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December2008 Issue 4
Stop TB
Up to Date
on HIV 

Spotlight on HIV/TB Integration 

This issue of Up to Date on HIV focuses on tuberculosis (TB) and HIV/AIDS integration. Issues highlighted include: developments from the 39th Union World Conference on Lung Health; an analysis of integrated interventions in Zimbabwe and Rwanda; and a review of pertinent research addressing the challenges of TB/HIV integration. PSI's TB Expert, Megan Elliott, also provides recommendations for identifying and attracting funding for TB/HIV integrated interventions.
TB/HIV integration has received heightened attention of late, emerging as a theme at both the Union World Conference on Lung Health in Paris and the International AIDS Conference in Mexico City. PSI is well-positioned to employ its counseling and testing (CT) services in Africa and Asia, along with its experience bridging the private and public sectors. PSI's TB/HIV integration strategy is to:
  • Improve the private sector's ability to manage TB effectively using a social franchising approach;
  • Implement social marketing and communication campaigns; and
  • Integrate and link TB and HIV services.
Technical expertise is provided by the following experts:
Megan Elliott: PSI TB Expert, New Business Manager
Dr Karin Hatzold
: Senior HIV Advisor, PSI Zimbabwe
Hope Hempstone: HIV Communication Technical Advisor, TB/HIV Integration
TB/HIV Integration
The Union Banner
Conference Report: 39th Union World Conference on Lung Health
By Megan Elliott
A report of the happenings at The Union, where the integration of TB and HIV service delivery was one of the three technical priorities highlighted at the conference.

Stigma Reduction Communication: A Key to Effective TB/HIV Programming
By Hope Hempstone
We know a good deal about what has worked in interventions addressing HIV-related stigma; however, less is known about TB- and TB/HIV-related communication largely because less has been done to date.
Program Reviews and Funding Options
Routine offer of HIV testing to TB patients
PSI Zimbabwe collaborated with the Ministry of Health and Child Welfare to integrate TB symptom screening for all HIV positive clients accessing counseling and testing (CT) services.

Rwanda National TB/HIV Integration Demonstrates Success
By Jason Walton
Rwanda launched a national TB/HIV campaign in 2005 modeled from the recommendations of the World Health Organization's Stop TB Department and Department of HIV/AIDS. To date, it has achieved marked success.

Finding Funding for TB/HIV Programming
By Megan Elliott
Are you interested in adding TB and/or TB/HIV activities to your platform, but are not sure where to look for funding?  What is PSI's competitive advantage?
Ask The Expert
Megan ElliottWhat you need to know about TB infection control?
By Megan Elliott
So what is true, what is not, and what do we need to communicate to our end beneficiaries?
In the News 
Lung X-ray
Treating TB, HIV Together Decreases Mortality
10/31/08 - Columbia University started a study to determine the best way to treat co-infected TB/HIV patients.

Possible TB vaccine for Aids patients
10/28/08 - Vaccine trials are currently underway in South Africa to stop TB before it starts.  

Blood test better than skin at detecting TB
10/21/08 - A new blood test will allow doctors to more accurately pinpoint patients likely to develop the symptoms of tuberculosis.
A New Class of Antibiotics Could Offer Hope Against TB
10/17/08 - Scientists at Rutgers University have isolated a compound and although the drug hasn't been tested in humans yet, cell-based experiments suggest that it is potent enough to kill a wide range of stubborn bugs, including drug-resistant strains of tuberculosis and the deadly type of staph known as MRSA.
Resources and Tools 
Recent Research
Murambinda Mission Hospital
Macq J, Solis A, Martinez G, Martiny P. Tackling tuberculosis patients' internalized social stigma through patient centered care: An intervention study in rural Nicaragua BMC Public Health. 2008 May 8; Vol. 8:154.
Background: We report a patient-centered intervention study in 9 municipalities of rural Nicaragua aiming at a reduction of internalized social stigma in new AFB positive tuberculosis (TB) patients diagnosed between March 2004 and July 2005. Methods: Five out of 9 municipal teams were coached to tailor and introduce patient-centered package. New TB patients were assigned to the intervention group when diagnosed in municipalities implementing effectively at least TB clubs and home visits. We compared the changes in internalized stigma and TB treatment outcome in intervention and control groups. The internalized stigma was measured through score computed at 15 days and at 2 months of treatment. The treatment results were evaluated through classical TB program indicators. In all municipalities, we emphasized process monitoring to capture contextual factors that could influence package implementation, including stakeholders. Results: TB clubs and home visits were effectively implemented in 2 municipalities after June 2004 and in 3 municipalities after January 2005. Therefore, 122 patients were included in the intervention group and 146 in the control group. After 15 days, internalized stigma scores were equivalent in both groups. After 2 months, difference between scores was statistically significant, revealing a decreased internalized stigma in the intervention group and not in the control group. Conclusion: This study provides initial evidences that it is possible to act on TB patients' internalized stigma, in contexts where at least patient centered home visits and TB clubs are successfully implemented. This is important as, indeed, TB care should also focus on the TB patient's wellbeing and not solely on TB epidemics control.
Van Rie A, Sengupta S, Pungrassami P, et al. Measuring stigma associated with tuberculosis and HIV-AIDS in southern Thailand: exploratory and confirmatory factor analyses of two new scales  Tropical Medicine & International Health. 2008 February 17; Vol. 8(1):21-30.
Objective: To develop scales to measure tuberculosis (TB) and HIV/AIDS stigma in a developing world context. Methods: Cross-sectional study of TB patients in southern Thailand, who were asked to rate their agreement with items measuring TB and HIV/AIDS stigma. Developing the scales involved exploratory and confirmatory factor analyses, internal consistency, construct validity, test/retest reliability and standardized summary scores. Results: Factor analyses identified two sub-scales associated with both TB and HIV/AIDS stigma: community and patient perspectives. Goodness-of-fit was good (TLI = 94, LFI = 0.88 and RMSEA = 0.11), internal consistency was excellent (Cronbach's alphas 0.8220130.91), test/retest reliability was moderate, and construct validity showed an inverse correlation with social support. Conclusion: Our scales have good psychometric properties that measure stigma associated with TB and HIV/AIDS and allow assessment of stigma from community and patient perspectives. Their use will help document the burden of stigma, guide the development of interventions and evaluate stigma reduction programs in areas with a high HIV/AIDS and TB burden.

Currie Christine SM, Floyd K, Williams BG, Dye C. Cost, affordability and cost-effectiveness of strategies to control tuberculosis in countries with high HIV prevalence BMC Public Health. 2005; 5: 130.
Background: The HIV epidemic has caused a dramatic increase in tuberculosis (TB) in East and southern Africa. Several strategies have the potential to reduce the burden of TB in high HIV prevalence settings, and cost and cost-effectiveness analyses can help to prioritize them when budget constraints exist. However, published cost and cost-effectiveness studies are limited. Methods: Our objective was to compare the cost, affordability and cost-effectiveness of seven strategies for reducing the burden of TB in countries with high HIV prevalence. A compartmental difference equation model of TB and HIV and recent cost data were used to assess the costs (year 2003 US$ prices) and effects (TB cases averted, deaths averted, DALYs gained) of these strategies in Kenya during the period 2004-2023. Results: The three lowest cost and most cost-effective strategies were improving TB cure rates, improving TB case detection rates, and improving both together. The incremental cost of combined improvements to case detection and cure was below US$15 million per year (7.5% of year 2000 government health expenditure); the mean cost per DALY gained of these three strategies ranged from US$18 to US$34. Antiretroviral therapy (ART) had the highest incremental costs, which by 2007 could be as large as total government health expenditures in year 2000. ART could also gain more DALYs than the other strategies, at a cost per DALY gained of around US$260 to US$530. Both the costs and effects of treatment for latent tuberculosis infection (TLTI) for HIV+ individuals were low; the cost per DALY gained ranged from about US$85 to US$370. Averting one HIV infection for less than US$250 would be as cost-effective as improving TB case detection and cure rates to WHO target levels. Conclusion: To reduce the burden of TB in high HIV prevalence settings, the immediate goal should be to increase TB case detection rates and, to the extent possible, improve TB cure rates, preferably in combination. Realizing the full potential of ART will require substantial new funding and strengthening of health system capacity so that increased funding can be used effectively.

Odhiambo J, Kizito W, Njoroge A, et al. Provider-initiated HIV testing and counseling for TB patients and suspects in Nairobi, Kenya The International Journal of Tuberculosis and Lung Disease, Vol. 12, Supplement 1, March 2008, pp. S63-S68(1).
Setting: Integrated tuberculosis (TB) and HIV services in a resource-constrained setting. Objective: Pilot provider-initiated HIV testing and counselling (PITC) for TB patients and suspects. Design: Through partnerships, resources were mobilized to establish and support services. After community sensitization and staff training, PITC was introduced to TB patients and then to TB suspects from December 2003 to December 2005. Results: Of 5457 TB suspects who received PITC, 89% underwent HIV testing. Although not statistically significant, TB suspects with TB disease had an HIV prevalence of 61% compared to 63% for those without. Of the 614 suspects who declined HIV testing, 402 (65%) had TB disease. Of 2283 patients referred for cotrimoxazole prophylaxis, 1951 (86%) were enrolled, and of 1727 patients assessed for antiretroviral treatment (ART), 1618 (94%) were eligible and 1441 (83%) started treatment. Conclusions: PITC represents a paradigm shift and is feasible and acceptable to TB patients and TB suspects. Clear directives are nevertheless required to change practice. When offered to TB suspects, PITC identifies large numbers of persons requiring HIV care. Community sensitization, staff training, multitasking and access to HIV care contributed to a high acceptance of HIV testing. Kenya is using this experience to inform national response and advocate wide PITC implementation in settings faced with the TB/HIV epidemic.

Libamba E, Makombe S, Harries AD, et al. Scaling-up antiretroviral therapy in Africa: learning from tuberculosis control programs - the case of Malawi The International Journal of Tuberculosis and Lung Disease, Vol. 9, No. 10, October 2005, pp. 1062-1071(10).
The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a 'medicalized' model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-TB treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART. Malawi, a small and impoverished country in sub-Saharan Africa, is embarking on a national scale-up of ART. In this review we describe how we have adopted several of the principles of DOTS for delivering ART in Malawi: case finding and registration, treatment, monitoring, drug procurement, staffing and the issue of free drugs. We also discuss ART for HIV-infected TB patients. We hope that by using the DOTS approach we will be able to deliver ART to large numbers of HIV-infected patients under controlled conditions, and minimize the risk of developing drug resistance.
PSI HIV Department