, a major cause of death for persons with HIV, according to an article in the July 23/30 issue of JAMA.

Tuberculosis is a threat throughout the course of HIV disease. “As HIV care expands further, there is both an opportunity and necessity for incorporation of TB control activities into these programs. Tuberculosis programs simply do not have the capacity to provide ongoing TB screening, prevention, and treatment for millions of individuals receiving HIV care,” the authors write.

Diane V. Havlir, M.D., of the University of California, San Francisco, and colleagues examined interactions between HIV and TB for HIV care programs and the framework for HIV programs to incorporate TB activities, and global progress in implementation.

The authors write that TB poses numerous challenges, including drug-resistance; difficulty in diagnosis and treatment in HIV-infected persons; and complications from drug interactions. “Finding and treating TB cases, administering antiretroviral therapy (ART) and isoniazid preventive therapy [IPT; an antibacterial drug], and infection control are critical activities to incorporate into HIV care programs, the first chronic care models to emerge in many developing countries. Because patients with HIV are at risk for TB throughout life, activities should be ongoing in pediatric and adult ART clinics, pre-ART clinics (keeping relatively healthy patients engaged in care), and maternal health programs.”

The authors propose several strategic approaches to reduce TB burden for HIV care and treatment programs. They include:

  * TB Intensified Case Finding - Finding and treating TB promptly is the most effective TB control measure. Intensified case finding includes both active identification of TB among patients with HIV in care and screening their household members for active TB.

  * Treating Individuals With Active TB – The authors propose expansion of a care model whereby TB is treated by HIV programs. HIV care staff are trained to diagnose and treat a wide array of infections associated with HIV disease. “Tuberculosis should be no exception.”

  * Isoniazid Preventive Therapy - HIV programs may need to work with country policymakers to permit IPT administration, which in some countries is either against national policy or impossible because of the stringent requirements for the exclusion of TB before IPT initiation.

  * Antiretroviral Therapy - ART is one of the most powerful weapons against TB. From the perspective of TB prevention, the earlier that ART is initiated, the less the risk for TB.

  * TB Infection Control - One of the most challenging areas in TB infection control is the implementation of measures in both outpatient and inpatient health care facilities that will reduce the risk of TB transmission and protect health care workers. Tuberculosis infection control guidelines exist but are rarely implemented.

  * TB Recording and Reporting - It is essential that HIV care programs adhere to TB reporting requirements. Standardized recording and reporting formats in accordance with national TB and AIDS control guidelines should be used.

  * Joint HIV/TB Planning - The successful implementation of TB interventions in HIV services requires effective communication, coordination, and collaboration with TB control programs.

“HIV care programs must take a bold approach to TB prevention, diagnosis, and treatment to successfully address the catastrophic and intersecting epidemics of HIV and TB. HIV programs need to take advantage of new earmarked funds for HIV/TB activities from agencies such as PEPFAR and the Global Fund to Fight HIV, TB, and Malaria. They must push for access for rapid TB diagnostic tests, conduct operational research, and launch educational efforts in partnership with the community to reduce TB transmission. Shortages in the health care workforce and laboratory capabilities clearly represent the greatest obstacles. However, the possibility for progress has never been greater with the global commitment to health care infrastructure strengthening geared toward consolidating the momentum through disease-specific efforts such as HIV and TB,” the authors conclude.

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(JAMA. 2008;300[4]:423-430. Available pre-embargo to the media at jamamedia.org)

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