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Talking points: the Launch of the updated WHO policy guidance on

Collaborative TB/HIV activities

Background and key messages:

In 2004, the World Health Organization (WHO) published an interim policy on collaborative
TB/HIV activities in response to demand from countries for immediate guidance on actions
to decrease the dual burden of TB and HIV. As the evidence base for all the
recommendations was not complete at the time the policy was developed, the term interim
was applied.

The policy, which provided guidance for Member States and other partners on how to
address the HIV-related TB burden, has been implemented in many countries. The rapid
implementation of the interim policy with financial support from national governments, the
US Presidents Emergency Programme for AIDS Relief, the Global Fund for AIDS, Tuberculosis
and Malaria and other donor has catalysed important gains in the fight again TB and HIV.
The Policy led to the WHO Three Is for HIV/TB and earlier ART when eligible initiative which
has focused on preventing TB and HIV in people living with HIV.
Key achievements since the launch of the policy in 2004
o More than 100 countries are now testing more than half of their TB patients for HIV.
Progress was especially noteworthy in Africa, the number of countries testing more
than half their TB patients for HIV rose from five in 2005 to 31 in 2010.
o The number of people living with HIV screened for TB increased 12-fold, from nearly
200,000 in 2005 to over 2.3 million people in 2010.
o More than 60% of the estimated people living with HIV who developed active TB
were identified and treated for TB in 2010
o Thanks to increased implementation and scale-up of the above activities, it is
estimated that nearly a million lives were saved between 2005-2010.
Since the launch of the interim policy, additional evidence in the field of TB and HIV has been
generated through research and implementation experience from countries and used to
update the policy. The updated policy will help scale up and accelerate coordinated public
health interventions to further reduce deaths from this lethal combination of TB and HIV.

What are the links between HIV and TB?
HIV and TB are so closely connected that the term co-epidemic or dual epidemic is often used to
describe their relationship. The intersecting epidemic is often denoted as TB/HIV or HIV/TB. HIV
affects the immune system and increases the likelihood of people acquiring new TB infection. People
living with HIV have an estimated 21 to 34 times greater risk of developing active TB than people
without HIV infection and in some settings people living with HIV have a 10% per year chance of
developing the disease. It also promotes both the progression of latent TB infection to active disease
and relapse of the disease in previously treated patients. TB is one of the leading causes of death in
HIV-infected people, 350 000 people died of HIV-related TB in 2010, which makes TB responsible for
one in four AIDS deaths.

How many people are co-infected with TB and HIV?

An estimated one-third of the 34 million people living with HIV worldwide are co-infected with latent
TB. In 2010, there were an estimated 1.1 million TB cases among people living with HIV globally the
majority of which (82%) are in sub-Saharan Africa.
What is the impact of co-infection with TB and HIV?
Each disease speeds up the progress of the other, and TB considerably shortens the survival of
people with HIV. HIV infection is the most potent risk factor for converting latent TB into active TB,
while TB bacteria accelerate the progress of AIDS infection. Many people infected with HIV in
developing countries develop TB as the first manifestation of AIDS. The two diseases represent a
deadly combination, since they are more destructive together than either disease alone.
TB is harder to diagnose and progresses faster in people living with HIV.
TB in HIV-positive people is almost certain to be fatal if undiagnosed or left untreated.
TB occurs earlier in the course of HIV infection than many other opportunistic infections.
What can be done to address the dual TB and HIV epidemics?
In 2004 the World Health Organization issued an interim policy on collaborative TB/HIV activities
giving guidance on what should be done to decrease the burden of TB and HIV in people at risk of or
affected by both diseases. It presents 12 key collaborative activities that address the interface of the
TB and HIV epidemics and that should be carried out as part of the health sector response to
The objectives of the collaborative TB/HIV activities are:
(1) To establish and strengthen the mechanisms of collaboration and joint management between
HIV programmes and TB-control programmes for delivering integrated TB and HIV services
preferably at the same time and location;
(2) To reduce the burden of TB in people living with HIV, their families and communities by ensuring
the delivery of the Three Is for HIV/TB and the early initiation of antiretroviral therapy (ART) in line
with WHO guidelines;
(3) To reduce the burden of HIV in patients with presumptive and diagnosed TB, their families and
communities by providing HIV prevention, diagnosis and treatment.
What has been the impact of the 2004 interim policy?
Since 2005 more than 100 countries have now adopted the TB/HIV policy and are testing more than
50% of their TB patients for HIV. This includes 31 countries in the WHO African region. Overall, it has
been estimated that 910,000 lives were saved between 2005 and 2010. The 2004 Interim policy has
provided a highly effective framework for implementing partners and donors to focus their
resources. As a result of implementation and scale-up of the collaborative TB/HIV activities, more
than 60% of TB patients estimated to have HIV were registered for HIV care in 2010, compared with
14% in 2005. The number of people living with HIV who were screened for TB increased more than
twelvefold from 200,000 to 2.3 million. Of those who did not have active TB disease, 180,000
received isoniazid preventive therapy, compared with 26,000 in 2005.

What is new in this policy update?

The 2012 policy update emphasizes the following new elements in the implementation of
collaborative activities:

maximizing the prevention impact of the Three Is for HIV/TB (Isoniazid preventive treatment,
Infection control for TB, and Intensified case finding) and earlier ART

establishing mechanisms for delivery of integrated TB and HIV services at the same place
and time as much as possible;
integrating TB and HIV services into other health programmes such as maternal and child
health, harm reduction services and prisons health services;
strengthening monitoring and evaluation in one national system using standardised and
harmonised TB/HIV reporting and recording formats and indicators;
incorporating TB screening as a routine practice into HIV surveillance systems;
the use of a simple clinical algorithm for TB screening that relies on the absence or presence
of 4 symptoms: current cough, weight loss, fever and night sweats, to identify people living
with HIV eligible for at least 6 months of IPT or for further diagnostic investigations for TB.
As part of the Three Is for HIV/TB, ensuring the early initiation of ART in line with WHO
guidelines to prevent TB among people living with HIV.

Who is this policy targeted at?

These policy guidelines are intended for decision-makers in the field of health and for managers of
TB-control programmes and HIV programmes working at all levels in the health sector, including the
private-for-profit sector, as well as donors, development agencies, nongovernmental organizations
and other civil society organizations supporting such programmes, and people living with, at risk of
or affected by HIV and TB. The recommendations contained in these guidelines also have important
implications for the strategic directions and activities of other line ministries working on TB, HIV or
harm reduction services, such as ministries responsible for prisons, mining and workplace health
services, youth in education facilities, and other stakeholders in maternal and child health
What are the enablers for nationwide scale-up and success in countries?
Setting time-bound targets for collaborative TB/HIV activities at all levels in a participatory
manner. This facilitates timely implementation and monitoring, and helps mobilize political
commitment from all the necessary stakeholders.
Creating an environment conducive to the development of appropriate policy, operational
guidelines, training manuals and protocols in line with international guidelines.
Expanding HIV testing in facilities and communities including by supporting TB health-care
workers to test TB patients.
Expanding the scale-up of ART, including using the highly decentralised TB service outlets.
Ensuring an uninterrupted supply of HIV rapid tests, anti-tuberculosis and antiretroviral
medicines, and other HIV and TB commodities.
Implementing recording and reporting formats that capture collaborative TB/HIV activities
with inclusion of TB components in HIV registers and HIV components in TB register.
Where are there good examples for scale-up of collaborative activities that we can learn from?
The coverage of HIV testing for TB patients was particularly high in the African and European regions,
where 59% and 80% of TB patients respectively knew their HIV status. In 22 out of 46 countries of
the African region, more than 75% of TB patients knew their HIV status.

Countries that included highest rates of enrolment of Co-trimoxazole Preventive Therapy (CPT) in
2010 included Burkina Faso, Burundi, India, Kenya, Lesotho, Mozambique, Malawi, Mali Myanmar,
Namibia, Rwanda, Swaziland, the United Republic of Tanzania and Uganda. The African and South
East Asia regions achieved particularly high levels of enrolment of CPT, with 76% and 87% of TB
patients known to be living with HIV provided with CPT respectively
The highest rates of enrolment of ART for TB patients were reported in countries in the Region of the
Americas, notably Brazil at 93%. Other examples include: Kenya that has increased the percentage
of TB patients receiving ART from 17% in 2005 to 48% in 2010; South Africa providing ART for 54% of
TB patients living with HIV in 2010; In India 57% of TB patients with HIV received ART in 2010.