Tuberculosis (TB) and HIV and AIDS affect each other strongly. Control programmes for the two diseases should also interact. This paper explores options for linking TB and HIV and AIDS programmes, concluding that a universal model is unlikely to suit all contexts.

The paper identifies six contextual factors that affect collaboration between HIV and AIDS and TB disease programmes: social and cultural factors; epidemiology and disease control; economic and financial flows; politics; ideology and values; and international factors. The authors analyse the impact of epidemiology and disease control factors on collaborative strategies, highlighting the following issues:

• Disease, diagnosis and treatment – who should provide services, how should health care units and referrals be organised, and who should manage them?
• Approach and mechanisms of service delivery – HIV and AIDS programmes often take an individualised approach with more inclusive, patient-sensitive methods, whereas TB programmes usually focus on a standardised public health approach.
• Organisational approaches to disease control – A National TB Programme tends to form one nationally organised and cohesive structure. HIV and AIDS programmes are often networks of diverse and dispersed projects.
• Prevention and control strategies – Comprehensive HIV and AIDS strategies link prevention, treatment, care and support for affected people, involving a wide range of agencies and sectors. TB control is primarily through the clinical DOTS (Directly Observed Treatment, Short-course) approach.
• Capacity for scaling up - this includes providing for people with long-term conditions, addressing increased workloads and staff shortages, and strengthening the interaction between TB and HIV control programmes.

There are various options for structuring the relationship between disease control activities. The first is to integrate HIV and AIDS and TB control activities into general health services. This offers a patient-centred approach, with better efficiency and reduced costs. A second approach is to merge HIV and AIDS and TB control activities into a joint programme, while the third option keeps the two programmes separate. Collaboration can then take the form of:

• Coordination – two units stay distinct but come together on specific groups of activities, agree on common objectives, and commit joint resources.
• Cooperation – a looser linkage where each unit agrees to help rather than hinder the other in achieving their objectives, without formal organisational machinery or joint financing.
• Nesting – placing a service element of one programme within another established programme, often without joint planning or finance.
• Referring – TB units refer patients to HIV and AIDS services for prevention, treatment or care, and vice versa.
• Sharing – units have access to services or facilities needed by all the programmes, such as distribution systems, laboratories or training.

Possible impacts of these choices include loss of external funding, reduced effectiveness, increased workload, interruptions to service delivery, inconsistencies between separate protocols and difficult supervision. More policy analysis and research is needed on these organisational options and the possible impact of change.

Source(s):
‘HIV/AIDS and TB: contextual issues and policy choice in programme relationships’, Tropical Medicine and International Health, 12 (2): 183-194, by Y. Wang et al., 2007

id21 Research Highlight: 5 April 2008

Further Information:
Yan Wang
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool
L3 5QA
UK

Tel: +44 (0)151 7053196
Fax: +44 (0)151 7053364
Contact the contributor: yan.wang@liverpool.ac.uk

Liverpool School of Tropical Medicine (LSTM), UK

Other related links:
'Public-private partnerships: potential for health equity in India'

'HIV-related TB deaths: impact of joined-up programmes in Estonia'

'Providing care in South Africa - lessons from TB/HIV pilot districts'