ReacciónPeople with HIV are 12–16 times more likely to develop tuberculosis (TB) disease. They also have poorer TB treatment outcomes and have more than two-fold higher mortality during TB treatment compared to people without HIV (1). Despite advances in the prevention, diagnosis and treatment of TB disease, TB remains the leading cause of death among people with HIV worldwide, accounting for 167 000 (27%) of global AIDS-related deaths in 2022 (1). In 2022, only 64% of TB episodes among people with HIV were diagnosed and notified, and the treatment success rate among people with HIV who started TB treatment in 2021 was 79%, lower than for all people with TB (1). A global review of autopsy studies, among people who had died from HIV, found 40% prevalence of TB among adults, with only 46% of TB diagnosed before death (2).
The World Health Organization (WHO) End TB strategy, endorsed by the World Health Assembly in May 2014, provides strategic direction for the achievement of the TB targets within the United Nations (UN) Sustainable Development Goals (SDGs). Integrated patient-centred prevention, care and social protection for people with HIV-associated TB are key components of the End TB strategy. The Strategy outlines a range of medical and socioeconomic interventions to address TB morbidity and mortality and the social determinants of TB (3). The importance of protecting human rights with integrated people-centred services is reiterated by the political declarations of the respective United Nations high-level meetings on the fight against TB (4) and on HIV and AIDS (5).
To help countries mitigate the burden of HIV-associated TB in populations at risk of or affected by both diseases, WHO published the Interim policy on collaborative TB/HIV activities in 2004 (6) which was updated in 2012 (7). The policy has served as a vehicle for a robust global response, advocating for further investment and scale-up of collaborative TB/HIV activities, and provided guidance to Member States and other partners on effectively addressing HIV-associated TB. Collaborative TB/HIV activities include the establishment and strengthening of mechanisms for delivering services for TB and HIV, reducing the burden of TB among people living with HIV, and reducing the burden of HIV in people with presumptive and diagnosed TB. Scale-up of these interventions between 2005 and 2022 is estimated to have saved 9.2 million lives according to modelling for the Global tuberculosis report 20231 . However, although there has been widespread rollout and uptake of antiretroviral therapy, HIV testing in TB services and TB screening in HIV services, in 2022 an estimated 671 000 (uncertainty interval: 600 000– 746 000) people living with HIV developed TB disease (1). To reach the End TB strategy target of ending TB, sustained efforts to implement and scale up collaborative TB/HIV activities are essential.
This section of the operational handbook aims to support the implementation of recommendations outlined within the TB/HIV section of the WHO consolidated guidelines on tuberculosis. Module 6: tuberculosis and comorbidities (in press) (hereinafter referred to as the TB/HIV guidelines). Whilst the focus of the handbook is primarily on adults, guidance on programmatic aspects is applicable to collaborative TB/HIV activities for all age groups.
1 To estimate the number of deaths averted by collaborative TB/HIV activities, the actual numbers of TB deaths can be compared with the number of TB deaths that would have occurred in the absence of antiretroviral therapy (ART) provided alongside TB treatment for people with HIV-associated TB. This number can be estimated conservatively as the number of estimated incident cases multiplied by the relevant estimated case fatality ratio for untreated HIV-associated TB. The estimates are conservative because they do not account for the impact of TB services or availability of ART or TB preventive treatment on the level of TB incidence; they also do not account for the indirect, downstream impact of these interventions on future levels of infections, cases and deaths.