Integrating tuberculosis and HIV services in Africa [editorial]

TUBERCULOSIS (TB) is the leading cause of death among people with HIV in Africa and without antiretroviral therapy (ART) 5-15% of HIV infected people develop TB each year. In addition HIV infection is associated with up to 80% of TB cases in Africa fuelling the worst TB epidemic in the world. There is increasing recognition of the need to diagnosis HIV and TB co-infected patients earlier in the course of disease; however implementing guidance has had challenges. In this issue Harris and colleagues present the results of a successful programme at seven primary care centres in Lusaka Zambia. Operational research such as this is important to help improve the quality of programmes while expanding needed services. While Harris et al. demonstrate increased uptake of both HIV testing of patients with TB and identifi - cation of clinical TB in HIV-infected patients they present several challenges related to patient and provider acceptability of integrated services. In particular adding services in an already overstretched health system resulted in the need for additional space new training programmes additional human resources and innovative referral and data collection methods. A limitation to the fi ndings is that no information is presented about HIV prevention efforts including HIV testing of sexual partners of people co-infected with HIV and TB and provision of Prevention with Positives education and condoms; yet without increased prevention efforts both the TB and HIV epidemics will continue to worsen. For an integrated service to have the most impact it must maximise the numbers of new cases of TB and HIV diagnosed from both services and the authors acknowledged that outcomes could have been improved with better community linkages for case follow-up and adherence support. It is clear that these traditionally disparate programmes need to cross barriers to make effective and effi cient public health impact. How to do this effectively and sustainably is the challenge of the next few years. There is need for good planning simple standardised algorithms and effective monitoring and supervision. While the focus has been on diagnosis and treatment there is also a need to integrate TB prevention into HIV programmes. This includes isoniazid prophylaxis which reduces the incidence of TB and has been used successfully in pilot programmes. However despite this prophylaxis has not been widely implemented. In addition we need to establish effective infection control measures to prevent TB transmission in HIV and TB clinics such as mask use reduced hospitalisation time and a shift to out-patient therapy- which in a mathematical model would avert a third of cases of XDR-TB in rural South Africa and consider other effective interventions such as triaging coughing patients away from other patients clinic waiting rooms and establishing outdoor waiting areas. Integration of TB and HIV services is a priority for public health systems in Africa and programmes like the one described by Harris et al. are important steps in that direction. (full-text)