Integrated delivery of HIV and tuberculosis services in Sub-Saharan Africa: A systematic review

MAIN FINDINGS:

The authors included in the review 56 articles from 52 different studies assessing the effectiveness of integrated strategies to deliver coordinated tuberculosis and HIV services in 14 sub-Saharan countries. The results suggest that by increased sharing of patient information, enhanced continuum of care, shared use of space and efforts to reduce stigma, and integrated HIV and tuberculosis services improve the delivery of medical services. Such integration fosters cost-effectiveness, leads to HIV reduction and more generally strengthens the health system. Indeed, the authors point out that, given the high prevalence of co-infection, tuberculosis and HIV health-care facilities and voluntary testing and counselling centres seem appropriate venues for the delivery of integrated health services for co-infected patients. The authors found evidence of a positive effect of co-trimoxazole preventive therapy (CPT) in tuberculosis-care treatments, measured in terms of mortality within co-infected patients. Antiretroviral therapy (ART) also seems to reduce tuberculosis incidence and improve health outcomes of co-infected patients. On the other hand, the authors point out that there is not enough evidence to prove any impact of isoniazid preventive therapy (IPT) on the health of co-infected patients, and the effectiveness of counselling services in tuberculosis-care facilities on sexual-risk behaviour seems to be limited to men. More research is needed to assess potential risks associated with the integration of HIV and tuberculosis services, such as the risk of tuberculosis acquisition in HIV health-care centres, and to investigate other barriers to the integration of HIV and tuberculosis strategies.

BACKGROUND:

Tuberculosis is one of the leading causes of death in HIV-infected people. Integrated services to deal with HIV and tuberculosis are therefore required, in order to create synergistic effects on health services, and to limit redundant treatments and services. The integration of HIV and tuberculosis services could increase the effectiveness and cost-effectiveness of health-care delivery services and strengthen health systems.

RESEARCH OBJECTIVES:

To assess the effect of integrating HIV and tuberculosis services on patients’ health outcomes, delivery services and cost-effectiveness of these interventions.

METHODOLOGY:

The authors included in the review randomised controlled trials, quasi-experimental trials, observational, qualitative and costing studies assessing the effect of the integration of HIV and tuberculosis services in health-care facilities and HIV voluntary counselling and testing centres in sub-Saharan Africa in terms of health outcomes, output of delivery and the cost-effectiveness of these integration strategies. The authors limited their selection to evidence from peer-review published articles written in English. The authors focused on eight integrated tuberculosis and HIV strategies recommended by the World Health Organization, classified in two categories: those that aim to control tuberculosis incidence and relieve tuberculosis consequences in HIV patients (establish intensified case-finding for tuberculosis, introduce IPT, control tuberculosis infection in health-care settings), and those that aim to control HIV incidence and relieve HIV consequences in patients with tuberculosis (provide testing and counselling for HIV, introduce methods for HIV prevention, provide CPT, offer HIV care and support, introduce ART). The authors conducted a systematic search in electronic databases, including PubMed, Ovid Journals and African Journals Online. They also checked reference lists of relevant studies and literature reviews on the subject. Finally, the authors presented the results of the review through a narrative synthesis.

QUALITY ASSESSMENT:

The systematic review uses appropriate methods to synthesise the results. However, the review has important limitations. First, the search strategy is not sufficiently comprehensive, and the authors exclude from the review unpublished literature and studies written in languages other than English. Second, although the review includes a wide set of study designs, the authors do not report any risk-of-bias assessment; and therefore the quality of the included evidence is not clear. However, this limitation is partly mitigated by the fact that for some outcomes the authors report the findings from studies using sound methodological designs separately. Finally, the authors do not report sufficient details about the included studies and the review does not report whether at least two authors carried out the data extraction from included studies independently.