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Expert View: Dr. Refiloe Matji on Integration of Care for TB/HIV Co-Infection

Dr. Refiloe Matji is an authority on TB surveillance, care, and control and has been a leader in raising awareness of TB/HIV co-infection, both in South Africa and internationally. As URC’s Regional Director for Southern Africa, she oversees the USAID-funded Quality Assurance Project's activities in South Africa, Lesotho and Swaziland, the TASC2 TB Project in South Africa, CDC-funded activities on HIV counseling and testing in South Africa, Lesotho and Swaziland, and the Injection Safety Project in Namibia. She has participated in numerous TB control and prevention workshops throughout Africa and at the World Health Organization in Geneva, has made numerous presentations on the topic of TB/HIV control and care at international conferences, and has published guidelines and training manuals on TB/HIV control strategies. We recently had an opportunity to speak with Dr. Matji about the challenges countries face in providing a coordinated response to the dual epidemics of HIV and TB.

Why do TB and HIV programs need to collaborate?

The emergence of multi-drug resistant tuberculosis (MDR-TB), followed by recent outbreaks of extensively-drug resistant tuberculosis (XDR-TB), and their association with very high case fatality rates in people living with HIV & AIDS, is a wake-up call for implementation of integrated TB/HIV services and gives urgency to the need for enhancing capacity for expedited diagnosis and treatment of TB among persons with HIV & AIDS.

South Africa carries a heavy burden of TB/HIV co-infection. Tuberculosis and HIV are posing a serious threat to the country’s public health and economic well-being because they affect the most productive segments of the population and disproportionately affect the poor. The HIV & AIDS epidemic has further complicated control and treatment of tuberculosis, the most common opportunistic infection among PLWHA. In South Africa, 60% of patients who present with TB also have HIV. In the neighboring countries of Swaziland and Lesotho, that number climbs to a staggering 80%.

The impact of TB/HIV co-infection is enormous. Co-infected patients are sicklier and pose unique diagnostic and treatment challenges. The emergence of XDR-TB, which is a result of inadequate TB control as well as inadequate laboratory diagnostic capacity, is associated with an unprecedented case fatality rate among HIV-infected patients. In 2005, an outbreak in KwaZulu-Natal resulted in the deaths of 52 out of 53 HIV-positive patients with suspected XDR-TB.

What are the barriers to diagnosing tuberculosis in HIV/AIDS clients?

In the past, TB diagnosis was easier, but now, the existence of advanced HIV disease hinders the standard tests used to diagnose TB. In essence, we are dealing with the limitations of old technology. It can be very difficult to rule out active TB infection in people with HIV. In hospitals, you see very ill patients, and x-rays don't always show whether there is active TB. Sputum smear microscopy, the primary diagnostic test for active and infectious tuberculosis, cannot detect TB that has spread from the lungs to other parts of the body, a common complication in people with HIV. Wherever HIV co-infection is prevalent, smear microscopy, at best, can detect around 45-60% of people who have active TB. If smears are negative, it may still be possible to find active TB by sending a specimen out to the regional reference laboratory for ‘culturing,’ but the process can take more than a month. Most laboratories have inadequate capacity to diagnose TB in PLWHA. The result has been increases in the number of undiagnosed TB cases and a greater number of very ill patients.

What has been the response at the country level to integration of treatment programs?

Traditionally, countries have had separate structures to deal with each type of disease. Collaboration involves creating synergies between two well-established vertical programs with little existing horizontal integration. Integrating TB and HIV detection and treatment requires governments to see the need for restructuring existing systems without creating a third (TB-HIV) system. Existing vertical programs must find ways to collaborate towards the common goal of saving lives. This collaboration is rarely a simple task.

HIV has been much higher on the political agenda of many countries—lobby groups have ensured that HIV has been made a top priority. There has been a multi-sectoral approach to addressing HIV/AIDS, and there are large funding discrepancies between HIV and TB programs. Also, there are many human resource issues, including a shortage of skilled staff. There has been much less of a sense of urgency surrounding improving services for treatment of TB and not enough progress has been made.

Also, there has been a greater focus on managerial issues instead of on facility-level clinical service integration.

What are the particular monitoring and evaluation challenges?

Most often you see one patient with two conditions managed by three M&E systems (TB, HIV, and TB/HIV) but only one health care worker to manage the same co-infected patient. The challenge lies in the question of how we monitor co-infected patients when programs are developing parallel M&E tools. We see healthcare workers bring more than 10 different registers to treat one patient. This raises significant confidentiality issues, which are of great importance given the strong stigma attached to both diseases.

How about the drug management component?

There are many issues that complicate the question of where co-infected patients should be managed and where they obtain their treatment drugs. Policies between the programs often conflict, resulting in patients not gaining access to the drugs that they need. There has been an emphasis on adherence counseling and antiretroviral therapy (ART) readiness prior to ART commencement for HIV-positive patients, but counseling has been limited in TB services. TB patients must be referred to another system to receive ART drugs. Globally, in 2005, only about 25,000 TB patients received ART. There are important discrepancies between programs. For instance, the policy of TB programs has been that all co-infected patients should be put on cotrimoxazole prophylaxis, while the policy of HIV/AIDS programs has been that only HIV-positive patients with CD4 counts of <200 should be on cotrimoxazole.

Infection control is fundamental to addressing XDR TB. What should countries be focused on in this area?

TB infection control includes implementation of administrative and environmental controls (i.e., natural or mechanic ventilation systems), and respiratory protection measures (i.e., use of respirators) as well as ensuring safety in micro-bacteria labs. The emergence of MDR (multi-drug resistant) and XDR TB poses a serious threat both to TB and to HIV/AIDS programs. Programs need to address these key questions: Are infection control policies in place at levels? Is there supervision to ensure implementation? What are the cost implications for implementing infection control policies? Are resources being made available? Are staff being trained in infection control measures?

What are the basic strategies for successful integration of TB and HIV/AIDS services?

These are really the basic components of effective TB control strategies worldwide. Political commitment is essential to increasing case detection and cure rates in any given country. The involvement of skilled clinicians in care delivery is particularly important for TB-HIV co-infection, since the clinical manifestations of the two infections can be complex. There must also be effective drug supply and management and compatible monitoring and evaluation systems. DOTS, a central component of the TB global strategy, demands effective collaboration between TB and HIV treatment and a continuum of care that extends into the community. Widespread access to counseling and testing is also fundamental to successful integration of TB/HIV services. At the international level, greater attention must be placed on development of new diagnostic tools for TB.

All of this speaks to a need to generate commitment to improve the management of co-infected clients at the highest decision-making levels of governments. TB programs must take a lead and emphasize the importance of improving management of co-infected patients through advocating for HIV counseling and testing, provision of ART, and implementation of a continuum of care. TB/HIV collaboration should not be seen as another new program; rather the focus should be placed on finding concrete ways in which existing TB and HIV/AIDS programs can collaborate to successfully manage co-infected patients.

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