integration of tb and hiv services: experiences from the kericho district hospital charles s....
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Integration of TB and HIV Services: Experiences from the Kericho District Hospital
Charles S. Kiptemas, MBChB, MPH
Director
South Rift Valley HIV Care & Treatment Program
Kenya Medical Research Institute/Walter Reed Project
Track 1.0 ART Program Meeting: Willard Intercontinental Track 1.0 ART Program Meeting: Willard Intercontinental Hotel, Washington, D.C.Washington, D.C. August 11-12, 2008
Background
• Need for integrated TB & HIV services
1 patients/2 diseases
2 clinics/2 ques/2 clinicians/2 treatment regimens
“Intensified case finding” – recognized potential for overloading very busy and overwhelmed clinics
- Identifying TB in HIV clinic
- Identifying HIV in TB clinic
• Aim: integrated TB/HIV clinic
Cadre of clinicians capable of treating both diseases in TB clinic
HIV care provided in TB clinic through at least intensive phase
• Goal: improved patient care
HIV Clinic In-patient
Integrated TB/HIV Clinic • HIV Testing & Counseling (PITC) • HIV Surveillance• HIV Prevention• TB Diagnosis and Treatment (for both HIV positive and negative patients)• HIV Care & Treatment (for co-infected patients)• Co-trimoxazole Preventive Therapy
TB Treatment Completion
Integrated TB/HIV Clinic (est. July 2005)
Out-patient
TB/HIV Clinic Characteristics (2005-2007)
• Cohort size (n) 1,220
• Age (mean, years) 31
• Female 53%
• Pulmonary TB 86%
• Sputum positive 41%
• PITC 94%
• TB-HIV coinfected 54%
TB/HIV Clinic Baseline CD4
0
5
10
15
20
25
<50 51-100 101-200 201-350 > 350
CD4 Distribution
%
78% eligible for ART
TB/HIV Co-infected Treatment Outcomes*
Mean 6-Month CD4 Change (cells/mm3)
Care +78
ART +139
TB Treatment Outcome
Completed 64%
Transferred out 11%
Loss to Follow up 14%
Deaths 11%
* Data presented on subset n=792
Intensified Case Finding
• Identifying TB in HIV clinic
symptom algorithm
CXR
cough monitors
• Identifying HIV in TB clinic
PITC
Contact tracing / case finding
- Family who can come to clinic
- Future contract tracing to home
TB/HIV Clinic Observations
• Successful management of co-infected patients with good clinical outcomes.
• Successful integration of TB and HIV services at a district hospital setting.
• High uptake of TB/HIV collaborative services.
• Patients with combined TB/HIV infections may receive benefit from:
primary TB treatment (“care”) alone;
and additionally ART.
• Patients with combined TB/HIV infections often present with advanced HIV disease.
Limitations/Strengths
• Primary Limitations: Inherent limitations in retrospective chart reviews:
- Clinic set-up not designed for systematic research.
- Incomplete/missing clinical data.
• Strengths: Advantage of electronic medical record system in TB/HIV
clinic where data accuracy can be verified against original clinic record.
Findings should be considered descriptive in nature; however, value of such descriptive data should not be overlooked in the early development of such TB/HIV programs.
Recommendations/Way Forward
• Integration of TB and HIV services needs to be considered in health facilities in order to improve uptake of collaborative services.
• Clinicians treating patients with TB/HIV should be aware of the benefit to HIV infection by treating TB and offering supportive care alone, and additionally ART.
• Efforts to identify patients with TB/HIV early in their disease may offer tangible benefit by providing the opportunity to consider early ART.
• Further controlled studies are needed to best identify when (and what settings) to initiate ART in patients receiving TB treatment.
• The Kenya team plans to roll out integrated TB/HIV clinic experiences from KDH to remaining district level ART treatment facilities in Southern Rift Valley.
Acknowledgements
• Kericho District Hospital TB/HIV ClinicKericho District Hospital TB/HIV Clinic
• Kenya Ministry of Health/NLTP/NASCOPKenya Ministry of Health/NLTP/NASCOP
• President’s Emergency Plan for AIDS ReliefPresident’s Emergency Plan for AIDS Relief
• Kericho District Hospital - Eunice ObieroKericho District Hospital - Eunice Obiero
• KEMRI – Fredrick Sawe & Jonah Maswai KEMRI – Fredrick Sawe & Jonah Maswai
• USMHRP – Doug Shaffer, Tiffany Hamm, Nelson MichaelUSMHRP – Doug Shaffer, Tiffany Hamm, Nelson Michael
• Brown University – Jane CarterBrown University – Jane Carter