Integrating HIV and TB delivery: models, results and
prospect
Haileyesus Getahun, MD, PhD, MPH.Stop TB Department
World Health Organisation, Geneva.
Africa
GlobalRegions other than Africa
TB patients tested for HIV (%)
Regions other than Africa
GlobalAfrica
TB patients received ART (%)
Number of facilities providing TB and ART, 2011
ART services are still too centralized and too few
WHO TB/HIV policy: 12 points policy package
• HIV testing for TB patients
• TB screening for PLHIV Isoniazid preventive
therapy TB diagnosis and
treatment ART for TB prevention
• ART and CPT
TB service One-stop service
HIV service
HIV testing
HIV prevention
CPT
ART
Referral to HIV
HIV testing
ART
CPT
Condoms
Partiallyintegrated
HIV and TB Services provided together
ART
TB diagnosis and treatment
Co-locatedAdjacent
TB screening
TB diagnosis
TB treatment
Referral to TB
TB screening
IPT
TB diagnosis
TB treatment
TB contact tracing
Partiallyintegrated
Models for integrated TB and HIV services delivery
Referral model in India• Routine referral of TB patients from TB clinics
to HIV testing centers with opt out option.
• TB screening of PLHIV in high prevalence states which later scaled up to all states
• PLHIV with symptoms of TB referred to the TB clinics for further investigation and treatment.
Referral from TB clinic for HIV testing in India
National HIV testing of TB patients increased 23 fold
Referral from HIV clinic for TB diagnosis in India
5%
6%
8%Reference: RNTCP Annual Reports
20% 11% 9%
Percent shows out of all PLHIV registered for HIV care (red) and out of all PLHIV referred (blue)
Mixed models in Kenya
• HIV testing in TB clinics followed by referral for HIV care
• TB screening at every visit in HIV clinic followed by referral for TB treatment
• Subsequent initiation of ART in TB clinics and one stop services
Separate Partial One stop
Results: mixed models in Kenya
Percent of TB patients tested for HIV
Percent of HIV positive TB patients received
ART
One stop
One stop service model in Rwanda
• TB nurse Provides HIV testing Draws blood for CD4 Provides ART and CPT
• Referral to ART clinic at the end of TB treatment
Results: One stop service model in Rwanda
ART coverage for TB patients increased five fold
Perc
ent
Percent shows out of all identified HIV positive TB patients nationally
Impact on patient cohorts (2 districts, India, Vijay et al PLoS One 2009; 4(11): e7899)
Objective: Referral of TB patients for HIV testing and ARTInterventions: a. Training to medical officers and TB and HIV staff b. New standard referral forms developed
Unknown HIV status4701 (100%)
Referred for HIV testing
3368 (72%)
HIV test done (66%)
HIV positive200 (4%)
Eligible for ART referral 396 (100%)
Referred for ART center
269 (68%)Reached ART center
220 (56%)
ART started 105 (27%)
Impact on patient cohorts (Urban HIV clinic, Uganda, Hermans et al JAIDS 2012;60:e29–e35)
Variables Before (2007)N=346
After (2009)N=366
Median time for ART initiation (days) 103 45ART during intensive phase (%) 23 60*Treatment success rate (%) 62 68*Default rate (%) 30 10*Death rate (%) 3 15*
Objective: establish a one stop TB service in HIV clinicInterventions: a. TB WG established and care provided by same staff b. Standard operating procedures for TB Dx and Rx c. Clinic separated by an outdoor open space d. 2 MDs, 3 nurses, a peer supporter, senior MD
* P<0.01Huerga et al, 2010 showed death rate reduction from 8 % to 3%*
HIV and TB into prison and drug use programs
• Scanty data and documented experience• Prisoners in Zambia (self reporting data) Todrys
et al, 2011
23% screened for TB; 57% tested for HIV• All Ukrainian Network of PLHIV experience
TB – HIV - Harm reduction services TB – Harm reduction services 25 sites established in 2009-2010 On site access for TB dx – key factor for success
(Reference: K. Lezhensev, Global TB/HIV Core Group meeting Almaty, May 2010)
Practical considerations
Space, staff and training
• More physical space
• Renovation and restructuring
• Qualified staff
• Training
Congested OPD, Kenya
Congested OPD, India
TB infection control• PLHIV with MDR caused 98% of
all TB transmission in Peru (Escombe et al , 2008)
• 67% of XDR patients had recent hospitalization(Ghandi et al, 2006)
• HCWs have >5 times risk of hospitalization for MDR and XDR TB (O’Donnell et al, 2010)
Documentation, monitoring and evaluation
• New tools and formats• Simplifying
documentation• Computerization needs
Worn out ART register
M and E in a peripheral clinic
Overcrowding with paper based M and E
What needs to be done? Macro level measures
Programme level interventions
Research and generating evidence
Intermediate
level
National level
TB clinic
District level
TB Program
TB services
Intermediate level
National level
Drug use services
Lower level
Drug use Program
Intermediate level
National level
ART clinic
District level
AIDS Program
HIV services
Intermediate level
National level
Prison services
Lower level
Prison H Program
Intermediate level
• Break up silos and minimize extreme verticality• Joint planning and implementation at minimum• Enhance MOH engagement in prison health
TB, HIV, drug use and incarceration are intricately linked
• Which countries?• At what level?• Will it work?• Who will swallow who?
• Competition and turf?
• Power imbalance?• Funding and resources?
Integrate the management of TB and HIV programs?
So many questions
TB clinic
District level
National level
Intermediate
level
NTP
District level
National level
Intermediate
level
NAP
ART clinic
NTP – National TB Program ; NAP – National AIDS Program
Number of facilities providing TB and ART, 2011
Use the decentralized TB facilities to provide ART using the TB nurses and clinical officers
Task shifting: nurse monitored ART is not inferior to doctor monitored ART
(Sanne I, et al, 2010)
Health officers and nurses (Health center)
Physicians ( Hospitals)
Mortality (%) 11 8 Lost to follow up (%) 13 25Retention rate (%) 76 67Median CD4 count (IQR) 322 (242, 414) 301 (217,411)
Nurses and health officers can initiate ART with better results (Assefa Y et al, 2011)
Outcome of patients initiated ART by nurses and physicians after 24 months of follow up, Ethiopia.
Build and strengthen integrated community based TB and HIV activities
Multidisciplinary implementation research
• High quality studies are inexistent so far• We should know:
Process and impact of integration both at service and management level
Enablers for successful integration with high impact
Sociopolitical interventions to trigger and sustain innovation and effectiveness
• Multi-disciplinary approach and earmarked financial support
Summary• There is no one model that fits all and local
context, resources and epidemiology define the best model
• Efficiency among harm reduction, prison health, TB and HIV services and programs critically needed.
• Decentralised TB services need to be used to scale up HIV treatment and prevention.
• Research funding needed to support multidisciplinary implementation research
Khayelitsha, South Africa – a pioneer clinic
Acknowledgement
• A. Baddeley, WHO• D. Havlir, UCSF• E. Goemaere, South
Africa• R. Granich, WHO• B.B. Rewari, India• M. Gasana, Rwanda• L. Nguyen, WHO• J. Sitienei, Kenya• G. Vendebriel, Rwanda