Friedland Gerald, Harries Anthony, Coetzee David
AIDS Program, Section of Infectious Diseases, Department of Internal Medicine and Epidemiology, Yale University School of Medicine, New Haven, CT 06510, USA.
J Infect Dis. 2007 Aug 15;196 Suppl 1:S114-23. doi: 10.1086/518664.
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. In this article, 3 such strategies, offering varying degrees of collaboration and integration, are described, 1 at a national level in Malawi and 2 at local sites in South Africa. These geographically and programmatically distinct experiences in TB/HIV service integration are instructive, illustrate common themes, and show that the strategy can be successful, but they also 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 prevalences, 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.
结核病（TB）与人类免疫缺陷病毒（HIV）感染之间存在诸多相互作用，这影响着旨在满足同时感染这两种疾病或有感染风险患者需求的项目的设计与实施。世界卫生组织及其他国际机构倡导国家结核病和艾滋病项目之间开展合作，并在地方层面实现一定程度的服务整合，在这两种疾病流行的地区，这种合作与整合被视为至关重要。然而，在大多数情况下，实现这一目标的策略才刚刚开始应用于实际工作中，其影响尚未显现，改善这两种疾病治疗效果的期望也尚未实现。本文描述了3种此类策略，它们在合作与整合程度上各有不同，一种是在马拉维的国家层面实施的，另外两种是在南非的地方层面实施的。这些在结核病/艾滋病服务整合方面地域和项目上截然不同的经验具有启发性，阐明了共同主题，表明该策略能够取得成功，但同时也表明在项目规划、医疗、人员配备、资源以及扩大规模等方面仍存在挑战。此外，这些经验还表明，尽管结核病/艾滋病服务整合的广泛项目原则至关重要，但由于结核病和艾滋病的疾病流行率、资源、专业水平以及项目环境（城市与农村和/或基层与地区与专科医院）存在差异，项目设计和组成部分可能因国家而异，甚至在一个国家内部也有所不同。大型国家项目能够成功实现快速、统一且广泛的变革与实施，但也必须应对结核病/艾滋病相互作用的细微复杂之处，这使得统一的“一刀切”公共卫生方法难以适用。相反，规模较小的示范项目即使取得了成功，也必须应对与研究结果推广、更广泛实施及扩大规模相关的问题，以便使更多有需要的人群受益。
