5.1

Because of the alarming potential for an increase in the number of HIV-related tuberculosis cases and the risk of multidrug-resistant tuberculosis in this population, policy makers must provide appropriate resources to address the recommendations under Clinical Practice Recommendations.

5.2

LCDC, in partnership with provincial and territorial agencies, should create a national data set of appropriate epidemiologic information about co-infection with tuberculosis and HIV, and should collect, analyze and disseminate these data; the security and confidentiality of such databases must be ensured.

5.3

LCDC and the provinces and territories should adopt HIV/AIDS and tuberculosis surveillance reporting forms to capture tuberculosis/HIV data wherever possible and appropriate.

5.4

LCDC should support, coordinate and collaborate in special investigations to determine the extent of tuberculosis/HIV co-infection in Canada. This support should include expertise, resources and staff.

5.5

LCDC, in collaboration with provincial/territorial, laboratory and community-based partners, should participate in cluster and outbreak investigations of co-infection with tuberculosis and HIV. Participation should include the provision of expertise, resources and staff. Other targeted supplementary epidemiologic investigations should also be carried out as appropriate to characterize the evolving interaction of tuberculosis and HIV.

5.6

LCDC should ensure the timely dissemination of information about tuberculosis/HIV co-infection using collaborative models of communication that are participatory in nature. This is particularly important because of the dynamic and ongoing changes in HIV/TB management strategies, e.g. anti-retroviral therapies (which have the potential to interact with therapeutic agents for tuberculosis).  In addition, the utilization of BCG for newborns where vertical transmission of HIV infection has taken place requires caution.

5.7

Sentinel clinical sites and community-based agencies should be used for evaluating interventions related to TB and HIV co-infection and, in particular, the barriers to their successful implementation.

5.8

Physicians and other health care providers should be encouraged to offer HIV testing in tuberculosis clinical settings with appropriate pre- and post-test counselling. Conversely, tuberculin skin testing should be encouraged in HIV clinical settings.

5.9

Improved communication and collaboration between AIDS and tuberculosis programs, where they function in parallel, as well as between these and community agencies should be encouraged. Education of health care workers and individuals in the community is critical.

5.10

The accumulating evidence that early intervention in the course of HIV infection, especially with combination therapies, including anti-retrovirals, can substantially change its course implies that every opportunity should be taken to identify HIV-infected individuals. HIV serology should therefore be evaluated in all patients presenting with tuberculosis after informed consent and appropriate pre- and post-test counselling.

5.11

The recognition that the development of tuberculosis in an HIV-infected person appears to hasten the progression of the underlying immune deficiency makes it essential for all HIV-infected persons to be regularly screened for the presence of tuberculous infection by tuberculin skin testing. Routine anergy screening is not recommended.

5.12

In the presence of tuberculosis/HIV co-infection appropriate chemoprophylaxis administered in accordance with the Canadian Tuberculosis Standards is strongly recommended.

5.13

All hospitalized patients with infectious tuberculosis should be placed in respiratory isolation until there is evidence of non-infectiousness, in accordance with Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and other Institutional Settings. Caution is recommended for patients with multidrug-resistant tuberculosis or those leaving hospital to enter an institutional or community environment with a high prevalence of HIV-infected patients.

5.14

Community agencies should have an appropriate tuberculosis surveillance and screening program in place for staff and users of the agencies to identify as early as possible individuals who may have tuberculosis infection or active disease.

5.15

Governments must recognize the risk of tuberculosis transmission in community agencies that work with people infected with HIV and must participate in developing strategies to reduce the risk. A central factor is early detection and treatment. Work place policies and environmental assessments must be optimized, and consideration given to high-tech interventions in the light of cost and efficacy.

5.16

Health care workers in the area of tuberculosis must have sensitivity training in AIDS and HIV infection with a focus on legal, ethical and human rights issues, and the impact of socioeconomic factors on people with TB/HIV co-infection.

5.17

Staff caring for street-involved HIV-positive individuals should regularly obtain sputum specimens from symptomatic persons to facilitate the early diagnosis of active tuberculosis cases.