Addressing tuberculosis in differentiated care provision for people living with HIV

Despite advances in prevention, diagnosis and treatment of tuberculosis and human immunodeficiency virus (HIV), tuberculosis remains the leading cause of death and illness among people living with HIV. In 2015, an estimated 1.2 million of the people who developed tuberculosis disease worldwide were HIV positive, and tuberculosis was the direct cause of at least one third of HIV-related deaths. (1) The 2015 "Treat All" strategy requires that everyone with HIV is offered antiretroviral therapy (ART) as soon as they are diagnosed. By treating HIV infections earlier, this strategy should mitigate the HIV-associated tuberculosis epidemic, but it alone is not sufficient to eliminate preventable tuberculosis suffering and deaths among people living with HIV. (2) The 2016 World Health Organization (WHO) guidelines recommend differentiated HIV service delivery, which is intended to facilitate the "Treat All" strategy by tailoring services to the differing needs of individuals. (3) As HIV programmes adopt these WHO guidelines, tuberculosis also needs to be addressed. (3) Compared to the general population, people living with HIV have a significantly higher risk of tuberculosis even if they are stable on treatment and have high CD4+ T-lymphocyte counts. (4) Therefore, WHO recommends that all people living with HIV are screened for tuberculosis symptoms (cough of any duration, weight loss, fever or night sweats) at every patient encounter. (3) One of the implications of differentiated care is that the intervals between clinic visits and/or antiretroviral pick-ups from pharmacies may be extended to three or six months for people who are stable on ART. However, routine tuberculosis screening is still needed regularly, followed by appropriate evaluation, accurate diagnosis and treatment for either tuberculosis disease or latent infection. (3) Patients should also be able to receive tuberculosis preventive therapy at the same time that they pick-up their antiretroviral medications. (5-7) As part of differentiated care, community health workers, ART clubs and other models of community service delivery are increasingly being used by HIV-treatment programmes. In these models, participants could be trained to screen for symptoms of tuberculosis and other opportunistic infections, refer people for further evaluation and dispense tuberculosis preventive therapy. This approach has been piloted in several sub-Saharan African settings. (8-12) In addition, improving participants' understanding of tuberculosis will help them to recognize symptoms in themselves and family members and advocate for their own care. …