Expanding Access and Demand for TB/HIV Service through Integration in Low Income Country of South Sudan

Abstract

Tuberculosis (TB) remains the leading cause of death and morbidity among people living with HIV in developing countries, and HIV infection the most potent known risk factor associated with developing active TB. According to UNAIDS, there are currently an estimated 33.3 million people living with HIV/AIDS and, in 2009, 1.2 million people were initiated on antiretroviral therapy for the first time. TB is a major problem of public health in South Sudan. According to the WHO estimates for the year 2014: i) the prevalence of TB was 319 cases per 100,000 population, ii) 17,000 people were newly affected with TB, indicating an incidence of 146 new TB cases per 100,000 population and iii) 3,400 persons died of TB which resulted in a mortality rate of 29 deaths from TB per 100,000 population. The information system of the National TB Programme (NTP) indicates that TB notification has increased from 2,955 cases in 2008 to 8,856 in 2014. The many interactions between tuberculosis (TB) and human immunodeficiency virus (HIV) infection influence the design and implementation of programs to address the needs of patients living with or at risk for both diseases. Collaboration between national TB and HIV programs and some degree of integration of services at a local level have been advocated by the World Health Organization and other international bodies and are recognized as essential in areas where the 2 diseases are prevalent. However, in most settings, strategies to accomplish this are only beginning to reach the field where their impact will be made and the expectation of improving the outcome of both diseases realized. These are not exhaustive or prescriptive, but describe the range of options from linkage and close collaboration to fully collocated integration. The assessment of integration of TB/HIV show that programmatic, medical, staffing, resource, and scale-up challenges remain. In addition, they indicate that, although broad program principles of TB/HIV service integration are essential, program designs and components may vary by country and even within countries, as a result of differing TB and HIV disease prevalence, resources, levels of expertise, and differences in program settings (urban vs. rural and/or primary vs. district vs. specialty site). Large national programs can successfully provide rapid, uniform and widespread change and implementation but also must negotiate the subtleties of intricacies of TB/HIV interactions, which confound a uniform "one size fits all" public health approach. Conversely, smaller demonstration projects, even with successful outcomes, must grapple with issues related to generalization of findings, wider implementation, and scale up, to benefit larger populations of those in need.