While tuberculosis remains the number one killer of people living with HIV – with one in three HIV-related deaths attributable to tuberculosis – the burden to provide TB-HIV integrated services falls heavily on tuberculosis programs, not HIV programs, a report from Action finds.
The report, “From Policy to Practice: How the TB-HIV response is working,” finds that national HIV programs often neglect World Health Organization recommendations for collaborative TB-HIV activities, and fail to develop adequate policy on such activities.
“National HIV strategic plans mention an average of six TB-HIV collaborative activities compared to national TB strategic plans’ average of 10 activities,” the report says, this, despite the fact that tuberculosis programs are greatly under-resourced compared to HIV programs.
“Despite including more collaborative activities in their strategic plans, national TB programs have far fewer resources with which to carry out these activities,” the report notes. In 2014, $6.6 billion was spent on tuberculosis globally, compared to $19.2 billion on HIV programs in low- and middle-income countries, the report says.
The global tuberculosis response is underfunded by $1.9 billion, the report says, and some national programs are massively underfunded, including Indonesia’s national program which is 66 percent unfunded, and Kenya’s which is 45 percent unfunded.
One essential TB-HIV activity that was missing from a majority of the 36 HIV strategic plans reviewed was treatment and care for TB patients living with HIV, the report notes. “Only half of the estimated number of people living with HIV who developed TB were diagnosed and provided with TB care,” the report says.
Only 58 percent of national HIV strategic plans include providing antiretroviral therapy for people co-infected with HIV and TB, compared to 81 percent of national tuberculosis strategic plans that include this policy. The report also notes only 47 percent of people on antiretroviral therapy are screened for tuberculosis and only 51 percent of people diagnosed with tuberculosis are tested for HIV.
Only 19 percent of the HIV strategic plans reviewed included providing HIV prevention interventions for people infected with tuberculosis, and 33 percent of HIV plans included setting up and strengthening a coordinating body for collaborative activities. Joint planning of national TB-HIV responses is largely left up to national tuberculosis programs, the report says.
The reluctance of national HIV programs to take up TB-HIV activities is largely driven by the fear that scaling up such services would come at the expense of other HIV-activities, namely scale up of antiretroviral therapy to meet UNAIDS treatment goals. The report recommends that the President’s Emergency Plan for AIDS Relief continue to use its leverage as a leading global HIV donor to “shift attitudes and practices so that HIV programs do see TB-HIV collaborative activities as their responsibility.”
In addition to reviewing TB and HIV national strategic plans, the study authors reviewed Global Fund HIV and TB grants, country operating plans funded under the President’s Emergency Plan for AIDS Relief, programs funded through the United Kingdom’s development assistance program and through the World Bank. They also conducted in-depth interviews with TB and HIV stakeholders in six high TB and HIV burden countries- Haiti, South Africa, Ukraine, Kenya, Cote d’Ivoire and Indonesia.
Other major findings outlined in the report include:
- Lack of appropriate tools undermines the TB-HIV response.
- Policy improvements have not all been translated into changes at the facility level.
- To achieve an effective TB-HIV response, more investment in human resources is needed.
- Donor assistance does not fill all of identified gaps in TB-HIV collaborative activities.
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