Challenge 4:Linking TB & HIV/AIDS Programs

Kayt Erdahl, Project HOPERodrick Nalikungwi, Project HOPE Malawi

December 18, 2008

Topics

• Introduction• Why is it important to link TB & HIV Programs?• TB/HIV Interactions• TB/HIV Strategies• Project HOPE TB/HIV Program in Malawi• Challenges • Program activities & progress• Lessons learned/recommendations

Why is it important to link TB & HIV programs?

“Tuberculosis (TB) is a leading cause of HIV-related deaths worldwide. In countries with

high HIV prevalence, up to 80% of people with TB test positive for HIV.

Globally there were 700,000 TB cases among people living with HIV in 2006, and an

estimated 230,000 people living with HIV will die as a result of TB in 2008 despite the fact

that TB is curable.”http://www.who.int/hiv/topics/tb/en/index.html

TB/HIV Interactions

• HIV promotes progression from TB infection to TB disease. People with HIV are up to 50% more likely to develop TB in a given year than HIV-people.

• High rates of mortality among TB/HIV co-infected patients

• TB is more difficult to diagnose in people with HIV• Infection control issues• Treatment coordination for both diseases: drug

interactions, IRIS, system policies

The Three Is

Three key public health strategies focused on decreasing the impact of TB on people living with HIV:

• Isoniazid Preventive Therapy (IPT)• Intensified Case Finding (ICF) for active TB• TB Infection Control (IC)

Examples of areas that NGOs/CBOs can get involved

• Coalition development, coordination between TB and HIV services, PHC and communities

• Incorporate screening and testing for TB within HIV services and for HIV in TB services

• Capacity building, TB/HIV education• Mobilize communities to demand coordinated services,

and to seek diagnosis, treatment and care• Decrease burden of HIV in TB patients: CPT, ART, HIV

prevention, care and support

Mulanjepop. 548,250

Phalombepop. 296,960

Project HOPE TB/HIV Project in Malawi

Tuberculosis Control in Southern Malawi

Child Survival TB & TB/HIV Grant funded by USAID

Dates: Oct 2006-2011

Location: 2 Districts in Southeastern Malawi

Malawi & Program area

Malawi• Country in Southern Africa, 13 million population• Health services provided mainly by Government, also

Mission Hospitals and private sector

Mulanje and Phalombe districts• Shared border with Mozambique• Population over 845,000• Largely rural, with inconsistent distribution of health

facilities• Communicable diseases are common –TB, HIV and Malaria

Malawi TB Goal & Objectives

Sub-objectives:1. Improve treatment outcomes of TB cases and TB

cases with HIV co-infection in Mulanje and Phalombe

2. Increase case detection of TB, including among people with HIV co-infection in Mulanje and Phalombe

Goal: to reduce morbidity and mortality due to TB and TB cases with HIV co-infection in the Mulanje and Phalombe Districts

Baseline, 2006 Year 2, 2008

Indicator Malawi1 2 Districts2 Malawi3 Phalombe4 Mulanje4

Case detection rate, new SS+

39% 29% 42% 34% 41%

Treatment success rate, new SS+

71% 77% 73% 73% 76%

Died, new SS+ 16% 19% 15% 24% 19%

HIV Prevalence 14.1% 18.6% 14%5 20-22%5

HIV prevalence est. in incident TB Cases

50% 70%

TB & HIV Epidemiologic data

1 WHO 2007 Global TB Control Report (2004 cohort)

2 Mulanje & Phalombe District Health Office (TB 08 Q3 2005-Q2 2006)

3 WHO 2007 Global TB Control Report (2005 cohort)

4 Mulanje & Phalombe District Health Office (CD 2007, Treatment outcomes, 2006)

5 2007 AIDS Epidemic Update, Africa (2005 data)

Challenges

• ART accessibility limited for TB/HIV co-infected due to the MOH quota system for ART

• Service Providers and the community are at risk of TB infection due to inadequate infection control

• Not all health facilities have access to microscopy for TB diagnosis

• Existing laboratories need strengthening to improve quality of diagnosis

• Accessibility to HIV testing still limited in remote areas

Challenges

• Link between TB and HIV programs still weak

• Clinical issues– Initiation of ART in TB/HIV co-infected only starts after

two months on TB treatment, by policy– Patients will not come for ART when they start feeling

well – less recruitment on ART and increased risk of dying from

AIDS– ART and TB drug interaction poses risks to patients

Program Activities - Community

• ASCM - Community education campaign– Increase recognition of TB symptoms,

importance of HIV testing, early TB diagnosis, knowledge of TB/HIV interaction, behaviors related to HIV prevention

– Volunteers, community leaders, shop owners, traditional healers, drama groups, families

• Improve TB symptom screening/referral by– Traditional healers & shop-keepers– HIV patients (self-referral)– Household contacts of SS+ TB cases– VCT/HIV Clinical care providers

Program Activities – Health Workers

• Train/mentor health workers (40) and health surveillance assistants (61)

– DOTS, strengthen recording & reporting system– Recognition of TB symptoms & referral for testing, repeat testing for

people with HIV– supervision of guardians, advocacy for TB & ARV treatment

adherence

• Advocate for client-friendly services: hours, confidentiality• Update/improve training manuals & curricula in

collaboration with NTP for HCW, HAS, community groups• Collaboration with national, local and international

organizations and programs

Program activities - System

• Technical assistance for integration of HIV testing into TB system, and strengthening referral system between diagnostic and treatment services for TB and HIV

• Establish Coordinating Committees for case management• Enhance quality assurance and standard operating

procedures in collaboration with local health care authorities– Supportive supervision training– Monitoring visits with district or zonal TB officers

• Work with NTP to correctly implement WHO TB guidelines and reporting/recording system

Program Activities -Laboratories

• Laboratory assessment done - determined microscopy system needed strengthening

• Train/retrain laboratory staff in microscopy and recording system

• Enhance external quality assurance for microscopy - Development of QA monitoring tools

• Equip new laboratories for sputum microscopy – 3 new peripheral sites established in last year

Program activities – new developments

• New NTP policy of Universal Access to TB Diagnosis – Project HOPE is assisting in implementation of Community Sputum Collection Points in Mulanje and Phalombe

• High mortality rates among TB and TB/HIV patients - Death audits

Program progress

Indicator Baseline, 2006 Year 2, 2008

% of TB suspects reporting to health facility within 8 weeks of cough

0% 71%

% registered TB patients who are tested for HIV

15% 96%

% TB/HIV Patients referred for HIV support services during TB treatment

15% 97%

Proportion of registered TB patients with HIV given ART during TB treatment

13% 15%

Lessons learned/recommendations

• TB/HIV management capacity building for health workers is particularly important: Health Surveillance Assistants are often allocated to work on TB/HIV with minimal knowledge

• HIV Counseling and testing done during the TB admission period has increased awareness and access to testing

• NTP and National AIDS Program should standardize approaches to TB and TB/HIV

Lessons learned/recommendations

• It is important for Programs to make strong links with other groups implementing activities in the community, e.g. nutrition-providing partners, Village health banks, etc.

• Programs/activities that put focus on community TB interventions are the most effective strategies in controlling TB, e.g. Decentralized microscopy, sputum points and transmission of results

• Proper data collection and documentation of activities important for sharing information at different levels.

Lessons learned/recommendations

• While clinical interventions are important, community health education is equally important

• Programs doing community interventions in TB/HIV co-infection should not be short term since they target behavior change that needs adequate time to have impact.

Thank you!Any questions?