Missed opportunities for synergy in the response to the TB-HIV co-epidemic in southern Africa

Background:

Several southern African countries are experiencing catastrophic TB-HIV epidemics. A broad literature has emerged that shows that while high HIV prevalence drives TB infection and illness, drug resistant TB epidemics may undermine the success of ARV rollout. Because of the interaction of TB and HIV, it has been suggested that areas with high-HIV prevalence consider integrated models for TB-HIV care. The purpose of this study was to assess the extent to which TB and HIV services are being integrated in ways that effectively address the co-epidemic.

Methods:

The findings are based a literature review, personal communication and experience, and a review current models of delivery for HIV and TB services in South Africa.

Results:

Despite consensus among policy, academic, and practitioner communities in public health that the interaction of HIV and TB warrants an integrated response in high-HIV prevalence settings, services are largely organized along separate continua of care for HIV and TB. The reasons for this include the historical organization of services and the separation of specialised health workers, information management systems, and budgets.

We find that the efficacy of the response to the TB-HIV co-epidemic could be significantly enhanced via the application of two key principles: 1) applying the lessons learned from the scale-up of HIV/AIDS to more effectively deliver TB services, and 2) using the opportunity of the current scale-up of ART to create complementary models of service delivery which simultaneously address TB and HIV. Opportunities for applying these principles exist in the areas of surveillance, counseling, adherence support, infection control, and positive prevention.

Conclusion:

There remains much missed opportunity in the response to the TB-HIV co-epidemic in southern Africa. The persistence of a suboptimal response to the intersection of the two diseases raises important issues of both efficiency and ethics.