5 Clinical and Support Services
The 2012 WHO TB / HIV policy recommends a 12-point package of interventions known as the collaborative TB / HIV activities. The aim of the package is to: establish and strengthen mechanisms for delivering integrated TB and HIV services; reduce the burden of TB among those living with HIV, which includes intensified case-finding, IPT and infection control( also known as the“ Three I’ s for HIV / TB”); and reduce the burden of HIV in TB patients. It recommends that all people living with HIV, including sex workers, should be screened regularly for the following four symptoms: current cough, fever, weight loss and night sweats. If they do not report any one of the four symptoms, active TB may be reasonably excluded and they should be offered IPT for at least six months. Those reporting one or more symptoms should be evaluated for TB and other conditions. If TB is suspected, WHOapproved molecular tests, such as Xpert MTB / RIF( a rapid automated test that looks for resistance to RIF), are recommended as the primary diagnostic test for TB in anyone living with HIV or at risk of drug-resistant TB.
Early ART significantly reduces the risk of mortality from HIV-associated TB. Given that TB is one of the most common AIDS-defining illnesses, WHO recommends that all TB patients, including sex workers, be offered HTC as a priority if their HIV status is not already known. If an individual is found to be living with both TB and HIV, WHO recommends that they should be started on ART as soon as possible, irrespective of CD4 count.
Programmes or community outreach services for sex workers are ideally placed to carry out TB screening and to support sex workers throughout the cycle of care, from TB prevention through diagnosis and treatment. They also play a vital role in training sex workers to recognise TB symptoms and understand TB transmission, as well as the importance of infection control and cough etiquette to reduce TB transmission. In addition, they can help sex workers identify nearby health facilities for diagnosis and initiation of treatment of active or latent TB, as necessary.
Ideally, the co-treatment of TB and HIV, as well as other co-morbidities such as drug dependence, should be made available at the same time and place. TB clinic staff should be trained on the need for respectful approaches to sex workers. Similar to ART, adherence is crucial for persons receiving TB treatment and prophylaxis, and health workers, counsellors, and community members serving sex workers should provide encouragement to sex workers receiving treatment for active or latent TB to ensure adherence.
Box 5.6
Case example: HIV and undiagnosed TB
Many people living with HIV also have TB and need careful diagnosis, including for extra-pulmonary TB. Daisy, a sex worker advocate in Uganda, was on ART for more than eight years but still had severe spinal pain. In her own words,“ I’ d lost hope, and almost wanted to commit suicide, the pain was so bad.” Clinicians first told her that she had back pain because of her sex work, and then that her pain was psychosomatic, and referred her to a psychiatrist. Neither the psychiatrist nor physiotherapy helped.
Finally, after suffering with severe pain for more than two years, additional diagnostics were done and it was found that Daisy had TB of the spine. Because her TB was untreated for so long, her spine is damaged and could collapse, causing paralysis. She is now on TB drugs and wears a corset to prevent further spinal damage.
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