Forty-one countries will from 2014 be required by the Global Fund to submit joint TB-HIV concept notes under the new funding model in what experts in both fields consider to be necessary and beneficial but also challenging to implement.
The decision by the Global Fund to require countries with high rates of TB-HIV co-infection to submit joint concept notes was announced last October (see article) and reflects the sense that separate programs for TB and HIV in countries with high rates of co-infection was wasting valuable resources. Most of those countries are in sub-Saharan Africa, reflecting the impact of co-infection on the continent. In 2012, the region carried the burden of most of the estimated 1.1 million new TB cases among people living with HIV.
Sobering statistics globally also underscore the need for a more integrated approach to the two diseases. At least one-third of the 35.3 million people living with HIV worldwide are infected with latent TB. They are 20 times more likely to develop active TB than people who are sero-negative, and more likely to die of TB than any other HIV-related illness.
“The public health response to HIV and TB in high burden countries needs to be fully integrated. Maintaining parallel HIV and TB programs is not an option,” said Luiz Loures, deputy executive director of programs at UNAIDS. “Encouraging and facilitating joint HIV/TB responses has the potential to be a ‘game changer’.”
Integration will be beneficial because it will result in reduced morbidity and mortality and better health outcomes, the experts said, and will lead to improved care for co-infected patients. In addition, integration should produce better epidemiological data.
Cost-savings can be re-invested to produce a stronger response by two groups of researchers, advocates and disease experts who could probably learn a lot from each other.
“There will be challenges, to be sure, but this is something that has to happen,” said Lucica Ditiu, executive secretary of the Stop TB Partnership, in a telephone conversation with Aidspan. “A critical factor will be getting TB and HIV programs to buy into the idea. They must understand that this is the only way to move forward.”
Among the challenges in bringing about integration, the experts said, is that the programs inhabit separate and different worlds. In the pantheon of global health programming and funding priorities, HIV has a higher profile. This will lead to natural, but avoidable, turf wars that will need to be overcome not just by research extolling the virtues of joint programming but a deep and abiding commitment to collaboration.
“This joint concept note process will be great for countries in the long term. There are many economies of scale and synergies to be leveraged,” said Ellen Mitchell of the Netherlands-based TB foundation KNCV.
There are also likely to be some struggles over resource allocation; one scenario that could play out is the overemphasis on key populations at heightened risk for co-infection at the expense of larger populations at risk of only TB.
This will require a robust monitoring and evaluation framework that does more than just combine HIV and TB indicators, the experts cautioned.
Finally, the experts noted that providers of technical assistance may themselves need training in new skills in order to provide relevant, timely and contextual assistance on joint TB-HIV concept notes.
Loures said that UNAIDS will collaborate with other agencies to organize regional workshops that bring together key stakeholders for strategy sessions on how best to fully integrate joint TB-HIV responses.
The full participation of civil society in developing these integrated concept notes is critical, he added. “I see the country dialogue as the central piece to promote and facilitate a much closer collaboration between the HIV and TB communities, but also as a platform to really engage with civil society,” he said.
According to Ditiu, prior to the decision to require joint TB-HIV concept notes, the Global Fund’s HIV disease committee and TB disease committee had established a working group on integration. The working group is developing strategies to make integration a reality in countries with high rates of co-infection. It has developed a draft concept note and will shortly be preparing an information note. In addition to the Global Fund itself, members of the working group are the WHO, UNAIDS, Stop TB and PEPFAR.
“Getting joint concept notes developed will be much easier than implementing joint initiatives,” she said, “but isn’t that true of Global Fund concept notes generally? That’s no reason to shy away from TB-HIV integration.”
A Global Fund FAQ on joint TB-HIV concept notes is available here.