Insights from the Ebola response to address HIV and tuberculosis

Although widespread Ebola transmission has been controlled in west Africa, the indirect consequences of the recent epidemic could be yet to fully manifest. In the past 2 years, management of other diseases in Sierra Leone, Liberia and Guinea has been limited as resources were focused on the Ebola response. HIV and tuberculosis programmes were among those affected by workforce depletion, closure of health facilities, and interrupted service and supply chains, leading to a worsening of the region’s HIV and tuberculosis epidemics.^1–3 These epidemics were major public health problems in those three countries before the Ebola outbreak: in 2013, 11,200 people died of AIDS-related causes and 7,900 died from tuberculosis. Fewer than two thirds of tuberculosis cases were diagnosed and only 30–57% of eligible people living with HIV were on antiretroviral therapy (ART) – largely due to health system challenges including uncoordinated mobilisation of scarce resources, insufficient staff and laboratory capacity, and inadequate data collection and management.^4–7

Although the Ebola crisis exacerbated many of these problems, it also provides an unprecedented opportunity to assess and address pre-existing and anticipated health challenges in the worst-affected countries. Although there have been multiple calls to heed lessons from the global HIV and tuberculosis responses when addressing Ebola,^8–10 we now have a unique chance to transition several elements of the Ebola response to rebuild and strengthen HIV and tuberculosis systems in the region, while sustaining capacity for emergency response.

Before the Ebola outbreak, systematic disease surveillance, data collection and data analyses were inadequate.¹¹ The Ebola response enhanced local public health capacity by training cadres of health workers in disease prevention, detection and response, including case finding and management of people suspected of being exposed to or having disease. The resultant workforce is ideally suited for providing rapid diagnostic tests, specimen transport, directly observed therapy, ART provision and adherence support, tuberculosis contact tracing, and case finding for other diseases. National and district health offices now have improved surveillance systems and staff with increased proficiency in compilation, management and dissemination of timely information. These systems can be expanded on for HIV and tuberculosis surveillance to monitor trends and focus resources and programmatic activities.

The Ebola response also emphasized the need for improved infection prevention and control measures and has facilitated the implementation of proper hand washing, waste disposal, isolation precautions, and use of personal protective equipment, which are also relevant for HIV and tuberculosis care. Additionally, strengthened social mobilisation, increased health awareness and condom promotion among survivors of Ebola provide an opportunity to prevent transmission of HIV and other sexually transmitted infections.

Finally, the Ebola outbreak resulted in increased general response readiness among ministries of health in countries that previously struggled to attain minimum International Health Regulations core capacities.¹¹ New emergency response centres have been established, health-care facilities built, laboratories improved, and resource mobilisation channels created. The multinational response challenged responders to unite rapidly and on a massive scale, fostering stronger collaboration and coordination between affected countries and international partners. These improvements in response readiness, facilities, technical capacity and partnerships could be extended for recovery and rebuilding of tuberculosis and HIV programmes, and programmes for other diseases.

In the wake of this crisis, HIV epidemic control would be facilitated by rapidly reequipping programmes to provide HIV testing, care and treatment services, reintroducing people living with HIV who have been lost to follow-up back to care, restoring preventive efforts, and securing ART supply chains. Likewise, urgent efforts to find and resume tuberculosis treatment among people for whom treatment was interrupted would improve patient outcomes and reduce the development of drug-resistant tuberculosis. Moreover, the rapid resumption and scale-up of TB case finding, diagnostic evaluation, directly observed therapy, and infection prevention and control would prevent further disease transmission. Finally, re-establishment of integrated HIV and tuberculosis service delivery with routine monitoring and evaluation will help to ensure the quality of implemented services. These endeavors will be challenging, but can be supported by investments in technical capacity and infrastructure from the Ebola response. In turn, a strengthened response to HIV and TB will further propagate health system resilience in these countries, to ensure that they are better prepared to respond to existing or future health threats.