Overview

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.

Contents

• Abbreviations
• Executive summary
• 1. Background and process
  • 1.1 Introduction
  • 1.2 Scope of the policy
  • 1.3 Target audience
  • 1.4 Process of updating the policy
  • 1.5 Quality of evidence and strength of recommendation
  • 1.6 Adaptation of the policy
• 2. Goal and objectives of collaborative TB/HIV activities
• 3. Recommended collaborative TB/HIV activities
  • A Establish and strengthen the mechanisms for delivering integrated TB and HIV services
  • B Reduce the burden of TB among people living with HIV and initiate early antiretroviral therapy (the Three I's for HIV/TB)
  • C Reduce the burden of HIV in patients with presumptive and diagnosed TB
• 4. National targets for scaling up collaborative TB/HIV activities
• References
• Annexes
  • Abbreviations
  • Annex 1 Earlier initiation of antiretroviral therapy prevents active tuberculosis in people living with HIV – summary of findings and evaluation of the quality of the evidence
  • Annex 2 Voluntary counselling and testing for HIV benefits patients with diagnosed and presumptive tuberculosis – summary of findings and evaluation of the quality of the evidence
  • Annex 3 Co-trimoxazole preventive therapy (CPT) reduces morbidity and mortality in tuberculosis patients living with HIV – summary of findings and evaluation of the quality of the evidence
• Chinese
• French
• Russian
• Spanish

This is an updated version of a document originally published in 2004 as Interim policy on collaborative TB/HIV activities (WHO/HTM/TB/2004.330; WHO/HTM/HIV/2004.1)

Summary of declaration of interests: All members of the Policy Updating Group were asked to complete a World Health Organization (WHO) Declaration of interests for WHO consultants form. Five members of the group declared a conflict of interest. Constance Benson declared consulting, scientific and technical advisory work on antiretroviral therapy new drug development with Merck, GlaxoSmithKline and ViiV for less than US$ 5000 each. Pedro Cahn declared ongoing research support and consulting work with Abbott for an amount of US$ 3000. He declared receiving US$ 2000 from Bristol-Myers Squibb and US$ 2000 from Tibotec for serving on a speakers' bureau. He also declared scientific advisory work for Merck, Pfizer, GlaxoSmithKline and Avexa for an amount of US$ 2000 each. Mark Harrington declared giving testimony to the Institute of Medicine of the United States National Academies in panels on multidrug-resistant TB in 2008 and 2009. Charles Holmes declared employment by Gilead up to January 2008 in the clinical research unit focusing on phase I studies of experimental antiretroviral drugs. He declared no financial or other interest in Gilead. Salim S. Abdool Karim declared receiving US$2500 from Merck to attend the advisory panel meeting on microbicides in March 2011.

The declared conflicts of interest were discussed within the WHO Steering Group and with the Policy Updating Group before deliberations on the policy document, and it was concluded that these conflicts would not prohibit any of the members from participating in the process. Declarations of interest were collected from all non-WHO reviewers. Four peer reviewers declared potential conflicts of interest. Helen Ayles declared an ongoing research grant for her research unit with Delft Diagnostic Systems of € 100 000 to develop a computer-aided diagnostic for reading digital chest X-rays as well as having received a digital chest X-ray unit for an amount of US$ 250 000. François Boillot declared being the owner, director of and employed by a consulting company providing services in international health including in TB/HIV issues. Susan Swindells declared consulting services (advisory board) with Pfizer in 2008 (US$ 1800) and 2009 (US$ 1750), with Merck in 2009 (US$ 3500), with Tibotec in 2009 (US$ 1500) and with Abbott Molecular in 2010 (US$ 1000). She also declared previous research support to her institution from Bristol Myers Squibb that ended in 2010 (US$ 14929), from Pfizer that ended in 2011 (US$28125) and ongoing research support from GlaxoSmithKline for an amount of US$ 104034 and US$ 60676. Jay K. Varma declared non-monetary support (supplies and equipment) in 2010 valued at approximately US$ 10 000 from Cellestis to the government research unit of China and collaborators in Inner Mongolia to examine the prevalence of TB in health-care workers in collaboration with the United States Centers for Disease Control and Prevention. The WHO Steering Group discussed these declarations and concluded that they would not exclude the reviewers from the process. All declarations of conflict of interests are retained on electronic file by the WHO Stop TB Department.

Acknowledgements: The development of these guidelines was financially supported by the Joint United Nations Programme on HIV/AIDS Unified Budget and Workplan (UNAIDS UBW) and the US President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention (CDC) and the United States Agency for International Development (USAID). Partial support for the systematic reviews on TB and HIV service integration was provided by the Global Fund to Fight AIDS, TB and Malaria.

WHO policy on collaborative TB/HIV activities: Guidelines for national programmes and other stakeholders is based on the interim policy on collaborative TB/HIV activities published in 2004 by the World Health Organization (WHO) and written by Haileyesus Getahun, Jeroen van Gorkom, Anthony Harries, Mark Harington, Paul Nunn, Jos Perriens, Alasdair Reid and Marco Vitoria on behalf of the TB/HIV policy writing committee for the Global TB/HIV Working Group of the Stop TB Partnership. This updated policy was written by Delphine Sculier and Haileyesus Getahun (Stop TB Department, WHO) in collaboration with the WHO Steering Group.

WHO Steering Group: Rachel Baggaley (HIV/AIDS Department), Haileyesus Getahun (Stop TB Department), Reuben Granich (HIV/AIDS Department), Christian Gunneberg (Stop TB Department), Craig McClure (HIV/AIDS Department), Eyerusalem Negussie (HIV/AIDS Department), Delphine Sculier (Stop TB Department), Marco Vitoria (HIV/AIDS Department).

WHO consultants for systematic and GRADE reviews: Martina Penazzato (Italy), Amitabh Suthar (USA), Helena Legido-Quigley (UK).

Policy updating group: Yibeltal Assefa (Federal HIV/AIDS Prevention and Control Office, Ethiopia), Abdool Karim S. Abdool Salim (Centre for the AIDS Programme of Research in South Africa, South Africa), Rifat Atun (Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), Switzerland), Constance Benson (University of California, San Diego, USA), Amy Bloom (United States Agency for International Development (USAID), USA), Pedro Cahn (Fundación Huésped, Argentina), Rolando Cedillos (Proyecto Regional VIH SIDA para Centroamérica, El Salvador), Richard E. Chaisson (Johns Hopkins Bloomberg School of Public Health Center for TB Research, USA), Jeremiah Chakaya (Kenya Medical Research Institute (KEMRI), Kenya), Lucy Chesire (Advocacy to Control TB Internationally, Kenya), Mean Chhi Vun (National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, Cambodia), Gavin Churchyard (Aurum Institute for Health Research, South Africa), William Coggin (Office of the US Global AIDS Coordinator (OGAC), USA), Riitta Dlodlo (International Union Against Tuberculosis and Lung Disease (The Union), Zimbabwe), Ade Fakoya, (The Global Fund, Switzerland), Peter Godfrey-Fausset (London School of Hygiene & Tropical Medicine, UK), Anthony Harries (The Union, UK), Mark Harrington (Treatment Action Group, USA), Diane Havlir (University of California, San Francisco, USA), Charles Holmes (OGAC, USA), Nina Kerimi (United Nations Office on Drugs and Crime, Kazakhstan), Robert Makombe (United States Centers for Disease Control and Prevention (CDC), Botswana), Bess Miller (Global AIDS Program, USA), Ya-Diul Mukadi (USAID, USA), Jintanta Ngamvithayapong-Yanai (Research Institute of Tuberculosis, Japan), Alasdair Reid (Joint United Nations Programme on HIV/AIDS, Switzerland), BB Rewari (National AIDS Control Organization, India), Ashurova Rukshona (National Center for Prevention and Control of AIDS, Tajikistan), Holger Schünemann (McMaster University Health Sciences Centre, Canada), Lakhbir Singh Chauhan (Central TB Division, Ministry of Health and Family Welfare, India), Joseph Sitienei (Division of Leprosy, TB and Lung Diseases, Kenya), Alena Skrahina (Republic Scientific and Practical Center of Pulmonology and Tuberculosis, Belarus), John Stover (Future Institutes, USA), Jeroen van Gorkom (KNCV Tuberculosis Foundation, Netherlands).

External peer reviewers: Helen Ayles (ZAMBART Project, Zambia), François-Xavier Blanc (Agence nationale de recherche sur le sida et les hépatites virales, France), François Boillot (Alter-Santé Internationale et Développement, France), John T. Brooks (CDC, USA), Kevin Cain (KEMRI/CDC, Kenya), Wafaa El-Sadr (Columbia University, New York, USA), Eric Goemare (Médecins Sans Frontières (MSF), South Africa), Yared Kebede Haile (KNCV Tuberculosis Foundation, Netherlands), Steve D. Lawn (University of Cape Town, South Africa), Gary Maartens (University of Cape Town, South Africa), Barbara J. Marston (CDC, USA), Elizabeth Marum (CDC, Zambia), Max Meis (KNCV Tuberculosis Foundation, Netherlands), Sue Perez (free lance consultant, USA), Eric S. Pevzner (CDC, USA), Yogan Pillay (Strategic Health Programme, Department of Health, South Africa), Peter Saranchuk (MSF, South Africa), Kenly Sikwese (Global Network of People Living with HIV/AIDS, Zambia), Susan Swindells (University of Nebraska Medical Center, USA), Javid Syed (Treatment Action Group, USA), Nonna Turusbekova (KNCV Tuberculosis Foundation, Netherlands), Marieke van der Werf (KNCV Tuberculosis Foundation, Netherlands), Eric van Praag (Family Health International, United Republic of Tanzania), Jay K. Varma (CDC, China), Lynne Wilkinson (MSF, South Africa), Rony Zachariah (MSF, Belgium).

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