HIV and TB in the context of universal access: What is working and what is not? - Report of an international open consultative meeting held in ...
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WHO/HTM/TB/2007.382
HIV and TB in the context
of universal access:
What is working and what is not?
Report of an international open consultative meeting held
in conjunction with the XVI International AIDS Conference,
Toronto, Canada, 12–13 August 2006
Summary
A meeting was co-organized by the World Health Organization (WHO), the Joint United Nations
Programme on HIV/AIDS (UNAIDS), the International AIDS Society, the Treatment Action
Group and the Forum for Collaborative HIV Research on behalf of the Global TB/HIV Working
Group of the Stop TB Partnership in conjunction with the XVI International AIDS Conference in
Toronto, Canada, on 12–13 August 2006. The objective of the meeting was to accelerate an effective
and joint response to the epidemic of HIV-related tuberculosis (TB) by facilitating the sharing of
information and experiences, networking and strengthening the partnership between TB and HIV
(human immunodeficiency virus) communities in a forum environment. Lively and interactive dis-
cussion was promoted by a very successful marketplace, where participants presented and promoted
their experiences, results, views, opinions and country-level findings in poster and display formats.
The meeting was attended by almost 300 participants, mainly representing the HIV community, who
were also attending the International AIDS Conference. A tribute was paid to Dr Lisa Onyemobi,
WHO TB/HIV National Professional Officer in Nigeria, who died suddenly earlier in 2006. The meet-
ing was followed by a TB/HIV satellite symposium on the afternoon of 13 August 2006, which was
held as part of the International AIDS Conference. The International AIDS Society, Forum for Col-
laborative HIV Research, co-organized the satellite symposium with the Stop TB and HIV Depart-
ments of WHO.
Achievements applauded
but still more to be done
T he goals, principles and achieve-
ments of the Global TB/HIV
Working Group of the Stop TB
in some countries, implementa-
tion at country level fell far short
of planned achievement. Moreover,
Partnership since its establishment the limited engagement of the HIV
in 2001 were reviewed by Dr Paul community in the global response
Nunn, Coordinator of the WHO to TB/HIV, and in the activities of
team in the Stop TB Department the Working Group, was repeatedly
concerned with TB/HIV and anti-TB cited as a key barrier. Dr Kevin De
drug resistance. The development of Cock, Director of the HIV Depart-
TB/HIV policy and implementation ment at WHO, echoed this limited
tools and the inclusion of TB/HIV in engagement of the HIV community
the new Global Plan to Stop TB, the in TB/HIV activities, saying “TB is
Patients’ Charter and Stop TB advo- the single biggest threat to the suc-
cacy activities were highlighted. The cess of antiretroviral therapy scale
Working Group promoted effective up. We [the TB and HIV communi-
and integrated TB and HIV preven- ties] often take a risk by not talking
tion, treatment and care through to each other and not engaging civil
development of all necessary tools society.” He affirmed that linking
and systems, advocacy and partner- the meeting of the Working Group
ship building and technical sup- with the International AIDS Con-
port to countries. Although, there ference provided the opportunity
was a rapid scale-up of activities for greater involvement of the HIV
community in TB prevention, diag- work more closely with the TB/HIV
nosis and treatment, particularly in Working Group and to raise the pro-
the wake of the emergence of exten- file of TB in their work and future
sively drug-resistant TB (XDR TB), conferences in order to reduce the
which had the potential to com- impact of TB in people living with
promise the gains of antiretroviral HIV. The role that the International
therapy programmes in those HIV- AIDS Society played in organizing
and TB-prevalent settings. this preconference and the satellite
A number of challenges for scaling meetings was greatly appreciated.
up collaborative TB/HIV activities
were acknowledged, including lack
of appreciation of the link between Universal
TB and HIV, weak health systems
to deliver the interventions, limited
access and
financial and human resources, dif- the Millennium
ficulties in coordinating or integrat- Development
ing TB and HIV services, cultural
differences between the two com-
Goals
munities and lack of effective tools
to prevent, diagnose and treat TB in I n July 2005, the G8 leaders made
a commitment in Gleneagles to
achieving universal access to HIV
people living with HIV. Increased
TB/HIV leadership was needed prevention, treatment, care and
from key HIV stakeholders, includ- support for all those who need it
ing WHO, UNAIDS, the Office of by 2010, a target that was further
the Global AIDS Coordinator in endorsed by the United Nations
the United States of America, the General Assembly in October 2005.
International Aids Society and oth- Dr Cate Hankins of UNAIDS pre-
ers, to ensure the implementation sented the universal access concept
of collaborative TB/HIV activities and its importance and contribu-
and ensure lives are saved. Dr De tion to TB prevention, diagnosis and
Cock reiterated the commitment treatment services.
of the WHO HIV Department to Rather than setting global tar-
those goals by announcing that his gets, UNAIDS had been coordinat-
department, in close collabora- ing regional consultation to enable
tion with the Stop TB Department, countries to set their own ambitious
would organize in due course a con- and time-bound targets for universal
sultation meeting to address and access and to monitor and evaluate
give clear guidance on implementa- their progress through the selec-
tion of the elements of TB/HIV that tion of appropriate key indicators.
were primarily the responsibility of Although universal access could
the HIV side, notably TB prevention contribute significantly towards
for people living with HIV (isoniazid achievement of Millennium Devel-
preventive therapy and TB infection opment Goal 6 (to combat HIV/
control), intensified TB case finding AIDS, malaria and other diseases),
and delivery of TB prevention, and many HIV activists and advocates
diagnosis and treatment services expressed their concern at the lack
within the context of HIV services. of ambitious global targets, which
In concluding the meeting, Craig would have stimulated countries to
McClure, Executive Director of the quickly set their targets and also held
International AIDS Society, rein- the global community accountable
forced the society’s commitment to for the achievement of those targets.
trol Strategic Plan, which intended included cross-referral between TB
to test at least 80% of all TB patients clinics (TB diagnosis), clinics deal-
for HIV and provide cotrimoxazole ing with sexually transmitted infec-
preventive therapy and antiret- tions (HIV testing) and general
roviral therapy for 80% of those hospitals (antiretroviral therapy,
TB patients who were found to be cotrimoxazole preventive therapy,
HIV-infected. It had established a and treatment for opportunistic
comprehensive policy framework, infection). The project facilitated an
guidelines and tools for TB/HIV organized system for recording and
control at national, provincial and reporting of TB and HIV without
district levels. The revision of the additional infrastructure or man-
routine TB recording and reporting power support.
form, which now included HIV test Russia was another country with
results, CD4 cell counts and provi- a rapidly spreading HIV epidemic,
sion of cotrimoxazole preventive and a twofold increase in TB inci-
therapy, had been useful to docu- dence and mortality had occurred
ment the range of activities. HIV in the last decade. The specific chal-
testing in TB patients increased lenges for scaling up collaborative
from 32% to 41% to 50% over three TB/HIV activities included the ver-
quarters in 2005 and 2006, of whom tical and rather isolated TB and HIV
56% were HIV-positive in the first control programmes, the tendency
quarter of 2006. Cotrimoxazole for longer inpatient management
preventive therapy was provided to and weak links between nongovern-
84% of HIV-infected TB patients mental organizations and the public
and antiretroviral therapy to a third health system. Although HIV test-
of the patients. However, isoniazid ing among TB patients was almost
The recent African Union Common preventive therapy had not been universal, proper counselling was
Position on universal access to HIV/ widely implemented due to slow often not conducted, compromising
AIDS, TB and malaria services by progress in the screening of people the quality and implementation of
2010 was applauded. This included living with HIV for TB. The expe- collaborative TB/HIV activities.
targets of screening for TB 100% of rience of Kenya demonstrated that
all clients accessing HIV care and nationwide scale-up of routine HIV
support services to ensure early testing for TB patients was possible Civil society
detection and treatment; giving and useful for HIV surveillance in
TB patients and was greatly facili-
engagement for
100% of TB patients access to HIV
testing and counselling services; tated by a revised TB recording and the better
T
and giving 100% of HIV-positive reporting system. he role of nongovernmental
TB patients access to antiretroviral In Myanmar, another country organizations and affected com-
therapy. The international commu- with a high TB burden, the HIV pre munities was crucial in expanding
nity must support these ambitious valence among TB patients was esti- collaborative TB/HIV activities,
targets as the region bears the brunt mated at 7%. The response to TB/HIV particularly through strengthened
of the global TB/HIV burden. by the Ministry of Health included partnership with the public health
development of treatment guide- system. Experiences of involvement
lines for TB/HIV, establishment of of nongovernmental organizations
Headlined coordination group with cross-
training of staff of the national TB
in TB/HIV were presented. For
country stories programme and national AIDS pro-
example, in Myanmar the Union
had established a model of inte-
E xperiences from Kenya, Myan-
mar and Russia were presented
during the plenary session. Kenya
gramme, TB/HIV service delivery
in five pilot projects and establish-
ment of a TB/HIV sentinel surveil-
grated HIV care for TB patients,
which included routine offers of
HIV testing for TB patients and free
had a National Five-Year TB Con- lance system. The pilot projects diagnosis, treatment and prevention
services, including cotrimoxazole
preventive therapy and antiretrovi-
Looking beyond
ral therapy. The model involved the patient
I
standardized HIV treatment and t was noted that expanding the
patient follow-up and recording and range of TB care beyond the indi-
reporting. The Government of vidual patient would help improve
Myanmar was planning to scale up the quality of care for HIV-infected
this model, pending the availability TB patients. For example, in Myan-
of funds. In India the LEPRA Soci- mar overall care was shown to be
ety, a nongovernmental organiza- improved by offering HIV testing for
tion that collaborated with the partners and family members of TB
Revised National Tuberculosis Con- patients, followed by post-test coun-
trol programme in urban and rural selling and home-based care. Simi-
areas, had educated various stake- lar experience was also documented
holders from both the public and from Ghana, where an antiretrovi-
private sector in TB/HIV and ral therapy clinic was instrumental
involved them in related activities. in improving the quality of life for
Nongovernmental organizations HIV-infected TB patients and their
working on HIV and AIDS needed families through provision of com-
to include TB as a core considera- prehensive prevention, care and
tion and their involvement in treatment services. Pediatric clin-
national responses to TB/HIV ics were held on the same premises,
should be strengthened. making it easy for families to be
In general, it was noted that the managed together. The exemplary
involvement at global and national experience was mentioned of Khay-
levels of civil society in advocacy elitsha District in South Africa,
and implementation of collabora- where a 24-hour social and foren-
tive TB/HIV activities needed fur- sic service to assist women who had
ther improvement. Public Health been raped was installed, and which tion among key TB stakeholders. He
Watch research in five countries resulted in increased prosecution of said increasing activism on human
found that few mechanisms existed rapists. These experiences called for rights and social justice grounds
to encourage broad public partici- broader involvement of the health had brought a new paradigm to
pation in the development and eval- sector in a holistic approach towards international public health and had
uation of TB and TB/HIV policy at solving the problems of patients, influenced the implementation of
the domestic or international level. even if they were not strictly in the programmes including treatment
The need for succinct and clear health domain. access for HIV and TB (Figure 1).
advocacy and communication mes- He viewed the new Stop TB strat-
sages to enhance the engagement egy as a response to this changing
of civil society in TB/HIV was dis- What direction global paradigm. However, despite
cussed. Primary messages should be
extracted from the key milestones
for TB? the importance of simplified tools
for clinical decision-making and
and planned achievements of the
Strategic Plan of the Global TB/HIV
Working Group (2006–2010) to
D r Jim Yong Kim of Harvard
University presented the his-
torical perspective of international
standardized case management, he
was concerned that clinicians had
been so dominant in the early stages
inform civil society decision-mak- TB advocacy and the DOTS (directly of HIV treatment scale-up. He also
ers on what needed to be achieved observed treatment, short-course) cited the controversy and the lack of
and to indicate what was needed strategy, contrasting it with the pub- consensus around HIV testing poli-
from civil society. lic health approach of antiretroviral cies as an issue with the potential
therapy scale-up. Although DOTS to limit the implementation of col-
was a clear strategy he recalled the laborative TB/HIV activities.
early resistance to its implementa- The role of activism for HIV was
Figure 1. The emerging paradigm in global health ism and advocacy were and TB and increased collaboration
not yet adequately devel- between the two programmes. Doc-
oped despite emerging umentation of the programmatic
positive experiences. impact of the nationwide roll-out
More resources should be of the isoniazid preventive therapy
leveraged for TB and TB/ programme in Botswana should
HIV research and imple- be urgently assessed and dissemi-
mentation. One partici- nated.
pant contrasted the
successful leveraging of
United States resources TB/HIV pre-
for HIV/AIDS and malaria
through the President’s
service training
also noted by Dr Michel Kazatchk-
ine, who chaired the session that dis-
Emergency Plan for AIDS
Relief (PEPFAR) and the presidential
malaria initiative with the lack of
P re-service training for health-
care workers should include
collaborative TB/HIV activities.
cussed the TB/HIV Working Group’s resources being committed to TB. The experience from Zambia on
Strategic Plan. He said intense activ- how revising the curriculum for
ism and greater treatment literacy in pre-service training contributed to
the developing world helped to changes in the practice of doctors
reduce antiretroviral drug prices by Isoniazid was cited as a good example. Along
95%, increase funding for HIV preventive with designing and revising the cur-
research and programme implemen- therapy for early ricula of health cadres, continuing
tation, and had resulted in antiretro-
viral therapy adherence rates that
HIV infection education and in-service training
were also emphasized.
were as good or better than in indus-
trialized countries. TB/HIV activ- T hough evidence existed for the
efficacy of isoniazid preventive
therapy, it was noted that imple- Debating the
mentation had been slow in many
countries, primarily due to con-
targets
cerns about screening protocols for
TB and resistance to isoniazid. The
role of chest X-rays in ruling out
D uring the discussion on the 10-
year Strategic Plan of the TB/
HIV Working Group, the time-
active TB was significantly reduced bound targets included in the plan
in those settings where infrastruc- were debated. Proponents of the tar-
ture was poorly developed and gets mentioned the “3 by 5” initia-
health systems were weak. Imple- tive, which had been criticized for
mentation of isoniazid preventive being introduced without proper
therapy by HIV services was called consultation with partners but had
for, with an emphasis on screening resulted in changes of mindset and
for TB in HIV counselling and test- demonstrated that antiretroviral
ing centres, where clients were more therapy scale-up programmes could
likely to have early HIV and screen- happen in resource-constrained set-
ing for TB was easier. TB screening tings. Moreover, it had triggered a
should be strengthened in all service strong reaction and forced stake-
delivery areas, including outpatient holders to discuss accountability.
departments and antiretroviral Similar movement was crucially
therapy programmes, to increase needed to rapidly scale up the imple-
early detection and treatment of TB. mentation of the collaborative TB/
This would entail cross-training of HIV activities of the Strategic Plan,
health-care workers in both HIV which were in line with the univer-
sal access concept. A participant cussed. However, it was emphasized
mentioned the case of Eastern that increased focus was needed to
Europe, where targets were com- ensure the delivery of integrated
monly used to ensure implementa- HIV and TB services through pri-
tion and progress, and where mary health care to the extent pos-
progress might be hampered by the sible. There was agreement on the
absence of such targets. importance of documenting and
Those opposing the targets, how- disseminating successful experi-
ever, argued that the lesson of the ences and developing generic mod-
“3 by 5” initiative was that targets els of service delivery that took into
should be set realistically at coun- consideration variations across
try level with due consideration for regions and health systems.
local situations and context. They
expressed concern that the TB/HIV
targets in the Strategic Plan were Research: Great
too ambitious and might therefore needs and little
deter global HIV stakeholders. They
called for more consultation and
investment
discussion about the TB/HIV tar-
gets, particularly within the global
HIV community. The importance
T he key research directions iden-
tified in discussions were inten-
sified TB case finding, the diagnosis
of having time-bound country-level of smear-negative TB among peo-
targets as critical steps to accelerate ple living with HIV, TB preventive
the implementation of collaborative treatment, clear understanding of
TB/HIV activities was reiterated. It the incidence and risk factors for
was also noted that massive invest- immune reconstitution syndrome
ment in health systems was required and its clinical definitions and diag-
to make them strong enough to nosis, the link between poor nutri-
deliver the services. However, it was tional status and mortality among
agreed that more detail was needed HIV-infected TB patients and the
to underpin discussions of health collective population-based impact
systems, particularly to highlight of the implementation of the 12-
how specific efforts related to TB point collaborative TB/HIV activi-
and HIV could contribute to the ties as a package. Researchers (in
overall efforts of strengthening the TB and HIV) and donors needed to
health system. prioritize these research areas.
Effective advocacy and activ-
ism were needed to ensure a great
Models for increase in investment not only in
options HIV-related TB but also for research
into TB prevention, diagnosis and
T he meeting was agreed that dif-
ferent models implementing
collaborative TB/HIV activities had
treatment in general. This was dis-
cussed by Mark Harrington, a long-
time HIV activist who was partly
been shown to work. The health sys- responsible for the notable increase in
tem structure, including human and investment in basic science research
financial resources, and the disease into HIV infection to ensure better
burden determined the way serv- HIV treatment and improved access
ices were delivered. The difficulty in to antiretroviral therapy globally.
defining one ideal model of delivery, He shared his experience to illus-
applicable across all regions, was dis- trate the important role that activ-
XDR TB: the windows, having outdoor waiting
areas and cough hygiene.
emerging threat
A presentation was made of a sur-
vey that had been carried out New tools,
in rural KwaZulu-Natal Province,
South Africa, among 1539 patients.
but more still
The survey had detected multidrug- needed
resistant (MDR) tuberculosis in 221
patients, of whom 53 had extensively
drug-resistant (XDR) tuberculosis.
A n overview was presented of the
diagnostic pipeline, particularly
the work pioneered by the Founda-
Prevalence among 475 patients with tion for Improved New Diagnostics
culture-confirmed tuberculosis was (FIND) to improve TB diagnosis
39% (185 patients) for MDR and among people living with HIV.
6% (30) for XDR tuberculosis. All FIND’s work on improving TB diag-
44 patients with XDR tuberculosis nosis in people living with HIV
who were tested for HIV were co- included development, evaluation
infected. 52 of 53 patients with XDR and demonstration of new molecu-
tuberculosis died, with median lar techniques, and demonstration
survival of 16 days from time of projects for the liquid culture myco-
diagnosis.1 It was noted that the find- bacteria growth indicator tube
ing had the potential to undermine (MGIT) system. A new fluorescent
achieved successes in TB control and microscope that was more sensitive,
compromise the benefit of the intro- low costing, robust and user friendly,
duction of antiretroviral therapy for and did not require use of a dark
HIV-infected TB patients. room, was being developed with a
ists could play through engagement
The circumstances that led to the competent manufacturing partner.
in the coordination and policy deci-
emergence of XDR TB in KwaZulu- Feasibility studies using the loop-
sions of research at all levels. He also
Natal needed to be investigated mediated isothermal amplification
presented the preliminary results of
in detail and the lessons learned (LAMP) technique had been funded
a survey that was conducted by the
shared with other countries. Fur- in Peru, Tanzania and Bangladesh.
Treatment Action Group among
thermore, it was noted that the Additional diagnostic methods
100 institutions involved in fund-
emergence of MDR and XDR TB based on rapid antigen detection
ing TB research and development in
called for improvement of basic TB that had been supported by FIND
2005.The survey found that US$393
control programmes and for greater included a test to identify lipoarabi-
million had been invested in TB
integration of TB and HIV services, nomannan (LAM) in urine (Tanza-
research and development in 2005.
with specific measures to address nia) and the evaluation of interferon
Intensified action was required to
transmission of TB to co-infected gamma release assays (studies of the
increase investment in TB research
patients. Improved diagnostic Consortium to Respond Effectively
and, at the same time, to increase
methods and treatment should be to the AIDS/TB Epidemic; CRE-
the visibility of the needs for TB
an additional priority for manage- ATE). The efforts of FIND in devel-
research. Special initiatives were
ment of XDR TB in people living oping new tools to improve TB
needed to attract young researchers
with HIV. XDR TB and the related diagnosis were acknowledged and
into TB research.
high mortality had also exposed the need for more effort and invest-
the importance of improving infec- ment to ensure the speedy develop-
tion control, for example by using ment of the new tools was
relatively simple methods to control emphasized.
hospital infection, such as opening
1
Lancet 2006, 368:1575–80.
Addressing HIV testing: PMTCT regimens for HIV-positive
women and the feasibility and effi-
neglected areas Still barriers ciency of symptom-based screening
C H
ritical issues that had been IV testing was the gateway for TB at pretest counselling and at
neglected in the global through which HIV-infected all antenatal clinic visits.
response to HIV-related TB were TB patients could receive HIV treat-
highlighted, including the optimal ment, care and support services.
treatment regimens to use when However, scale-up was slow. Lack Marketplace
treating TB and HIV at the same
time, mainly due to the interactions
of operational details on how to
perform diagnostic counselling and
presentation:
between rifampcin and nevirapine. testing, particularly for TB patients, Experiences
Although the current WHO antiret- the perceived stigma associated from countries
roviral therapy guidelines were with the testing and the scarcity of
Brazil
permissive for the concurrent use human resources were cited as criti-
Data from the THRio study,
of these drugs where liver enzyme cal barriers.
designed to determine whether the
testing was readily available, the
routine detection and treatment of
meeting participants reiterated that
TB infection found in HIV-infected
the message was not clear enough PMTCT services: patients in HIV clinics in Rio de
to promote nevirapine as first-line
drug for TB patients.
Missed Janeiro reduced TB incidence in
The Working Group should opportunity for the clinic population receiving
HIV care, showed that combining
maintain its focus on sub-Saharan TB/HIV? isoniazid preventive therapy with
Africa, which carried the brunt of
E xperiences from South Africa antiretroviral therapy significantly
the problem. However, the rising
and Zambia on the integra- reduced the incidence rate (IR) of
burden of HIV in Asia and Eastern
tion of TB prevention, diagno- TB. It was found that compared to
Europe also needed more attention,
sis and treatment into prevention
particularly to address HIV-related
of mother-to-child transmission
TB in injecting drug users. HIV-
(PMTCT) services were reported
related TB in children also required
and discussed. TB was increasingly
an intensified action in the global
a cause of maternal mortality, par-
response.
ticularly in HIV-prevalent settings.
New diagnostic tools were re
The risk of vertical transmission
quired, particularly to prevent the
of maternal TB, and the associated
deaths from undiagnosed TB of
higher rate of premature births,
people living with HIV. In the mean-
low birth weight and intrauterine
time it was important to ensure that
growth retardation, was also noted.
existing tools were widely available
However, certain obstacles impeded
and used appropriately. Mobilizing
the mainstreaming of TB preven-
financial and human resources to
tion, diagnosis and treatment serv-
strengthen the TB and HIV capa-
ices into PMTCT services, such as
bilities of laboratories remained a
low coverage of antenatal care and
challenge but remained crucial to
PMTCT services, and the short cli-
mounting an effective response.
ent contact time typical of routine
antenatal services, which did not
allow enough time for TB screening.
It was also likely that most pregnant
women presented late for their fist
visit. Several research issues that
needed to be addressed urgently
were noted, including alternative
patients receiving neither isoniazid Cambodia in an existing chest clinic in a hos-
preventive therapy nor antiretroviral Special approaches were needed for pital. It had been instrumental in
therapy (IR=3.6/100 person-years), the implementation of the National improving the quality of life for
patients with only antiretrovi- Framework for TB/HIV in urban HIV-infected TB patients and their
ral therapy had a decreased risk areas. A mobile voluntary and confi- families through provision of com-
(IR=1.7/100PY); patients with only dential counselling and testing serv- prehensive prevention, care and
isoniazid preventive therapy had ice by a TB/HIV coordinator at health treatment services.
further decreased risk (IR=0.7/ centres had been implemented, and Haiti
100PY); and patients receiving both the number of TB patients taking a Work done to determine whether
isoniazid preventive therapy and HIV test had increased. Similarly, a chronic cough (≥3 weeks) could be
antiretroviral therapy had the low- formal referral system between TB used as an effective public health
est risk (IR=0.6/100PY). and HIV services through a home- tool to identify patients with active
based care team and a mechanism tuberculosis was presented. Among
to share information and reporting people who presented for HIV vol-
systems had been established. untary counselling and testing 10%
reported chronic cough, and a third
Democratic Republic of were diagnosed with active tuber-
the Congo culosis. The majority (60%) had
Experience from Kinshasa showed smear-negative tuberculosis and the
that most HIV-positive TB patients HIV co-infection rate was 54%. The
were started either on cotrimoxazole approach allowed for rapid diagno-
preventive therapy or antiretrovi- sis and treatment of individuals with
ral therapy while on TB treatment. tuberculosis, prevention of nosoco-
However, an evaluation carried out mial transmission of tuberculosis,
one year later found that this HIV and provision of prophylaxis for
care stopped after patients had com- HIV-infected individuals without
pleted their TB treatment, indicat- active TB.
ing the need for continued HIV care
and support groups at TB clinics or India
better functioning HIV care cen- The LEPRA Society, a nongovern-
tres. mental organization based in And-
hra Pradesh collaborated with the
Dominican Republic Revised National Tuberculosis Con-
In 2003 the Dominican Repub- trol programme to sensitize and
lic started a joint plan for TB/HIV involve various stakeholders from
activities, including setting up a both public and private sectors in
technical coordination body, deter- order to improve the quality of
mining national HIV prevalence care provided for HIV-infected TB
among TB patients, and defining patients.
TB/HIV care packages. Isoniazid
preventive therapy and intensified Nigeria
TB case finding had been estab- The experience of the National TB/
lished. Mechanisms for human HIV Working Group, which was
resource training, budget and mon- revitalized during a national consen-
itoring and evaluation plans, and sus-building meeting held in March
obtaining regular reports had yet to 2005, was presented. The experi-
be established. ence highlighted the importance of
a functional, broad-based TB/HIV
Ghana working group at all levels to roll
Experience was presented of an out collaborative TB/HIV activities.
antiretroviral therapy clinic housed The experience also showed that
10strengthening the health delivery Ukraine
system was an important factor for A study conducted by the Program
successful and sustainable imple- for Appropriate Technology in
mentation of collaborative activi- Health (PATH) found that aware-
ties. ness about TB among people living
with HIV was low, and due to mis-
Senegal conceptions about TB people living
A survey that was conducted among with HIV were often discouraged
regional and district medical offic- from seeking care, resorting instead
ers in Senegal about universal access to self-treatment. Remedial meas-
to HIV and TB prevention, treat- ures being undertaken included TB
ment and care found low levels of education targeting people living
awareness and absence of specific with HIV; strengthening the qual-
policies. Although both antiretrovi- ity of TB care for people living with
ral therapy and TB treatment were HIV; and training in TB for medical
free, they were not readily accessi- personnel caring for people living
ble to patients due to distance from with HIV.
health facilities and financial con-
straints making it difficult to afford Zambia
diagnosis and treatment services A presentation was made of a hos-
(for example chest X-rays). pital-based model for integrated TB
and HIV services. First, an assess-
Sudan ment had been made of existing out-
The Omdurman voluntary counsel- patient, voluntary counselling and
ling and testing and clinical man- testing, TB, HIV, laboratory and
agement clinic was established in pharmacy services to map a strategy
2002 by the Sudan National AIDS for services integration. A two-day
Control programme. It had been clinic-based training workshop was
observed that many of the patients then conducted to cross-train health
attending the clinic had TB, stimu- staff from various departments on
lating collaboration with the Epi- TB/HIV. Patient flow algorithms collaborative TB/HIV activities,
demiological Laboratory Centre, and reformatted registers were and meeting the costs for CD4 test-
the National Tuberculosis Control developed for each department. A ing and transportation costs. This
programme and the Stop TB Board, second clinic-based training work- helped HIV-infected TB patients to
and improved provision of quality shop was held to introduce revised benefit from antiretroviral therapy.
care for HIV-infected TB patients. algorithms and registers. The model
Another experience presented involved HIV diagnostic counsel-
from Sudan was the outcome of
brainstorming sessions on TB/HIV
ling and testing, immediate CD4
measurement for newly diagnosed
Marketplace
held with people living with HIV HIV-infected TB patients, and spot presentation:
and TB. Socioeconomic status, sputum sampling in several clinic Experiences
stigma, education, medical care, departments (voluntary counsel- from partner
rights and psychological well-being
were identified as the core concerns
ling and testing, HIV clinic, outpa-
tient).
organizations
of both groups. However, while Another experience presented Public Health Watch
stigma was of particular concern for from Zambia was the collaboration Findings were presented of research
people living with HIV, it had little of Zambart, part of CREATE, with conducted by civil society research-
importance for a TB patient. Chongwe District health manage- ers of the Public Health Watch of the
ment team in helping to construct Open Society Institute in Bangla-
a room to offer HIV testing and desh, Brazil, Nigeria, Tanzania and
strengthen the implementation of Thailand. The research monitored
11Research Institute of could assist countries in addressing
Tuberculosis, Japan the epidemic only if their support
The institute had been conducting supplemented national government
international courses in TB control funding and commitments.
and HIV prevention and care in
Asia. TB/HIV was one of the core
Tuberculosis Control
components of the TB course and
Assistance Program
TB/HIV operational research had
This funding mechanism, sup-
been introduced recently. Partici-
ported by the United States Agency
pants were encouraged to develop
for International Development
action plans on TB/HIV opera-
(USAID), was operated by the TB
tional research. The institute would
Coalition of Technical Assistance,
introduce TB/HIV and operational
which comprised eight technical
research as core components of the
agencies. TB/HIV featured as an
AIDS course and planned to receive
important element in its area of
participants from both HIV and TB
work, with scaling up being the pri-
programmes to promote TB/HIV
ority. The comparative advantage of
collaboration in Asia.
the programme was that it formed a
coalition of major TB agencies and
World Health
thus comprised expertise in all areas
Organization
of the Stop TB strategy, including
The WHO Integrated Management
TB/HIV.
of Adult Illness (IMAI) toolkit con-
sisted of simplified, operationalized
ZAMSTAR (Zambia South
guidelines; clinical and manage-
Africa TB and AIDS
ment training materials; and patient
Reduction) study
self-management and educational
ZAMSTAR, part of the CREATE
governmental policies to control aids to support scale-up. A new draft
consortium, aimed to evaluate
TB, and advocated improvements. guideline module, TB Care with TB-
interventions to reduce TB at the
HIV Co-management, supported
community level by means of a com-
Centres for Disease effective clinical co-management of
munity randomized trial in Zambia
Control and Prevention TB and HIV by primary care work-
and South Africa. The cooperation
A presentation was made on the ers. The guideline module had been
of all stakeholders, although impor-
Routine Diagnostic Testing and adapted for use in several coun-
tant for the successful implemen-
Counselling in TB Clinical Settings tries, including Tanzania, Ethiopia,
tation of the study, was difficult to
Trainer’s Manual, which provided Namibia, and Haiti.
achieve, and greater collaboration
a standardized approach through The WHO Regional Office for
between the TB and HIV control
which programmes could imple- Europe, in a presentation, said its
programmes was needed.
ment and scale up routine diagnos- priorities included technical assist-
tic HIV testing and counselling. It ance for countries in policy devel-
included a curriculum and four-day opment, strengthening TB/HIV
training package for health-care surveillance, training in operational
providers. research for TB/HIV, training in
TB/HIV management, organization
of regional TB/HIV conferences and
the development of guidelines. Many
interventions, however, remained
vertical in nature, and there was
limited interaction between HIV
and TB activities. It was concluded
that financial and technical partners
12Conclusions including those related to TB/
HIV;
and recommen- n Include PMTCT policy-makers
dations and service providers in Working
T he following conclusions and
recommendations emerged from
the meeting, categorized here
Group membership and reach
out more to the reproductive and
maternal health community;
according to the organizations and n Urgently develop technical guid-
programmes to which they were ance on how to conduct diagnos-
most applicable. tic HIV counselling and testing,
particularly for TB patients.
Global TB/HIV Working
Group, including partner National policy-makers,
organizations HIV and TB control
n Pay greater attention to the TB/ programmes
HIV situation in Eastern Europe n Introduce programmatic issues
and Asia, and focus on address- on TB/HIV and collaborative
ing structural and health systems activities in pre-service training
barriers; of all health cadres, including
n Design improved ways of deliver- medical schools;
ing isoniazid preventive therapy, n Include TB prevention, diagnosis
especially to those with early HIV and treatment in national HIV
infection. The experience in Bot- strategic plans. TB strategic plans
swana in rolling out a nationwide needed to include HIV preven- ties. However, the pilot projects
isoniazid preventive therapy pro- tion, treatment and care serv- needed to be scaled up with speed
gramme had to be assessed and ices; once their effectiveness is dem-
experiences shared; onstrated;
n Whenever feasible take up TB
n Promote the use of fixed drug services and provide HIV pre- n Prioritize, in all countries, the
combinations of antiretroviral vention and treatment, including crucial activity of HIV surveil-
drugs for HIV-infected TB antiretroviral therapy, for HIV- lance among TB patients. WHO-
patients by identifying the most infected TB patients; recommended guidelines should
effective types of drugs and sup- be applied and used for conduct-
porting their registration by n Emphasize the implementation
ing the surveillance;
national authorities; of isoniazid preventive therapy
for early HIV infection through n Define clear and time-bound
n Prioritize national planning pro focusing mainly on HIV coun- national targets for implemen-
cesses that set national TB/HIV selling and testing centres, where tation of collaborative TB/HIV
targets; clients were likely to have early activities;
n Accelerate efforts towards ensur- HIV, and when it was easier n Mainstream TB prevention, diag-
ing rapid scale-up of collaborative to screen for TB. Likewise, TB nosis and treatment services into
activities and ensure adequate screening should be strength- existing PMTCT services in HIV-
progress towards the 2007 TB/ ened in all service delivery areas, prevalent settings. Discussion
HIV milestones of the Global such as outpatients departments between PMTCT and TB policy-
Plan (2006–2015); and antiretroviral therapy pro- makers and service providers at
grammes, to increase early detec- global and national levels was
n In the case of the Stop TB Part-
tion and treatment of TB; essential.
nership, give more prominence
to health system strengthening n Use pilot and demonstration
as an important means of achiev- projects for national scale-up
ing the targets in the Global Plan, of collaborative TB/HIV activi-
13Civil society, including Other related XVI International AIDS
nongovernmental Conference
organizations events: During the Conference there was
n In the case of nongovernmental
Summary greater support than at any previ-
ous Conference for inclusion of TB
organizations working on HIV TB/HIV satellite symposium
in the service delivery, policy and
and AIDS, include provision of The symposium was held on the
advocacy response to HIV. TB/HIV
TB prevention, diagnosis and afternoon of 13 August 2006 and
was addressed in an abstract ses-
treatment services as their core was attended by about 400 par-
sion, a non-abstract session, post-
function, and actively engage in ticipants. The International AIDS
ers, late breaker sessions, and in
the national and local response Society and the Forum for Collabo-
passing references in several high-
to TB/HIV in the countries in rative HIV Research co-organized
visibility presentations and talks,
which they were working; the symposium with the Stop TB
such as the speech by ex-president
and HIV Departments of WHO.
n In the case of global and national of the United States Bill Clinton,
The symposium was chaired by
advocates, activists and civil Dr De Cock’s plenary talk, and the
Dr Kevin De Cock, Director of the
society organizations, press for rapporteur sessions, particularly
HIV Department of WHO, and Dr
inclusive formulation of TB/HIV the clinical research, treatment and
Helene Gayle, the outgoing Chair
targets, and be aware of them care section. The late breaker ple-
of the International AIDS Society.
when holding governments and nary presentation on MDR/XDR
The keynote address was given by
institutions accountable for their stimulated considerable reaction,
Stephen Lewis, the United Nations
achievements; including media coverage. Results,
Secretary-General’s Special Envoy
n Develop clear messages at coun- an advocacy organization based in
for HIV/AIDS in Africa. The sympo-
try level to mobilize all stakehold- Washington, D.C., United States,
sium highlighted the importance of
ers, including community groups organized two sessions on TB/HIV
TB prevention, diagnosis and treat-
and patients, in an unprecedented advocacy, which encouraged a high
ment as a care issue for people living
scale-up of implementation and level of discussion. The Stop TB
with HIV through sharing experi-
resource mobilization; Department of WHO also organ-
ences and strategies that worked,
ized a skills building workshop on
n Extract primary messages from demonstrated the potential role of
the use of a simple questionnaire to
the key milestones and planned TB control programmes in scaling
screen people living with HIV/AIDS
achievements of the Strategic Plan up HIV prevention, treatment and
for TB.
of the Working Group (2006– care services, and shared the pri-
2015) to inform civil society orities and the recent advances in
decision-makers on what needed research on TB/HIV issues.
to be achieved and on what was
needed from civil society.
14Acknowledgements
Overall organization of the meeting
Haileyesus Getahun (WHO), with contributions from Mamadou Diallo (International AIDS Society),
Carole Francis (WHO), Charlie Gilks (WHO), Cate Hankins (UNAIDS), Veronica Miller (Forum for Collaborative
HIV Research), Paul Nunn (WHO), Fabio Scano (WHO) and Javid Syed (Treatment Action Group).
Administrative and secretarial support
Lynne Harrop supported by Leslie Angeles and Rosaline Edma.
Charipersons, presenters and moderators
Slim Abdool-Karim, Richard Chaisson, Kevin De Cock, Gerry Friedland, Haileyesus Getahun, Peter Godfrey-Faussett,
Mark Harrington, Michel Kazatchkine, Jim Kim, Rick O’Brien, Elizabeth Madraa, Neil Martinson, Bess Miller,
Paul Nunn, Kwame Shanaube, Soumya Swaminathan and Isabelle De Zoysa.
Rapporteurs
Lisa Nelson, David Cohn, A. Reid, Jeroen van Gorkom, Alwyn Mwinga and Michael Kimerling.
Photos by Lynne Harrop and Glen Thomas
Written by Haileyesus Getahun.
WHO/HTM/TB/2007.382
© World Health Organization 2007
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This publication does not necessarily represent the decisions or the stated policy of the World Health Organization.
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