HIV/AIDS and tuberculosis (TB) continue to present significant health problems worldwide, specifically for many developing nations, with millions of people of all ages affected. These diseases have negative impact on health and economic stability of affected countries. Therefore, the present review aims at gathering diverse and promising recent strategies that have been successfully implemented in some countries and from which the researcher country (Rwanda) may take a lesson of how to deal properly with HIV/AIDS and TB.
According to an analyst in global health known as (Alexandra 2011:2), Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome (HIV/AIDS) and tuberculosis (TB) are two of the world's leading causes of morbidity and mortality. In 2007, according to estimates from UNAIDS, 33 million of people in the world were living with HIV. The annual number of new infected individuals was estimated to be 2.7 million, of which 1.9 million were in Sub - Saharan Africa in 2009, 1.8 million people died from AIDS and 1.3 million died from TB. Along with the direct health effects, HIV/AIDS and TB have far- reaching socio-economic consequences, posing what many analysts believe are threats to international development and security.
In 2003, 70 percent of that co-infected with TB and HIV lived in Africa. High rates of HIV caused TB rates to skyrocket. For example, in Kenya, the number of new TB cases is increasing at the alarming rates of 12 percent each year. In Cote d'Ivoire, Ethiopia, Mozambique, Namibia, Nigeria and South Africa, the rate is increasing at 7 percent annually. Corbett EL et al (2003:163) .This is a contrast to a global annual rate of increase in TB of just 0.4 percent. WHO Report (2003).
While TB works in deadly synergy with HIV/AIDS to take advantage of those with weakened immune systems, TB is far more than just an opportunistic infection. TB is an airborne infectious disease that kills 2 million people a year (the majority of whom are HIV negative), making it the greatest curable infectious killer on the planet .This has significant implications for public health in regions with high levels of HIV and TB, and for the global community .A person with active TB has been estimated to spread the disease to some 15 other people in a year even in low HIV prevalence settings.
Open Society Institute (2004: 13).
What about Rwanda?
Rwanda's high rates of TB and HIV can be expected to rise further if the current political situation does not improve. TB/HIV co-infection rate stands at 37 percent-one of the highest in the region -demonstrating the importance of reversing the decline in TB control efforts and the importance of expanding and strengthening Directly Observed Therapy (DOTS) programs as a main entry for scaling up HIV/AIDS efforts. Open Society Institute (2004: 33).Currently Rwanda ranges With HIV prevalence of 5% in the 15-49 year old population in the country, 400 per 100,000 of the population have tuberculosis with a small but growing number of Multi drug resistant TB cases. The present situation calls upon strong strategies so as to reduce that high prevalence of HIV and fighting against TB.
Main goal: To contribute to strengthening of HIV/AIDS and TB control programs in Rwanda
To identify strategies (in terms of Governance and regulatory issues, Health information systems and product supply delivery) that have been implemented successfully both in developed and developing countries as far as HIV and TB are concerned.
To identify the ways of transferability of those successful strategies and evidence supporting them in Rwanda
HIV/AIDS AND TB CONTROL STRATEGIES WORLWIDE
Fighting against the negative consequences of TB and HIV needs multidimensional strategies. Good governance and regulatory policies are required in order to enable decentralization and coordination of service of quality to the people in need. Furthermore strong Health Information System is recommended in order to manage properly patient and diseases information and to face a problem of data duplication within health facilities.
Strategic components used in EUROPE Vis à Vis TB and HIV control (Pierpaolo et al, 2003.p. 17-23)
The strategic framework to reduce the burden of TB/HIV in Europe is based on the following key operations: political commitment, collaboration of national HIV/AIDS programs and national TB programs in promoting, intensified case-finding, coordinated treatment and strengthened surveillance, policy development, training, supply management, service delivery, health promotion and research. Each country should determine the most effective way of
Implementing these key operations, depending on the burden of TB/HIV, the
organization of the health system and the availability of resources.
1. Political commitment
Political commitment is needed to promote full implementation of the strategies for HIV/AIDS prevention and control, for TB control and for the programs collaborative efforts to tackle TB/HIV. Establishing a national high-level committee may promote coordination, and inter sector collaboration and additional political and financial support. Existing international initiatives should be utilized to foster government commitment and provide additional resources, such as the Stop TB Partnership and the Global Fund to Fight AIDS, Tuberculosis and Malaria
(Http: //www. globalfundatm.org).
2. Collaborative prevention for TB and HIV transmission.
The core responsibilities of the national HIV/AIDS program for HIV/AIDS prevention include promoting safer sex and safer injecting drug use, treating Sexual Transmission Infection STI, screening blood for HIV, implementing universal precautions, and providing prophylaxis to prevent mother-to-child transmission (MTCT) of HIV and diagnosing HIV infection early. All these interventions can reduce HIV transmission, thereby contributing to a declining burden of TB/HIV. The core responsibility of the national TB program is to fully implement the international strategy for controlling TB. Four specifics preventive interventions are recommended for collaborative action by national HIV/AIDS programs and national TB programs: Isoniazid preventive therapy, prevention with positive, environmental measures and post-exposure prophylaxis.
3. Intensified case-finding of HIV among people with TB and of TB among people living with HIV WITH HIV PLWHA
Early diagnosis of both conditions can limit transmission, decrease the related morbidity and mortality and improve people's quality of life. Voluntary counseling and testing (VCT) is an important entry point for providing comprehensive care to PLWHA. This also includes antiretroviral therapy (ART) among TB patients and TB
Screening among PLWHA, followed by treatment or IPT. Investigation of PLWHA with respiratory symptoms consistent with TB should always include sputum smear
Microscopy (and culture for Multi resistant tuberculosis where available).
4. Coordinated treatment of PLWHA who have TB with TB drugs and ARV drugs
It requires careful clinical management. TB treatment should usually have priority over antiretroviral therapy (ART). It should contain rifampicin and be initiated promptly and directly observed. Careful evaluation is necessary in judging when to start ART because of the potential interaction of ARV drugs with rifampicin and
the risk of a paradoxical reaction (due to immune reconstitution syndrome). In patients with pulmonary TB and CD4 T-lymphocyte count exceeding 200 per mm3, ART should be deferred until TB treatment is completed. In patients with a high risk of HIV disease progression and mortality - extra pulmonary TB or CD4 count less than 200 per mm3 - ART should be provided concurrently with TB Treatment.
5. Strengthened surveillance is critical in controlling TB and HIV/AIDS
Effective surveillance provides data that can be used to develop evidence-based
policy, to monitor programs and to evaluate impact. An effective surveillance system should be able to identify the number and proportion of PLWHA who have TB, the number and proportion of TB patients who are HIV-positive, the risk factors associated with TB/HIV infection, the gender differences, the modalities and outcome of care and the level of drug resistance. Surveillance systems for TB
and HIV/AIDS should be sufficiently integrated to be able to perform these functions. Effective methods of linking data on TB and HIV/AIDS must preserve people's right to confidentiality. Notification of HIV together with notification of the same person for other diseases should maintain confidentiality.
6. Policy development
It supports the effective coordination of and collaboration on TB/HIV interventions. The main areas of work include: Ii) developing policies that promote closer collaboration between national HIV/AIDS programs and national TB programs; ii) reviewing the guidelines of national HIV/AIDS programs and national TB programs
to ensure that they include TB/HIV; iii) developing national protocols and standards for good clinical practice, including ethics and confidentiality; iv) developing partnership with stakeholders, including NGOs (such as patients' organizations
and charitable organizations) and private enterprises; v) establishing referral systems between the services of national HIV/AIDS programs and national TB programs. An advisory group should develop national TB/HIV policies and
guidelines. Such a group should include epidemiologists, public health officials and representatives of the ministry of health, other relevant ministries, NGOs and other partners such as specialized HIV/AIDS and drug control agencies.
7. Training on the job
This training should be planned for personnel and other service providers (such as volunteers) to increase and update knowledge on the transmission, prevention and care of HIV/AIDS, TB and TB/HIV. It should also cover universal
precautions against HIV and preventing HIV and TB transmission in special settings (such as hospitals, drug dependence treatment services and prisons). Training on how to communicate effectively with patients is also important, especially considering barriers resulting from stigma and social differences. Collaboration between universities, training institutions, professional societies and NGOs is important in developing graduate and postgraduate education and training
for health staff involved in HIV/AIDS and TB programs.
8. Supply management
Supply management is essential to ensure an uninterrupted supply of high-quality anti-TB drugs. This enables TB patients to receive an uninterrupted course of effective treatment and reduces the risk of drug resistance. . When PLWHA are screened for TB by non-TB services, this should be supported by at least adequate supplies for collecting sputum smears and shipping the samples. The availability of ARV drugs may promote uptake of VCT. The national HIV/AIDS programs and national TB programs need to collaborate in providing PLWHA who have TB with ART, whether in TB or in infectious disease or HIV facilities. The Global TB Drug Facility (GDF) provides a good model for procuring, controlling the quality of and distributing antiretroviral drugs.
9. Service delivery
It involves clarifying the professional and administrative responsibilities necessary to provide six priority collaborative services between the national TB
Programs and national HIV/AIDS: I) making available VCT for all TB patients; ii) referring TB patients who are found to be HIV-positive for lifelong HIV
support, care and treatment; iii) detecting and treating TB among PLWHA; iv) ensuring IPT treatment to PLWHA who are infected with TB but found not to have active TB; v) Applying universal HIV precautions and environmental TB measures for health care workers and users;
vi) making available post-exposure prophylaxis for everyone exposed to HIV. These collaborative services are part of an HIV/AIDS essential package that includes interventions against HIV (and therefore indirectly against TB) and interventions directly against TB. Services can be delivered at home and at the primary, secondary and tertiary levels of care. Service delivery in each country should be planned based on the epidemiology of TB/HIV, the organization of the health system and the resources available. NGOs may be key partners in serving populations at high risk of HIV and TB.
10. Health promotion through advocacy, communication and social mobilization
It is essential for expanding the HIV/AIDS and DOTS strategies. Combining the resources and experiences of national HIV/AIDS programs and national TB programs could enhance advocacy, communication and social mobilization.
11. Research is essential in all public health programs
Epidemiological research and surveillance should inform the priorities set among
interventions and monitor their impact. Clinical research may improve the diagnosis, treatment and prophylaxis of HIV-related TB. Operational research is relevant to improving intensified TB case-finding, managing TB/HIV patients, supply, training and intra sector and inter sector collaboration.
Achievements of Africa and Asia in area of HIV/TB control
USAID/Uganda began its support in 2001 to develop and implement the TB control strategy , including integrating TB-HIV , expanding community -based DOTS (CDOTS) to all District, and strengthening district level TB planning , surveillance ,timely reporting , and supervision. (USAID/Uganda, Tuberculosis Profile, May 2005. P. 2 ). The overall aim was to increase capacity at the national and district levels to manage TB control programs effectively, and to contribute to the national goal of increasing case detection and treatment success rates, leading to reduced mortality in TB-HIV/AIDS co-infected by 50 percent .The USAID/Uganda achievements have been:
Achieved case detection and treatment success rates above the national average in US. Government -supported district, reaching 53 and 86 percent, respectively.
Increased HIV care and treatment for TB patients from 20 to 69 percent, increased the number of TB-HIV/AIDS patients on antibiotics to prevent opportunistic infections from 40 to 88 percent, and increased the number of TB -HIV/AIDS patients on antiretroviral from 5 to 29 percent in USAID -supported areas; developed and distributed TB-HIV/AIDS supervision tools for district and managers.
Developed and tested management information systems tools for TB laboratories , updated infection (IC) policy , and assisted the NTLP in IC strategy development and so on …
Some other African and Asian countries have taken also strong Information Technologies strategies to weaken and control the spread of HIV and TB. Among these strategies we can name diseases focuses Information Systems in order to be able to control the trends of diseases and to procure quick and service of quality. Thus Information System knows as Cell - PRIVEN was developed in PERU, CA: SH was developed in INDIA, Epihandy was developed in Uganda, Zambia and Burkina Faso (Furaha 2011: 15)
Rwanda should take example of Europe, some African and Asian countries according to the above mentioned achievements and see where it can improve. Therefore the following recommendations can be helpful:
Rapid acceleration of DOTS coverage, access and quality increase case detection and treatment success rates towards attainment of regional and global TB control targets including those of MDGs.
Roll out of TB / HIV collaborative activities to contain the TB epidemic in the context of the HIV epidemic.
Ensure availability of sufficient numbers of trained human resources for delivery of health services including TB services.
Adopt the task shifting policy and decentralization of ARVs and TB drugs
Strengthen and expand national laboratory networks to contribute efficiently to TB control, including drug resistance surveillance.
Improve political and community commitment and involvement in HIV and TB control, particularly at District level and health facility level.
Meet the technical and financial needs for tackling TB as public health emergency in the region.
Strengthen surveillance systems to measure and monitor selected HIV and TB related indicators and targets.
Forging new partnership, especially public -private partnerships at national and district levels.
These strategies have been successful in Europeen and African can countries researcher, beneficiaries and stakeholders were supportive to them so there is evidence that transferability of these strategies can really be achieved through positive collaboration among above mentioned countries since our country is peaceful without any conflict. Accordingly there is a political commitment and awareness regarding HIV/TB control.