Perumal Rubeshan, Padayatchi Nesri, Stiefvater Ellen
Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
BMC Public Health. 2009 Jul 16;9:243. doi: 10.1186/1471-2458-9-243.
Despite widely acknowledged WHO guidelines for the integration of TB and HIV services, heavily burdened countries have been slow to implement these and thus significant missed opportunities have arisen.
The individual-centred, rights-based paradigm of the SA National AIDS Policy, remains dissonant with the compelling public-health approach of TB control. The existence of independent and disconnected TB and HIV services results in a wastage of scarce health resources, an increased burden on patients' time and finances, and ignores evidence of patients' preference for an integrated service. The current situation translates into a web of unacceptable, ongoing missed opportunities such as failure to maximize collaborative disease surveillance, VCT, adherence support, infection control, and positive prevention. TB services present a readily identifiable cohort for HIV provider-initiated testing. Integrating HAART and DOTS will promote efficient usage of health workers' time and a more navigable experience for patients, ultimately ensuring increased TB treatment completion rates and MDR-TB prevention. As direct observation evolves into a more supportive, empowering experience for patients, adherence to both TB drugs and HAART will be bolstered. Little attention has been paid to the transmission of TB within HIV services. Low cost infection control interventions include: triaging patients, scheduling new and follow-up patients separately; well-ventilated, sheltered waiting rooms; and the use of personal respirators by patients and staff. A more patient-centred approach to TB care may be able to recruit the active participation of TB patients in positive prevention efforts, including maximizing personal infection control, limiting exposure of social contacts to TB during the intensive phase of treatment, advocating isoniazid prophylaxis within the home and patient-centred education efforts to reduce overall transmission. Several model programmes demonstrated synergy, in which the impact of the "whole" or integrated response was greater than the sum of the non-integrated parts.
The full potential of an integrated TB-HIV service has not been fully harvested. Missed opportunities discount existing efforts in both programmes, will perpetuate the burden of disease, and prevent major gains in future interventions. This paper outlines simple, readily-implementable strategies to narrow the gap and reclaim existing missed opportunities.
尽管世界卫生组织关于结核病与艾滋病服务整合的指南已得到广泛认可，但负担沉重的国家在实施这些指南方面进展缓慢，因此出现了大量错失的机会。
南非国家艾滋病政策以个人为中心、基于权利的模式，与结核病控制引人注目的公共卫生方法仍然不协调。独立且互不关联的结核病和艾滋病服务的存在，导致稀缺卫生资源的浪费、患者时间和经济负担的增加，并且忽视了患者对综合服务的偏好证据。当前的状况转化为一系列不可接受且持续存在的错失机会，例如未能最大限度地开展协作疾病监测、自愿咨询检测、依从性支持、感染控制和积极预防。结核病服务为艾滋病服务提供者发起的检测提供了一个易于识别的人群。整合高效抗逆转录病毒治疗（HAART）和直接观察短程治疗（DOTS）将提高卫生工作者时间的使用效率，并为患者提供更便捷的就医体验，最终确保提高结核病治疗完成率和预防耐多药结核病。随着直接观察发展成为一种对患者更具支持性、赋权性的体验，对结核病药物和HAART的依从性将得到加强。艾滋病服务中结核病传播问题很少受到关注。低成本的感染控制干预措施包括：对患者进行分流，分别安排新患者和复诊患者；通风良好、有遮蔽的候诊室；患者和工作人员使用个人呼吸器。一种更以患者为中心的结核病护理方法或许能够促使结核病患者积极参与积极预防工作，包括最大限度地进行个人感染控制、在治疗强化阶段限制社会接触者接触结核病、倡导在家中进行异烟肼预防以及开展以患者为中心的教育工作以减少总体传播。一些示范项目显示出协同效应，即“整体”或综合应对措施的影响大于各非整合部分的总和。
结核病与艾滋病综合服务的全部潜力尚未得到充分挖掘。错失的机会削弱了两个项目现有的努力，将使疾病负担持续存在，并阻碍未来干预措施取得重大成效。本文概述了一些简单、易于实施的策略，以缩小差距并挽回现有的错失机会。
