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