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12 Collaborative activities to address HIV associated TB: The Global Policy for TB/HIV Activities
The global policy on collaborative TB/HIV activities is a policy guideline developed by the World Health Organisation Stop TB Department and Department of HIV/AIDS, in collaboration with members of the Stop TB Partnership, which is the global public health initiative assigned responsibility for developing a strategy for eliminating TB. The Stop TB partnership is housed by the World Health Organisation. Its members include intergovernmental agencies, national government agencies, private philanthropies, research and academic institutions and representatives of affected communities and civil society groups derives from the Stop TB partnership and is intended to mitigate against the joint TB and HIV epidemics.

Rationale - the interaction of TB and HIV
The rationale for the establishment of the global policy is the acknowledgement of the burden of disease caused by the individual diseases TB and HIV/AIDS, and equally of the exacerbated burden these diseases cause in people living with both. In 2008, one-third of the world's population is though to be infected with TB. In 2008 there were also an estimated 33.4 million people infected with HIV globally, of whom 1.4 million also had TB. TB is one of the leading causes of death among people living with HIV. There is a clear overlap between HIV and TB. HIV weakens immune systems and as such people living with HIV are much more likely to become sick with TB. People living with HIV can be immune-suppressed and as such must in partnership with health care providers take extra care to reduce the risk of developing TB.

Forms of TB
There are two forms of TB; 1) TB infection with the bacteria Mycobacterium tuberculosis (latent TB), which cannot spread from person to person, and 2) TB disease (active TB), which can. TB spreads through the air when a person with TB disease coughs, sneezes, talks or sings, much like the common cold. TB is not spread by shaking hands, sharing food, drink, clothes, tooth brushes or using the same toilet seat. Most of us with TB have TB infection (latent TB). Anyone who comes into contact with the airborne bacteria can breathe in the bacteria, but not everyone who does will become sick. People not infected with HIV have a lifetime chance of 5-10% of developing TB. People however however living with HIV have a ~5-10% chance of developing TB disease every year.

MDR TB, XDR TB and HIV
Some people who develop TB disease, become sick with a form that cannot be treated using the two most common antibiotics for TB, isoniazid and rifampicin. They are said to have MDR TB (multi-drug resistant TB). If the TB does not respond to these and other drugs used to treat TB, it is said to be extensively drug resistant, or XDR-TB. MDR TB and XDR TB are very difficult and expensive to treat, particularly for people already living with HIV. They require close collaboration between health care providers, individual patients and the communities in which they live.

Thresholds for starting recommended collaborative TB/HIV activities
The global policy considers that HIV prevalence the most sensitive and reliable indicator of the intersection of TB and HIV epidemics in any country. It has defined guidelines for national health sector action for countries in an HIV epidemic state to be used both where this data is readily available, and where the data is not available, for which it recommends the use of national data on adult HIV prevalence rates as the indicator to start activities, and to classify the epidemic state of a country. Countries are divided into three categories and the threshold for activities to be undertaken are set out as shown in the matrix below:

Collaborative TB/HIV activities
Collaborative activities for addressing the interface of the tuberculosis and HIV epidemics fall into three broad areas, under which more detailed activities are envisioned:
 * Establishing mechanisms for collaboration (4 activities)
 * Decreasing the burden of TB in people living with HIV/AIDS (3 activities)
 * Decreasing the burden of HIV in tuberculosis patients (5 activities)

These, in total 12, activities requires a number of steps and broad collaboration from amongst a number of sectors and affected communities.

Establishing mechanisms for collaboration
The 4 activities required to establish adequate collaborative activities to comprehensively tackle HIV associated TB are:


 * 1) Setting up a coordinating body for TB/HIV activities
 * 2) Conducting surveillance of HIV prevalence among TB patients
 * 3) Carrying out joint TB/HIV planning
 * 4) Conducting monitoring and evaluation

Each of these interrelated activities requires the integration of services for TB, HIV and risk factors for the two epidemics. Health service providers, researchers, civil society groups, patient and patient advocacy groups and affected communities all have a role to play in carrying out these activities.

Setting up a coordinating body for TB/HIV activities
Primary responsibility for setting up coordinating bodies for TB/HIV rest with national health authorities. Traditionally HIV/AIDS and TB programmes have pursued separate courses. Stark differences in approach of these programmes have been driven by the histories of TB and HIV, and by the communities primarily involved in advocating care. In the past, approaches in TB have tended to be hospital based and medicines provider driven, while HIV programmes have been strongly influenced by advocacy from affected communities. Coordination of services provides not only coherence but allows the exchange of experiences that enrichen and advance the efforts to stop the dual epidemics.

Because both the structure and the nature of services provided for HIV and TB varies from country to country, coordination is important to ensure coherent communication about the intersection of the epidemics, for governance and mobilization of resources for HIV associated TB, for involving and building the capacities of communities that have not previously involved in dealing with either disease and for establishing and maintaining databases for tracking progress.

Conducting surveillance of HIV prevalence among TB patients
As is generally true for all infectious disease programmes, surveillance is necessary for the formulation and implementation of programmes, to address the dual epidemics of HIV/AIDS and TB. Three primary types of surveillance are promoted as part of the global policy for TB/HIV, according to the country categories as described above, availability of resources, and experience of health service providers: periodic cross-sectional HIV sero-prevalence surveys; sentinel surveys with a sub-population of TB patients already living with HIV, and data collection surveys from routine HIV testing and counselling of TB patients.

Carrying out joint TB/HIV planning
Strategic cooperation between national HIV and Tb programmes is considered a prerequisite for successful systematic elimination of the epidemics. The global policy considers the complete implementation of the 12 collaborative activities, resource mobilization, capacity building and training, advocacy, programme communication and social mobilization, enhanced community involvement and operational research critical elements of joint plans. It further considers that clear definition of the roles and responsibilities of all involved at all levels in implementing policy should be undertaken and formally prescribed from the outset of the joint planning process.

Conducting monitoring and evaluation
Monitoring and evaluation allows the assessment of the degree of success, the quality, effectiveness and scope of collaborative TB/HIV activities and allows for adjustment of these to better meet programme targets, and respond effectively to the dual epidemics. The WHO global policy stresses that confidentiality and other ethical issues arising from monitoring and evaluation are important integral components of monitoring and evaluation programmes, as are collaboration between TB and HIV programmes, collaboration of both with the wider health sector and the development of appropriate linkages between those implicated by the collaborative activities.

Decreasing the burden of TB in people living with HIV/AIDS
To reduce the burden of TB disease among people living with HIV the World Health Organization (WHO) recommends anti-retroviral therapy (ART), which has both TB treatment and prevention benefits. In addition, the WHO strongly recommends three further important activities. These 3 activities are called the Three I's for HIV/TB and if implemented reduce the burden of TB disease among people living with HIV.

The Three Is for HIV/TB to reduce the burden of TB disease among people living with HIV
The three activities for people living with HIV/AIDS are
 * 1) the establishment of intensified TB case finding
 * 2) the introduction of isoniazid preventive therapy
 * 3) ensuring TB infection control in health care and congregate settings.

Together, these activities are commonly referred to as the three I's for HIV/TB

The Three I's for HIV/TB
The first I, Intensified Case Finding (ICF) for TB. ICF means regularly screening everyone with HIV for the 4 main symptoms and signs of TB and then doing the same for household members. This is particularly important for people living with HIV in congregate settings (such as mines, drug user galleries, prisons, refugee and internally displaced population camps and military barracks). Basic knowledge about symptoms of TB or simple TB screening questionnaires can be used by health care providers, community based organizations, the broader community, family members and people living with HIV to quickly identify and refer suspected cases of TB. This collective proactive response in turn allows health care providers to either quickly start TB treatment or prevent people living with HIV from getting TB by starting early preventive therapy.

The second I, Isoniazid preventive therapy (IPT) is TB preventive therapy. Preventive therapy means that medicines are given to us before we get a particular disease. Preventive therapy for TB uses isoniazid to kill latent TB infection. IPT can safely be given to people living with HIV without TB disease. This greatly reduces the chances of ever getting TB by between 30-60%, which is particularly important because TB is one of the leading causes of death among people living with HIV.

The third I refers to TB infection control (IC). These activities are crucial in preventing the spread of TB to vulnerable populations: including those who are immune suppressed because of HIV, those who live or work in  congregate settings (such as prisons, mines, refugee and internally displaced population camps, and military barracks), Injecting Drug Users (IDUs) and health care workers. To control TB collective responsibility is required. TB infection control requires the implementation of activities from national to personal levels. A national coordinating body can, for example, ensure the implementation of TB infection control measures in public facilities and individuals, for example, can make sure that homes are adequately ventilated.

The policy guidelines stress that immediate and full adoption of the Three I’s for HIV/TB is critical for communities, in protecting people living with HIV from TB, in helping to prevent active TB disease and in improving the chances of curing active TB. To meet this common responsibility, the policy guidelines envision a role for all people in the implementation the Three I's for HIV/TB.

(insert know your status table)

Decreasing the burden of HIV in TB patients
Access to health for people living with HIV/AIDS is implicated in the human right to health of which access to health care is a part. Such access includes clinical care and an uninterrupted continuum of care (prophylaxis, diagnosis, rational treatment, follow-up care) for people living with HIV/AIDS is a human right. Despite this, the vast majority of people infected with HIV do not know their status, their rights or their responsibilities as members of a given community. The global policy guidelines for people living with HIV/AIDS and TB considers five activities of crucial importance to changing this state of affairs.

The five activities are:
 * 1) Provision of HIV/testing and counselling
 * 2) Introduction of HIV prevention methods
 * 3) Introduction of co-trimoxazole preventive therapy
 * 4) Ensuring HIV/AIDS care and support
 * 5) Introduction of anti-retroviral therapy (ART)

Provision of HIV/testing and counselling
HIV testing and counselling for TB patients using rapid tests provide an entry point for prevention, care, treatment and support for individual patients: benefits accrue to their families and communities. testing provided in integrated care facilities should as in other environments should, as in other facilities for HIV, be readily available, voluntary, have the informed consent of the patient and protect patient confidentiality.

Introduction of HIV prevention methods
Control of the dual epidemics is enhanced by prevention of transmission of sexually, parenterally or vertically transmitted HIV. Reduction of sexually transmitted HIV requires delay in onset of sexual activity, measures to promote safe and responsible sexual behaviour and practices. limiting the number of sexual partners, correct and systematic use of barrier prophylaxes, diagnosis and treatment of other sexually transmitted diseases. Improving the safety of blood supply, and sterility of medical equipment, reduces parenteral transmission in medical settings, as does attention to strategies for harm reduction among people who inject drugs. These latter also include access to drug dependency treatments and outreach services. Provision of ART to pregnant women living with HIV reduces vertical transmission of HIV.

Introduction of co-trimoxazole preventive therapy
The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the WHO recommend co-trimoxazole and preventive therapy against bacterial and parasitic infections in eligible patients in Africa. This includes those living with HIV and TB.

Ensuring HIV/AIDS care and support
As discussed above, the global policy stresses that access to health for people living with HIV/AIDS is implicated in the human right to health, of which access to health care is a part. Such access includes clinical care and an uninterrupted continuum of care (prophylaxis, diagnosis, rational treatment, follow-up care) for people living with HIV/AIDS is a human right. Integration of services affords part of this continuum. The global policy calls for people who are living with HIV and are receiving or have completed treatment for TB to be retained within the services provided in the continuum of care, support and referral for services.

Introduction of anti-retroviral therapy (ART)
There is strong evidence that the introduction of anti-retroviral therapy improves the quality of life and the chances of survival for people living with HIV. The provision of ART is also considered to be a useful tool in controlling the dual epidemics because availability of and access to ART increases the likelihood that individuals are willing to learn their HIV status. The integration of TB and HIV services, as recommended by the global policy, would be significant for controlling TB in itself, controlling TB as the leading killer of those living with HIV and TB and control HIV by increasing diagnosis in people presenting to TB or HIV clinics who are unaware of their status. The WHO TB/HIV Core Group considers ART the best way to prevent HIV associated TB.