CDC pushing for integration of TB, HIV surveillance

Greater efficiency, but some see conflicts

During a recent review of data from the local tuberculosis control program in Nashville, TN, health officials acknowledged that the majority of patients newly diagnosed for TB are not tested for HIV. ToWilliam Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University, this kind of missed opportunity makes no sense, and yet it happens constantly in public health.

"It’s unbelievable to anyone who comes to the system de novo," he tells TB Monitor. "It’s quite believable to anyone who understands how public health works."

How public health works — or doesn’t work — in integrating services is gaining widespread attention at the Centers for Disease Control (CDC) and Prevention. "Integration" has become the new buzzword and the push to find ways to make public health programs more effective and efficient makes both logical and economical sense, say CDC officials.

Uniting programs

The recent restructuring of the divisions of HIV/AIDS, STDs, and tuberculosis into the combined Center for HIV, STD, and TB Prevention is a byproduct of this new philosophy. The next step is finding ways in which different programs among the three diseases can work closer together and find common ground among the overlapping populations they serve.

For TB and HIV, the communication apartheid between the surveillance systems for the two diseases has made it difficult to track the substantial population of patients who are infected with both diseases, CDC officials recently told a joint meeting of its Advisory Committee for the Elimination of TB and its Advisory Committee for HIV and STD Prevention.

"We feel very strongly it is something we need to look at and see what is reasonable to further prevention activities and also lighten the burden on folks who do surveillance," says the center’s director, Helene Gayle, MD, MPH.

While emphasizing that the CDC is not interested in creating a new and costly surveillance system for the two diseases, it has been frustrated by a lack of coordination and communication between the two systems at the state and local levels. New York City, for example, recently integrated its TB and STD surveillance systems but chose to leave HIV surveillance separate. At the same time, the CDC is expanding the traditional definition of surveillance from simply counting and analyzing data to contact investigations, outbreak control, and evaluation of prevention efforts, says Michael St. Louis, MD, medical officer in the CDC’s division of TB elimination.

The potential advantages of integrating the two surveillance systems include a more efficient use of data entry and analysis staff, as well as better coordination of field investigations and outreach work in communities. For TB and AIDS surveillance, integrating the programs would make it easier for the two case registries to share information on patients who are co-infected without concerns about compromising confidentiality. In Florida, as many as 15% of the state’s 60,000 AIDS patients also are infected with TB. The co-infection rate may be even higher in New York City, health officials say.

Information must be explicit

While acknowledging that integration involves trade-offs, such as less control over patient confidentiality, St. Louis says an integrated approach would better ensure that patients are being diagnosed and treated for HIV and/or TB. That is not to say that changing the system isn’t difficult.

"We need to be very explicit when we formulate steps forward in the area of integration and be explicit about what we may be gaining or losing," he says.

Lack of explicit information and guidance is the main reason local TB programs have not followed CDC recommendations to offer HIV testing to all newly diagnosed TB patients, Schaffner says.

"The local programs don’t initiate that activity because the TB program that funds TB has not issued explicit instructions and directives about how to do that and where the funding is supposed to come from and how the information is supposed to be shared," he says. "I think most people who work in the field and certainly in clinical medicine believe it is long overdue that a TB and an HIV program share information."

The need for sharing information is becoming increasingly important now that HIV treatment is being initiated earlier in the course of infection, Schaffner notes. Nonetheless, the thought of TB programs handling AIDS surveillance information is disturbing for AIDS providers who are aware of the serious consequences of confidentiality breaches for HIV-positive patients.

In Denver, for example, patients diagnosed with TB receive a letter from the city health department stating they are under supervision of the department and could be incarcerated if they fail to adhere to treatment, says Bruce Davidson, MD, MPH, director of TB control for the Philadelphia Department of Public Health and president of the National TB Controllers Association in Atlanta.

"I am not sure we want HIV and AIDS information in the hands of the same person who is doing that kind of program work because society has made those decisions about the importance of TB control, but it has not made the same kind of decision about enforcing TB control," he told the joint committees.

One disadvantage to programs not sharing data bases is the fact that for an HIV-positive person with TB, TB surveillance ends one or two years after treatment. Those patients, most of whom will still require follow-up for HIV treatment, can be lost to the system. The missed opportunities for intervention resulting from a TB program not knowing a patient’s HIV status — and vice versa — may supersede the concerns about confidentiality, they say.

St. Louis warns that health officials need to discuss the best ways to integrate before political forces decide for themselves. He alluded to the proposed HIV Prevention Act of 1997, which would make states report HIV and AIDS cases.

Moving beyond surveillance to treatment

One of the models for coordination of TB and AIDS services in the public health sector is the Los Angeles Department of Health, where the standard of care requires that all HIV-positive patients infected with TB must be treated in the same setting. That degree of integration is the exception and is rarely found in health departments that serve smaller cities and rural areas, CDC officials note.

Integration of public health programs in general and for TB and HIV programs specifically "would be a major new way of doing business when the rubber hits the road in public health departments," Schaffner says. "Leadership in this regard has got to come from the top, but conversations have to go both ways because there are constraints on how money for TB programs can be spent, and those are often barriers to horizontal communication."

The growing complexity of providing care for co-infected patients makes integration even more challenging for public health staff who are used to managing a single disease according to rigid protocols, he adds.

"You can’t do this all by algorithm, so there are lots of people who are going to have to learn an awful lot outside the narrow programmatic arena in which they have worked," he explains.

Consequently, public health departments may find themselves having to compete in the marketplace for well-trained physicians and nurses — a radical change that would require new resources, he adds.