title: Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.
abstract: OBJECTIVE
  Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration.
  
  
  METHODS
  Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts.
  
  
  RESULTS
  Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness.
  
  
  CONCLUSIONS
  While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures.
authors.affiliation: Department of Clinical Research, London School of Hygiene and Tropical Medicine and Evidence for Action Consortium, London, UK. helena.legido-quigley@lshtm.ac.uk
authors.forename: Helena
authors.initials: H
authors.lastname: Legido-Quigley
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Montgomery
authors.forename: Palwasha
authors.initials: P
authors.lastname: Khan
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.forename: Ade
authors.initials: A
authors.lastname: Fakoya
authors.forename: Haileyesus
authors.initials: H
authors.lastname: Getahun
authors.forename: Alison D
authors.initials: AD
authors.lastname: Grant
mesh_terms: D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000379:methods / Q000458:organization & administration*; D003906:Developing Countries; D015658:HIV Infections / Q000191:economics / Q000517:prevention & control*; D017048:Health Care Costs; D006302:Health Services Research; D006801:Humans; D008962:Models, Theoretical; D011634:Public Health; D014376:Tuberculosis / Q000191:economics / Q000517:prevention & control*