Maher BMC Public Health 2010, 10:394 http://www.biomedcentral.com/1471-2458/10/394 Page 5 of 11 Table 2: Estimates of key selected indicators of current status of HIV and tuberculosis epidemics Indicator annual incident cases (all) annual deaths annual incident cases of drug-resistant strains HIV Tuberculosis 2·5 million incident infections in 2007 [4] 9.3 million incident cases in 2007 [13] 2.1 million [2] (includes 0.5 million people with tuberculosis and HIV co-infection) [13] 1.3 million (excludes 0.5 million people co-infected with HIV) [13] Global estimate not available. 0.5 million in 2007 [13] HIV interventions"), despite some progress the imple- mentation of these interventions is far below the need [46], and far below the targets for 2015 set out in the "Global Plan to Stop TB" (Table 4) [51]. Re-thinking established practices and policies for effective epidemic control A key question arises from consideration of the current status of the HIV and tuberculosis epidemics and of implementation of epidemic control measures: what is the most effective and efficient health system approach to ensuring more widespread and sustainable access to interventions for HIV and for tuberculosis epidemic con- trol? One approach is to continue with more of the same, i.e. specialised services for HIV and for tuberculosis with what may in some ways be regarded as a third pro- gramme of TB/HIV collaboration. Alternatively, a funda- mental re-think of the current strategic approach involves promoting integrated services for HIV and tuberculosis which are part of strengthened general health services. The contrasting experiences of global HIV and tuber- culosis control provide some insights in answering this question. Accompanying the development of antituber- culosis chemotherapy regimens in the 1960s and 1970s, the move away from the previous policy of specialised tuberculosis diagnosis and treatment services to integra- tion into primary care in most countries, played a critical role in facilitating widespread access [23]. After integrat- ing tuberculosis services with general health services, and decentralizing with community support [52], the bottle- neck in expanding access to tuberculosis diagnosis and treatment is the quality of the general health services. This was recognised in the early years of this decade by the second ad hoc committee on the tuberculosis epi- demic: "progress in tuberculosis control... depends on actions which are beyond the specifics of tuberculosis control" [53]. Although the committee's recommenda- tions to stakeholders in tuberculosis control included to "strengthen health systems, particularly primary care delivery", progress in harnessing tuberculosis control efforts to the cause of health system strengthening has been slow and the health system bottleneck remains. Regarding HIV programmes, the process of ensuring widespread and sustainable access has largely been through specialised services, rather than decentralized, integrated services. The picture of service provision for HIV in many developing countries is a mix of specialised services and integrated services, but the process of inte- gration is generally at an earlier stage than with tubercu- losis programmes. The UNAIDS policy advice that "greater attention must be paid to integrating HIV ser- vices into primary health care as part of managing chronic diseases" [46] is yet to be widely translated into action. Given the different stages of development of integrated services for HIV and for tuberculosis programmes, the picture for areas of collaborative activity between HIV and tuberculosis programmes is predictably complicated. Although in the early years of this decade, the World Health Organization developed a global policy on HIV and tuberculosis programme collaboration representing an integrationist approach, with HIV and tuberculosis programme activities integrated into general health ser- vices [54], this was soon replaced by a revised approach, with emphasis on collaboration between HIV and tuber- culosis programmes and little reference to the need for integration with general health services [55]. This led to the establishment of what may be considered a third ver- tical programme on "TB/HIV" [56] alongside the existing HIV and tuberculosis programmes. The slow progress in expanding access to interventions of mutual concern to HIV and tuberculosis programmes may be attributable at least in part to the policy failure to promote integrated services (taking into consideration the need for attention to infection control) within strengthened general health services. Many of the types of activities for epidemic control undertaken by HIV and tuberculosis programmes are the same but are often undertaken separately e.g. epidemio- logical surveillance, programme monitoring and evalua-