Health system barriers affecting the implementation of collaborative TB-HIV services in Uganda

SETTING

Despite Uganda's efforts to improve tuberculosis and human immunodeficiency virus (TB-HIV) collaborative services, implementation remains low and operational barriers have not been systematically identified and documented.

OBJECTIVE

To assess barriers to implementation of TB-HIV collaborative services in five districts in Uganda.

DESIGN

In this qualitative study, focus groups and key informant and in-depth interviews were conducted for patients (HIV, TB), health providers and community members. TB registers were also assessed for data on use of TB-HIV collaborative services.

RESULTS

Of 333 adult TB patients registered between July and September 2006, 185 (56%) were tested for HIV, of whom 134 were HIV-co-infected. Of these, 52% were on cotrimoxazole preventive therapy (CPT), 12% were on antiretroviral therapy (ART) and CPT, while 36% had not received any HIV service. Health system barriers identified included poor TB-HIV planning, coordination and leadership, inadequate dissemination of policy, inadequate provider knowledge, limited TB-HIV interclinic referral, poor service integration and recording, logistical shortages, high costs of services and provider shortages amidst high patient loads.

CONCLUSION

Implementation and utilisation of collaborative TB-HIV services remains suboptimal. The barriers identified highlight the need for TB and HIV programmes to support districts to plan, coordinate and invest resources in TB-HIV collaborative services, especially in policy dissemination, training health providers, integration of TB-HIV services, logistical management and monitoring.

Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues

Isoniazid preventive therapy (IPT) is recognised as an important component of collaborative tuberculosis (TB) and human immunodeficiency virus (HIV) activities to reduce the burden of TB in people living with HIV (PLHIV). However, there has been little in the way of IPT implementation at country level. This failure has resulted in a recent call to arms under the banner title of the 'Three I's' (infection control to prevent nosocomial transmission of TB in health care settings, intensified TB case finding and IPT). In this paper, we review the background of IPT. We then discuss the important challenges of IPT in PLHIV, namely responsibility and accountability for the implementation, identification of latent TB infection, exclusion of active TB and prevention of isoniazid resistance, length of treatment and duration of protective efficacy. We also highlight several research questions that currently remain unanswered. We finally offer practical suggestions about how to scale up IPT in the field, including the need to integrate IPT into a package of care for PLHIV, the setting up of operational projects with the philosophy of 'learning while doing', the development of flow charts for eligibility for IPT, the development and implementation of care prior to antiretroviral treatment, and finally issues around procurement, distribution, monitoring and evaluation. We support the implementation of IPT, but only if it is done in a safe and structured way. There is a definite risk that 'sloppy' IPT will be inefficient and, worse, could lead to the development of multidrug-resistant TB, and this must be avoided at all costs.