Фонд содействия защите здоровья
и социальной справедливости
имени Андрея Рылькова

Delivery of Effective Tuberculosis Treatment to Drug Dependent HIV-positive Patients

Photographer Misha Friedman www.medvedia.com

Photographer Misha Friedman www.medvedia.com

To read the study report please click at this link: Delivery of Effective Tuberculosis Treatment to Drug Dependent HIV-positive Patients

The study was conducted:

By the Andrey Rylkov Foundation for Health and Social Justice (Moscow) with support from the Treatment Preparedness Coalition in Eastern Europe and Central Asia (ITPC.ru) and Tides Foundation.  Quantitative data were collected as a part of a larger project on monitoring and advocacy of treatment access “Simona+” supported by the  International Harm Reduction Development Program of Open Society Foundations.

Key Findings:

  • Drug-dependent HIV-positive patients are the most vulnerable risk group in TB treatment

Among patients with TB/HIV co-infection mortality is exceptionally high, when undergoing TB treatment: in three cities co-infected patients represented almost 100% of all those TB patients who died during treatment.

  • HIV and TB prevention and testing interventions for drug dependent individuals are not conducted at adequate levels

The study underlined the lack of adequate prevention interventions for both diseases among drug dependent individuals.  Late detection of HIV and late initiation of HIV treatment serve as key barriers to effective treatment of co-infection among this population.  These factors are a direct result of poor interactions between health service providers and this group and inadequate prevention efforts.  Though harm reduction and outreach work projects, allowing continuous contact with drug users, operate in the cities where the survey was conducted, the reach of these projects is not significant enough due to poor financial and organizational support and lack of their integration with other health services.

  • A poor link between TB services and infectious diseases services

In half of the cities surveyed, almost every fifth (and in some cities every second) patient of a TB hospital is HIV-positive.  Despite this, the level of collaboration between TB and infectious diseases services is extremely low.  The following are seen as the key issues in establishing a link between TB and other services: lack of special training and knowledge about treating HIV-positive patients among TB professionals and lack of similar specialized knowledge about TB among infectious disease professionals; difficulties in conducting viral load and CD4 testing and prescribing and accessing ART for patients; limited abilities in terms of delivering TB treatment for HIV-positive patients at AIDS Centers.

  • Lack of effective drug treatment services for patients with co-infection

The absence of effective drug treatment services at TB hospitals and in general is the most serious structural barrier to effective in-patient TB treatment for patients with co-infection.  The majority of drug-dependent patients with TB drop out of treatment: in some cities the level of drop out from in-patient treatment among this group is at 100%. Inability of the health system to offer adequate drug treatment creates an institutionalized “trap,” when drug dependent patients are excluded from stable TB treatment de-facto.

  • Emphasis on in-patient treatment and underdevelopment of DOTs in the community
  • Drop-out of patients during the transitional stages of treatment

The lack of well-established cooperation within the TB services is expressed in the following problems: absence of a system for managing patients, when they transfer from one TB institution to another; absence of a unified patient data base, allowing patients to continue treatment of TB if they move (for example in a case of being released from prison, or internal migration); absence of motivation among out-patient TB service providers to work with HIV-positive patients.

  • Lack of professional training in the area of work with drug dependent patients among health care practitioners

Poor professional training in the area of drug dependence and existing attitudes towards this condition among health practitioner manifest into a lack of motivation to engage with drug dependent patients and improve the conditions that would increase their adherence to treatment.

Main Recommendations


  • Expand and support prevention programs (programs reducing harm associated with drug use) for difficult to reach population groups, vulnerable to HIV-infection and TB, particularly those programs that actively engage drug users through outreach work.  Harm reduction programs reduce the risk of TB among drugs users by increasing access to prevention, information and early diagnosis.


  • Increase access to HIV testing and counseling for “hidden” population groups, such as drug users, including street outreach programs that would utilize express testing systems, and also by directing clients to low-threshold programs.
  • Increase access to modern diagnostic systems that can diagnose tuberculosis and drug resistance in the shortest time possible and make them accessible through the wider medical services network.


  • Review possibilities for shortening hospital stays and developing socio-medical treatment services, utilizing directly observed methodologies in the community (where the patients live). These services may be realized through close collaboration of medical institutions and programs, serving drug users, in particular harm reduction programs, as well as through relatives, social workers and junior medical staff.
    • Lift the legal ban on methadone and buprenorphine substitution treatment programs in Russian Federation.  These programs are recommended by the WHO and are a key element of HIV and TB prevention,drug dependence management, and increasing treatment adherence (both in-patient and out-patient HIV and TB treatment) for drug dependent patients.
    • Scale up work to provide additional training to medical practitioners (doctors, medical staff, and public health program managers) in the area of co-infection and managing patients with co-morbid conditions, such as HIV, TB and drug dependence

Integration of Services

  • Scale up efforts in retaining patients in treatment during transfer, i.e. when a patient is referred from one treatment institution to another (for example from a hospital to an out-patient clinic), or during release of a TB patient from prison and transfer to the civilian health sector: increase collaboration between systems and professional trainings for staff, provide thorough social support and case management services, improve the system for transferring data on the patient and on the patient’s treatment status.
  • Strengthen collaboration between TB and infectious disease services and increase the level of service integration at all points of service delivery: at harm reduction sites, at the AIDS Centers through scale up of TB diagnosis and prevention, and at TB clinics through diagnosing, monitoring, and treating HIV among TB patients.

Monitoring and access to data

  • Systematically collect data, conduct situational analysis, and monitor treatment outcomes and quality of treatment for patients with co-morbid conditions.  Make this information publicly available and use it for developing health policies.
  • One concrete step that the health system can make is to systematically study the factors that influence treatment interruption or drop-out among patients, and implement appropriate interventions based on these findings.

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