Lessons Learned in Scaling Up TB/HIV Collaborative Activities

The Tuberculosis Control Assistance Program (TB CAP) is an 8-organisation collaboration that published this report, led by Family Health International (FHI), on lessons learned in three countries - Cambodia, Kenya, and Malawi - to encourage the scale-up of tuberculosis (TB)/HIV collaborative activities. TB CAP is funded in part by the United States Agency for International Development (USAID). The report investigated collaborative TB/HIV activities considered important by the World Health Organization (WHO) and carried out in these three countries. It describes the mechanisms for collaboration and what has been done in each country to decrease the TB burden among people living with HIV (PLHIV) and the burden of HIV among TB patients.

Because the greatest increase in TB infection in the past 10 years, as stated here, has been in association with HIV infection, the WHO’s 2004 Interim Policy on Collaborative TB/HIV Activities suggests steps for creating collaborative mechanisms between national TB and AIDS programmes. The government in each of the three countries represented in the case studies facilitated TB/HIV collaboration by forming working groups charged with leading and implementing joint TB/HIV activities that had broad representation of all stakeholders - from national TB and HIV/AIDS programme staff to implementing partners and people living with HIV.

Key communication and training findings from the case studies include:

• Offering TB patients provider-initiated counselling and testing for HIV “significantly increases the number of patients who are tested.”
  
• Informants considered it critical to cross-train staff in TB/HIV, especially those at community health centres.
  
• Scaling up joint TB/HIV activities by starting with three or four pilot projects increased collaboration.
  
• Joint monitoring and evaluation (M&E) is important in TB/HIV collaboration, as is the training of staff in these joint (M&E) systems.
  
• Challenges include: getting patients anti-retroviral therapy services after testing; generating policy documents that are sufficiently specific to define and guide
  collaboration; and designating a person affiliated with a national TB programme to train staff in more detailed standard operating procedures (SOPs).
  

By country, programme highlights are the following:

1. Cambodia’s continuum of care includes a network of daytime care centres for people living with HIV/AIDS. Mobile VCT at health centres increased the number of patients tested. One key in Cambodia is greater emphasis on management of opportunistic infections, including TB, instead of focusing only on anti-retroviral therapy. Some of this management is done by home-based care workers.
   
2. Kenya’s national TB and AIDS programmes were brought together in 2000 in one division in the Ministry of Health (MOH)’s Department of Preventive and Promotive Services and housed in one building. This department launched a VCT policy based on VCT’s three Cs - consent, confidentiality, and counselling - which prompted a rapid uptake of testing. The revision of recording and reporting tools contributed to Kenya’s improved TB/HIV services. Scale-up success in health workers’ responsiveness to reporting may come partially from close staff supervision and strict data-reporting requirements. Collaboration with PLHIV has facilitated more effective provision of service and strengthened district health systems.
   
3. Malawi developed a phased-in plan in 2002 to bring together TB and HIV services. Training has been a component of efforts to integrate services, including a TB/HIV training manual designed for newly recruited doctors, paramedics, and nurses. Decentralised collection of samples for testing has increased TB detection. Tools for registration and supervision of patients have improved documentation and treatment referral and follow-up. Traditional community leaders have increased acceptance of integrated testing and treatment.