Integrated delivery of HIV and tuberculosis services in sub-Saharan Africa: a systematic review

Tuberculosis is a major cause of morbidity and mortality in people with HIV and about a quarter of HIV-related deaths are attributed to tuberculosis. In this Review we identify and synthesise published evidence for the effectiveness and cost-effectiveness of eight integrated strategies recommended by WHO that represent coordinated delivery of HIV and tuberculosis services. Evidence supports concurrent screening for tuberculosis and HIV, and provision of either co-trimoxazole during routine tuberculosis care or isoniazid during routine HIV care and at voluntary counselling and testing centres. Although integration of antiretroviral therapy into tuberculosis care has shown promise for improving health outcomes for patients, evidence is insufficient to make conclusive claims. Evidence is also insufficient on the accessibility of condoms at tuberculosis facilities, the benefits of risk reduction counselling in patients with tuberculosis, and the effectiveness of tuberculosis infection control in HIV health-care settings. The vertical response to the tuberculosis and HIV epidemics is ineffective and inefficient. Implications for policy makers and funders include further investments in implementing integrated tuberculosis and HIV programmes with known effectiveness, preferably in a way that strengthens health systems; evaluative research that identifies barriers to integration; and research on integrated strategies for which effectiveness, efficiency, and affordability are not well established.