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2.2.1 Assess the joint burden of TB and HIV
Routine surveillance is essential for understanding the characteristics of the TB and HIV epidemics in the country and to inform programme planning and implementation. The surveillance of TB disease among people with HIV can be based on the analysis of routine programme data collected for people with HIV who are newly initiated on ART. Surveillance of HIV among people with TB can be performed through: (i) periodic cross-sectional HIV seroprevalence surveys among a representative sample of people with TB in a country; (ii) sentinel surveys using people with TB as a sentinel group within the general HIV sentinel surveillance system; and (iii) using data from routine HIV testing of people with presumptive or diagnosed TB. The surveillance method depends on the state of the underlying HIV epidemic, the overall TB epidemiology, and the level of integration and decentralization of services for HIV-associated TB. Inclusion of surveillance of other comorbidities and social determinants, common to TB and HIV, may also be considered as part of this assessment. These might include undernutrition, pulmonary disorders other than TB, mental health disorders, smoking and substance use disorders (alcohol and drugs), viral hepatitis and diabetes. If the collection of data on comorbidities and social determinants is not integrated into routine TB surveillance, then these data may be shared by other programmes responsible for their surveillance or can be collected through population- or facility-based surveys. Key considerations for assessing the joint burden of TB and HIV are summarized in Box 2.1.
Incorporating HIV testing within TB prevalence surveys and antituberculosis drug resistance surveys provides an opportunity to optimize HIV testing coverage and improve knowledge among national TB and HIV programmes on the relationship between HIV, TB and drug-resistant TB at the population level (26, 27). It also provides critically important benefits to individuals living with HIV, including better access to testing, early detection and rapid initiation of treatment (7).
In the context of a TB prevalence survey, HIV testing may be offered according to the following strategies: in settings with a generalized HIV epidemic or where HIV care is more decentralized, HIV screening and testing should be offered for all participants in a TB prevalence survey; in settings where the HIV epidemic is concentrated or where HIV care is more centralized, HIV testing should be offered to all participants diagnosed with TB and to participants presenting with symptoms and/ or chest X-ray findings suggestive of TB, in accordance with WHO recommendations. The minimum acceptable standard would be to offer HIV testing to all participants found to have TB.
Further guidance on inclusion of HIV and other comorbidities within TB prevalence surveys is published in WHO consolidated guidelines on tuberculosis data generation and use. Module 3: national tuberculosis prevalence surveys guidance, tuberculosis data generation and use (in press) (28).
Whatever strategy is selected, HIV surveillance among people with TB should follow nationally recommended guidelines related to HIV testing, in terms of who to test, the testing strategy and in accordance with the 5 Cs: Consent, Confidentiality, Counselling, Correct test results and Connection or linkage to prevention, care and treatment (17, 26). Unlinked anonymous testing for HIV is not recommended because results cannot be traced back to individuals who need HIV care and treatment (26). For HIV testing to be offered, HIV care and ART provision need to be in place so that those individuals newly diagnosed with HIV during the surveillance can immediately receive TB and HIV treatment and services based on national guidelines.
Evidence from descriptive studies has shown HIV surveillance among people with TB to be a critical activity in understanding the trends of the HIV epidemic and in the development of sound strategies to address the dual TB/HIV epidemic (7). Mortality audits may also highlight other causes of death, such as undernutrition, that need to be addressed during care for HIV-associated TB (29). These data can be consolidated and analysed as part of overall country review and planning processes for TB and HIV as well as other relevant comorbidities. Gaps in evidence identified during this process can inform further data collection.
2.2.2 Determine access to services and the financial burden for people with TB and HIV
To deliver human rights-based people-centred services, it is crucial to understand the factors that affect general access to services for HIV-associated TB, with attention to barriers experienced by subpopulations, including people with other comorbidities, barriers specific to certain geographic locations, and the socioeconomic impact of HIV-associated TB (30). Access to TB/HIV services can be determined through patient pathway analyses, or operational research. Understanding the root causes to the barriers is essential in planning for improving access to TB/HIV services for those in need. The financial burden may be assessed through analysis of data from TB patient cost surveys which include disaggregation by HIV status, national demographic and health surveys and health expenditure and utilization surveys. When assessing the socioeconomic impact of HIV-associated TB, access to existing social protection schemes that mitigate the financial impact of HIV-associated TB and enable affected people to adhere to treatment should also be considered.
2.2.3 Map health service delivery for TB and HIV
Data on the current capacity, performance, limitations and distribution of health and social protection services for HIV-associated TB and other comorbidities can be gathered from sources including health system reviews or readiness assessment mapping such as the Harmonized Health Facility Assessment (31). The mapping of service delivery for TB, HIV and HIV-associated TB should assess public and private sectors and nongovernmental stakeholders, including an assessment of access to services among the key populations for HIV and other vulnerable or at-risk populations. Guidance on public-private mix is published in Guide to develop a national action plan on public-private mix for tuberculosis prevention and care (32). Availability of, or proximity to, equipment and consumables to screen for and diagnose TB and HIV should be assessed in the respective services. For diagnostics, it is also important to understand the connection with the laboratory and sample transportation network, including factors such as frequency of sample collection and speed of turnaround of results. It is also important to determine the availability, deployment, qualifications and training needs of the health workforce for the detection, prevention, treatment and care of HIV-associated TB, including community health workers and social workers.
2.2.4 Identify gaps in services and conduct root cause analysis
Data collected on epidemiology, access to services from the user perspective, the health system and service delivery, as described above, should be analysed to identify gaps and opportunities. Root cause analysis (33) can help understanding of the reasons for gaps in services and inform strategies to address these.