Mean Chhi Vun, MD, MPHMean Chhi Vun, MD, MPHNCHADS DirectorNCHADS Directormchhivun@nchads.orgmchhivun@nchads.org

Cambodia’s Experience on the Scale-Up Cambodia’s Experience on the Scale-Up of Collaborative TB/HIV Activitiesof Collaborative TB/HIV Activities

The 15th Core Group Meeting of the TB/HIV Working Group, November 3-4, 2009, Geneva

Demography and Health Status in Cambodia Demography and Health Status in Cambodia

Total pop. In 2008 = 13,69 million* Total pop. In 2008 = 13,69 million*

Male to Female sex ratio is 93.5* Male to Female sex ratio is 93.5*

Age group 15-49 is 47.9%** (estimated total female pop. = 2,98 Age group 15-49 is 47.9%** (estimated total female pop. = 2,98

million) million)

Rural pop. (85%) and Urban pop. (15%)*Rural pop. (85%) and Urban pop. (15%)*

Annual Growth rate = 1.81%* (estimated No. of baby born per Annual Growth rate = 1.81%* (estimated No. of baby born per

year = 540,000)year = 540,000)

IMR in 2005 = 66 per 1,000 LB and U5MR = 83 per 1,000LB**IMR in 2005 = 66 per 1,000 LB and U5MR = 83 per 1,000LB**

MMR in 2005 is 472 deaths per 100,000 LB** MMR in 2005 is 472 deaths per 100,000 LB**

Sources: * 2008 census (MOP)Sources: * 2008 census (MOP)

** CDHS, 2005** CDHS, 2005

HIV/AIDS Situation in CambodiaHIV/AIDS Situation in CambodiaFirst HIV detected in 1991 and first AIDS case diagnosed in 1993First HIV detected in 1991 and first AIDS case diagnosed in 1993

Main route of HIV transmission: heterosexual intercourse (95%)Main route of HIV transmission: heterosexual intercourse (95%)

MARP Group: EW, MSM, DU including IDU, Mobile people MARP Group: EW, MSM, DU including IDU, Mobile people

In 2006: HSS’06, SSS’05 and BSS’05In 2006: HSS’06, SSS’05 and BSS’05

- Estimated- Estimated HIV prevalence among adult pop. age 15-49 is 0.9% and HIV prevalence among adult pop. age 15-49 is 0.9% and

among pregnant women at ANC is 1%among pregnant women at ANC is 1%

- Estimated number of PLHAs among adult population: 67,100 (women - Estimated number of PLHAs among adult population: 67,100 (women

57,500) and AIDS patients: ~ 30,00057,500) and AIDS patients: ~ 30,000

- No official data on HIV infected children (estimated number was 9,000 - No official data on HIV infected children (estimated number was 9,000

HIV infected children including 3,000 AIDS patients)HIV infected children including 3,000 AIDS patients)

Situation of TB in CambodiaSituation of TB in Cambodia

• Cambodia is one of the 22 high-burden countries of TB in the world

• 64% of the total population has been infected with TB

• Incidence Rate of TB all forms: 495/100,000

• Incidence Rate of TB SS +: 219/100,000

• Prevalence of TB all forms: 664/100,000

• Mortality due to TB: 89/100,000

5

HIV Prevalence Among Adult pop. HIV Prevalence Among Adult pop. 15-49, between 1995 and 200615-49, between 1995 and 2006

1.8

2.3

2.52.6

2.4

2.12.0

1.8

1.6

1.4

1.21.1

1.1

1.5

1.71.9

1.7

1.5 1.5

1.3

1.21.1

0.90.8

1.2

1.7

1.92.0 1.9

1.6

1.51.4

1.21.1

1.00.9

0

0.5

1

1.5

2

2.5

3

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Urban Rural Total

AEM-projected prevalence of HIV among the general population AEM-projected prevalence of HIV among the general population aged 15 aged 15 –– 49 years from 2006 49 years from 2006 –– 2012 (with ART available) 2012 (with ART available)

0.9

0.8

0.7 0.7 0.7

0.6 0.6

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

2006 2007 2008 2009 2010 2011 2012

HIV incidence* among ANC by survey yearHIV incidence* among ANC by survey year

Actual number of AIDS Patients Receiving ART Actual number of AIDS Patients Receiving ART as of September 2009as of September 2009

36,08432,586

3,498

1,716

914

802

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

Total Adult ChildrenEs

tim

ate

d n

um

be

r o

f p

eo

ple

in

ne

ed

of

AR

T

on ART not yet on ART

(81%)

(95%)(97%)

2009 Target:

Adult: 33,500

Children: 4,300

Total: 37,800

OI&ART: 52 sites

PAC: 29 sites

9

HIV sero-prevalence trend among TB HIV sero-prevalence trend among TB casescases

10

TB/HIV Collaborative Activities TB/HIV Collaborative Activities (1)(1)

1999 : TB/HIV Sub-Committee was set up 1999 : TB/HIV Sub-Committee was set up 2001 : First TB/HIV Clinic (CENAT/JICA) at Capital City2001 : First TB/HIV Clinic (CENAT/JICA) at Capital City 2002 : TB/HIV Framework has been endorsed by MoH 2002 : TB/HIV Framework has been endorsed by MoH 2003 : TB/HIV Pilot Projects at 4 sites: TB screening at OI and ART service 2003 : TB/HIV Pilot Projects at 4 sites: TB screening at OI and ART service 2003: CoC including TB screening and TB diagnosed for suspected case among PLHA before to start ART2003: CoC including TB screening and TB diagnosed for suspected case among PLHA before to start ART 2005: Joint statement between TB and HIV Program:2005: Joint statement between TB and HIV Program:

- Clearly - Clearly defined role defined role and and responsibiliresponsibility of each ty of each Program: Program: LSM LSM

- Joint - Joint training training activitiesactivities

2005: SOP for HIV testing among TB patients (HPITC)2005: SOP for HIV testing among TB patients (HPITC)

- Option 1: - Option 1: Refer TB –Refer TB –DOT to the DOT to the nearest nearest VCCT VCCT

- Option - Option 2 : 2 : Transport Transport blood blood sample of sample of TB to the TB to the nearest nearest VCCT by VCCT by HC HC

- Option - Option 3 : Taken 3 : Taken blood blood sample of sample of TB by HC TB by HC staff staff through through outreach outreach

and send and send it to the it to the nearest nearest VCCT VCCT

11

TB/HIV Collaborative Activities TB/HIV Collaborative Activities (2)(2)

2008 : Standardized TB/HIV Monitoring tools (TB Register, 2008 : Standardized TB/HIV Monitoring tools (TB Register, Reporting,...) Reporting,...)

2008 : TB/HIV training curriculum and Clinical manual have 2008 : TB/HIV training curriculum and Clinical manual have been developed and endorsed by MoHbeen developed and endorsed by MoH

2009 : Revised TB/HIV Framework has been submitted to 2009 : Revised TB/HIV Framework has been submitted to MoH MoH

2009 : Reviewed TB/HIV Monitoring and Reporting System 2009 : Reviewed TB/HIV Monitoring and Reporting System assisted by WHOassisted by WHO

2009 : 3 Is Concept have been translated into action 2009 : 3 Is Concept have been translated into action

- TB screening among all PLHA newly diagnosed - TB screening among all PLHA newly diagnosed (interviewed by HIV Counselors and OI and ART team)(interviewed by HIV Counselors and OI and ART team)

- TB Infection Control at CoC services- TB Infection Control at CoC services

- IPT (3 sites have been piloted since 2004), but No - IPT (3 sites have been piloted since 2004), but No ExpansionExpansion

As a Result of the Combined EffortsAs a Result of the Combined Efforts

For Over the Last 10 Year, 1999-2009 For Over the Last 10 Year, 1999-2009

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Result of TB/HIV Training Result of TB/HIV Training Activities Activities

By 2008 : Health workers in 68 of 77 ODs trained on TB/HIV By 2008 : Health workers in 68 of 77 ODs trained on TB/HIV collaborative activities collaborative activities

By April 2009 : 6 batches of 5 days training program on clinical By April 2009 : 6 batches of 5 days training program on clinical management were completed:management were completed:

- Trainees: Clinicians working at TB Ward of National Hospital,- Trainees: Clinicians working at TB Ward of National Hospital,

RH at Provincial and OD level, NGOs,...RH at Provincial and OD level, NGOs,...

- Training Site: 11 provinces, 1 NGO, 3 National hospitals- Training Site: 11 provinces, 1 NGO, 3 National hospitals

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HIV testing and ART in TBHIV testing and ART in TB

20072007

(all ODs)(all ODs)20082008

( all ODs)( all ODs)

Total TB cases Total TB cases registeredregistered

36,42136,421 39,82039,820

Unknown HIV status Unknown HIV status after TB registeredafter TB registered

31,13631,136 36,94236,942

Referred to VCCTReferred to VCCT 13,53513,535

(43%)(43%)19,96319,963

(54%)(54%)HIV testedHIV tested 11,82011,820 18,64518,645HIV positiveHIV positive 497 (4.2%)497 (4.2%) 431(2.3%)431(2.3%)TB/HIV under CPTTB/HIV under CPT 1,1011,101 1,2791,279TB/HIV under ARTTB/HIV under ART 610610 733733

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Intensified TB case finding and Intensified TB case finding and IPTIPT

20072007 20082008HIV+ Registered at HIV+ Registered at VCCTVCCT

11,64111,641 9,5119,511

HIV+ clients screened HIV+ clients screened for TB for TB

5,318 (46%)5,318 (46%) 5,980 5,980 (63%)(63%)

TB diagnosedTB diagnosed 1,9741,974 2,159 2,159 Sputum smear+Sputum smear+ 501501(25%)(25%) 522522(24%)(24%)

Sputum smear-Sputum smear- 787 787 (40%)(40%) 826826(38%)(38%)

EPTBEPTB 686 686 (35%)(35%) 811811(38%)(38%)

IPT (3 sites only)IPT (3 sites only) 7777 6666

Main Challenge: Human ResourceMain Challenge: Human Resource

VCCTVCCTANCANC

FP/BSFP/BS

MNCHMNCH

PMTCTPMTCT

STISTI

Health StaffHealth Staff

EPIEPI

OI and ART

PAC

TB

CPA and MPA

Challenges Challenges

Work load of existing health staff at NCHADS, CENAT and PHD/ODWork load of existing health staff at NCHADS, CENAT and PHD/OD

Creating conflict of interest and benefit (competition for resources)Creating conflict of interest and benefit (competition for resources)

Limited capacity for program management including finance and Limited capacity for program management including finance and

budgeting, reporting at peripheral levelbudgeting, reporting at peripheral level

Limited Capacity to own the TB/HIV collaborative activities at OD Limited Capacity to own the TB/HIV collaborative activities at OD

levellevel

Limited Understanding of the issues at all levelsLimited Understanding of the issues at all levels

Unclear about Vertical and Integrated Programming ?Unclear about Vertical and Integrated Programming ?

Limited Capacity in strategic thinking for having new approaches or Limited Capacity in strategic thinking for having new approaches or

models and Acceptance of Change. models and Acceptance of Change.

Harmonization among partners – needs strengtheningHarmonization among partners – needs strengthening

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Increase access to IPT through Linked Response package Increase access to IPT through Linked Response package activity at OD level (Linked response between HIV/AIDS activity at OD level (Linked response between HIV/AIDS /STI/RH/TB):/STI/RH/TB):

- 2010: If enabling environment will be good and - 2010: If enabling environment will be good and supportive ,supportive ,

in 15 OD providing one stop service (increasing access to IPT in 15 OD providing one stop service (increasing access to IPT from 66 to 1320 PLHA)from 66 to 1320 PLHA)

- Develop SOP for implementing IPT at OD level- Develop SOP for implementing IPT at OD level

- Standardize monitoring tools for IPT including - Standardize monitoring tools for IPT including community base support activitycommunity base support activity

- Strengthen the referral and follow up TB/HIV co-- Strengthen the referral and follow up TB/HIV co-infection who are receiving IPT through LR network (HIV infection who are receiving IPT through LR network (HIV services and TB service and linking them with community base services and TB service and linking them with community base support activity)support activity)

- Build ownership of the OD/HC Management Team - Build ownership of the OD/HC Management Team to incorporate IPT into LR package to incorporate IPT into LR package

Next steps

NCHADSHIV/AIDS/STI

Prev., Care and treatNCMCH

(RH, FP, MNH)

MOH

Package of Services:

- Policy, strategy ...- Planning and monitoring- Capacity building - Technical support- Logistic management- Data management

PAOHIV/AIDS/STI

Coordinator HIV/AIDS/STI

PMCH (RH, FP, MNH)

CoordinatorMCH

HIV/AIDS/STI and RH: Program ManagementHIV/AIDS/STI and RH: Program ManagementAfter 2002After 2002

Good collaboration

Good collaboration

TB +TB

+IPT

+TB screening

Thank youThank you