For files in Word, please e-mail create@jhmi.edu. A link to each toolkit module and its cases is available at the end of each this page.

Introduction

The dual epidemic of tuberculosis and human immunodeficiency virus (TB/HIV) is a significant global health threat.   The World Health Organization (WHO) estimates that approximately one-third of the world’s population – two billion people – is currently infected with Mycobacterium tuberculosis. i  The diseases are inextricably intertwined with each fueling the progression of the other: HIV infection is the most important known risk factor for advancement from latent TB infection to active TB disease, increasing by 100-fold the risk of reactivation of tuberculosis1i, and TB is the leading cause of death in HIV positive individuals and one of the most common causes of morbidity. ii  

Amidst an unprecedented scale-up of HIV prevention, care and treatment in resource-constrained settings, the need to co-manage TB to maximize the gains in HIV management is readily apparent.  In 2008, the WHO and key stakeholders developed the Three I’s Strategy to reduce the burden of TB among people living with HIV.iii  The Three I’s are: Intensified case finding, Isoniazid preventive therapy and Infection control.   Many countries with high TB/HIV burden are responding with revised TB and HIV guidelines and/or TB/HIV specific recommendations.

Because TB and HIV programs have been developed separately in all countries, integration of services for the benefit the patient with both diseases (or the potential for both diseases) has been challenging, yet rewarding when undertaken.  

As we have trained healthcare providers and program officers in Africa, we have found that real-life cases, supplemented with questions to direct providers to consider their own health facilities and clinics, are well-suited to the training needs of those seeking to implement the Three I’s.  

This leads us to develop the Three I’s Toolkit of Cases.  They are intended to complement country guidelines and provide the basis for planning implementation strategies through discussion of operational needs.   The Toolkit is divided into 4 modules:  the Three I’s and a section entitled TB/HIV Service Integration.    Modules may be implemented separately or adapted to a clinic’s schedule and to the availability of clinicians and staff .   We encourage HIV programs to consider multi-disciplinary training and planning by teams, as participatory strategies maximize implementation and sustainability.  

By conducting training at the clinic level, the cases can assist HIV programs to implement enhanced TB detection and prevention, strengthen linkages with TB programs, minimize occupation-related TB among health care workers, and ultimately, improve quality of life for persons living with HIV.

We encourage review of these cases followed by free modification of the questions posed in each case to make the cases relevant for planning and problem-solving in your setting.

Module 1 - Intensified Case Finding
Module 2 - Infection Control
Module 3 - Isoniazid Preventive Therapy
Module 4 - TB/HIV Service Integration

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i WHO Global Tuberculosis Control. http://www.who.int/tb/publications/global_report/2010/en/index.html
ii Chaisson, Richard E., Martinson, Neil A. Tuberculosis in Africa -- Combating an HIV-Driven Crisis. N Engl J Med 2008 358: 1089-1092.
iii  WHO Three I’s Meeting: Report of a Joint World Health Organization HIV/AIDS and TB Department Meeting.  www.who.int/hiv/pub/meetingreports/WHO_3Is_meeting_report.pdf

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Introduction to Toolkit of 3 I's Cases (PDF file)