WHO policy on collaborative TB/HIV activities

Publication Year 28 Aug 2023

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Executive summary

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 tuberculosis (TB) and human immunodeficiency virus (HIV). The term interim was used because the evidence was incomplete at that time. Since then, additional evidence has been generated from randomized controlled trials, observational studies, operational research and best practices from programmatic implementation of the collaborative TB/HIV activities recommended by the policy. Furthermore, a number of TB and HIV guidelines and policy recommendations have been developed by WHO’s Stop TB and HIV/AIDS departments. Updated policy guidelines were therefore warranted to consolidate the latest available evidence and WHO recommendations on the management of HIV-related TB for national programme managers, implementers and other stakeholders.
The process of updating the policy was overseen by a WHO Steering Group and advised by a Policy Updating Group that followed WHO recommendations for developing guidelines. The Policy Updating Group comprised policy-makers, programme managers, experts in TB and HIV, donor agencies, civil society organizations including people living with HIV, and a grading of recommendations assessment, development and evaluation (GRADE) methodologist. The WHO Steering Group prepared the initial draft, which was circulated to the Policy Updating Group and discussed via e-mail and a conference call. The refined draft policy was reviewed again by the members of the Policy Updating Group and sent to a wide range of peer reviewers before finalization.
These policy guidelines on collaborative TB/HIV activities are a compilation of existing WHO recommendations on HIV-related TB. They follow the same framework as the 2004 interim policy document, structuring the activities under three distinct objectives: establishing and strengthening mechanisms for integrated delivery of TB and HIV services; reducing the burden of TB among people living with HIV and initiating early antiretroviral therapy; and reducing the burden of HIV among people with presumptive TB (that is, people with signs and symptoms of TB or with suspected TB) and diagnosed TB.
Unlike the 2004 document, the updated policy emphasizes the need to establish mechanisms for delivering integrated TB and HIV services, preferably at the same time and location. Those working to integrate the services should consider the epidemiology of HIV and TB, the health-system factors that are specific to individual countries, the management of HIV programmes and TB-control programmes and evidence-based models of service delivery. In addition, mechanisms for delivering the integrated services should be established as part of other health programmes such as maternal and child health, harm reduction services and prison health services. Monitoring and evaluation of collaborative TB/HIV activities should be done within one national system using standardized indicators and reporting and recording formats. TB prevalence surveys should include HIV testing, and HIV surveillance systems should incorporate TB screening as routine practice. The updated policy recommends setting national and local targets for collaborative TB/HIV activities through a participatory process (for example, through the national TB/HIV coordinating body and national consultations) to facilitate implementation and mobilize political commitment. Long-term and medium-term national strategic plans aligned with the health system of individual countries should be developed to scale up activities nationwide. National HIV programmes and TB-control programmes should establish linkage and partnerships with other line ministries and civil society organizations – including nongovernmental and community organizations – for programme development, implementation and monitoring of collaborative TB/HIV activities.
Interventions to reduce the burden of TB among people living with HIV include the early provision of antiretroviral therapy (ART) for people living with HIV in line with WHO guidelines and the Three I’s for HIV/TB: intensified TB case-finding followed by high-quality antituberculosis treatment, isoniazid preventive therapy (IPT) and infection control for TB. The policy recommends the use of a simplified clinical algorithm for TB screening that relies on the absence or presence of four clinical symptoms (current cough, weight loss, fever and night sweats) to identify people eligible for IPT or for further diagnostic work-up of TB. Managerial direction at national and subnational levels is needed to implement administrative, environmental and personal protective measures against TB infection in health-care facilities and congregate settings. These measures should include surveillance of HIV and TB among health-care workers and relocation of health workers living with HIV from areas with high TB exposure, in addition to providing ART and IPT.
The updated policy, in contrast to the 2004 policy, recommends offering routine HIV testing to patients with presumptive or diagnosed TB as well as to their partners and family members as a means of reducing the burden of HIV. TB patients who are found to be HIV-positive should be provided with co-trimoxazole preventive therapy (CPT). Antiretroviral treatment should be given to all HIV-positive TB patients as soon as possible within the first 8 weeks of commencing antituberculosis treatment, regardless of their CD4 cell-counts. Those HIV-positive TB patients with profound immunosuppression (e.g. CD4 counts less than 50 cells cells/mm3) should receive ART immediately within the first 2 weeks of initiating TB treatment. TB patients, their family and community members should be provided with HIV prevention services.
HIV programmes and TB-control programmes should collaborate with other programmes to ensure access to integrated and quality-assured services for women, children, prisoners and for people who use drugs; this population should also receive harm-reduction services including drug dependence treatment in in-patient and out-patient settings.