In the meantime, healthcare workers engaged in providing care to people with HIV should start with the people sitting right in front of them. Getting HIV programmes to become more proactive about TB has long been a challenge, but this is changing as more and more people from the HIV community are calling for implementation of ICF.
“When we had a stake holders meeting in May, the preliminary draft of intensified case finding guidelines and intensified case finding tools – TB screening tools – were presented not by the TB programme but by the HIV programme,” said Dr Odhiambo. “This increasing recognition, that both the HIV and the TB programmes require each other in this process, is important for Kenya.”
“HIV infected persons are at increased risk for TB from the onset of HIV infection, and this risk only increases over time. HIV care programmes can and must integrate TB screening into longitudinal care,” said Dr Diane Havlir, chair of the TB/HIV working group of the Stop TB Partnership.
“Since cohort analyses of HIV-infected patients reveal high rates of TB both prior to and after initiation of ART, ICF in settings providing HIV care and treatment is a vital part of the package of essential TB/HIV services,” Dr. Tom Kenyon, Principal Deputy Coordinator and Chief Medical Officer for PEPFAR told HATIP.
“Moreover, the timely diagnosis and treatment for TB interrupts transmission and is an important protection measure for patients, healthcare workers and the community. PEPFAR strongly supports the rapid scale-up of ICF through partnerships with host country governments, implementing partners and our multilateral partners, including the World Health Organization and the Global Fund to Fight AIDS, Tuberculosis and Malaria.”
WHO’s Stop TB Department is in favour of HIV service providers taking up more TB services.
"Screening PLHIV for TB, and depending on the outcome of the screening, to provide them with isoniazid preventive therapy and with proper TB treatment should be a core function of any HIV care service,” Dr Mario Raviglione, Director of WHO's Stop TB Department, told HATIP.
"In the last 2-3 years many countries particularly in sub-Saharan Africa demonstrated that successful and rapid scale-up of HIV services to TB patients such as HIV testing and the provision of cotrimoxazole preventive therapy and antiretroviral treatment for HIV-infected TB patients is possible," he went on.
"These experiences and best practices have to be nurtured and have to be used as models to scale up TB prevention, diagnosis and treatment services to PLHIV so that we can prevent unnecessary deaths from a curable disease"
Again, the approach needs to be patient-centred, as Krista Dong et al wrote in the Journal of Infectious Diseases: “for coinfected patients living in poverty, maximizing programme coordination should reduce some of the challenges facing patients seeking HIV and TB care. A system that is responsive to patient needs may help to restore hope and encourage patients to participate in their own treatment success. When patients are empowered and made responsible for their care, they are less likely to experience treatment default.”
"People living with HIV are faced with a number of threats - TB is one of the most serious and in the past they have often faced serious challenges in accessing and benefiting from life-saving TB services,” said Dr. De Cock.
“There are an unprecedented amount of resources being devoted to HIV and TB programmes and now is the time for programmes and communities to work together to address key technical challenges such as intensified case finding, isoniazid preventive therapy and infection control in a way that is patient-centred ...to ensure that patients and their families do not fall in the "gap" between the two programmes."
Grass roots, community-based organisations must be included as stakeholders, and people with HIV should be empowered to help reduce the burden of TB in their community.
“HIV programmes have scaled up dramatically because of strong community-based organisations, who are involved in advocacy, support, testing, care, and treatment. [We] need to engage these groups in ICF, and these groups (i.e., the HIV community) needs to recognise why ICF should be a high priority. Community or faith-based organisations could use [a simple tool] to screen HIV persons in the community and bring them to TB diagnostic services,” said Dr Varma.
“HIV patients already gather together frequently in day care centres and support groups so their baseline exposure to TB is already high. In fact, implementing TB screening into such groups would be a way of keeping the entire group safe.”
In addition, community-based organisations, PLHIV networks and community groups can help generate demand for TB screening among people living with HIV. One place to start is to make certain that people with HIV are aware that they should be screened for TB regularly and that they have a right to demand it as part of their routine care, and if they aren’t being adequately screened, if their symptoms are not being investigated, then they should hold their healthcare provider and service accountable.
“Not screening people with HIV for TB is tantamount to medical malpractice," said Mark Harrington of the Treatment Action Group at a session during the UWCLH.
And yet, thus far, there has been relatively little pressure from community-based organisations and from people living with HIV to promote more regular screening for TB (or other activities to reduce the burden of TB in people with HIV, such as IPT or infection control).
"Maybe we emphasise too much that TB kills people with HIV rather than saying there are several simple positive actions that individuals can take and that communities can and should demand access to — that can protect people from infection, help prevent active disease from developing, and can identify disease early and improve the chances of cure,” Dr Charlie Gilks, Coordinator of Antiretroviral Treatment and HIV Care at WHO’s HIV/AIDS Department, told HATIP.
Just like HIV testing and counselling, ICF should thus be seen as a potentially life-saving intervention that is an essential part of HIV services — and that can be implemented today.
At the same time, there needs to be a renewed focus on advocacy demanding accountability for ICF implementation from the national government, the public health system, and the local clinic. Likewise, even though external advice and guidelines may not sway programmes to adopt more sensitive evidence-based screening tools, the local community can demand it.
Finally, global TB/HIV activism must demand low cost point-of-care TB diagnostic tools, which could remove the obstacles between screening and diagnosis and move TB diagnosis from the reference lab directly to wherever people at risk of TB/HIV are, in the community or their homes.