Integration of TB and HIV Screening, Care and Treatment in Mulago

Hospital, Uganda

Rhoda Wanyenze, Doris Mwesigire, Henry Luzze, Violet Gwokyalya, Julius Sempiira, Alphonse Okwera,

Alice Namale, Edwin Charlebois, Moses Kamya

Mulago-Mbarara Teaching Hospitals’ Joint AIDS Program (MJAP)

PEPFAR Meeting, Kigali - RwandaJune 16, 2007

Background

• Overlapping TB and HIV epidemics– HIV increases susceptibility to TB infection/

disease– TB/HIV co-infection is common– TB/HIV co-infection increases morbidity &

mortality especially with late initiation of care• Early & concurrent treatment for both

infections desirable to improve outcomes• Programs for TB & HIV often parallel

– Delayed diagnosis & linkage to care is common

Context of MJAP TB/HIV Services

• International TB/HIV guidelines• Uganda TB/HIV Collaborative Policy -

2005• MJAP initiated integration of TB & HIV

services in 2005• Other MJAP services - 10 sites

– HIV testing and counseling• Routine HIV testing and counseling (RTC) • Home based HIV counseling and testing

– Care and treatment

Integrated TB/HIV Services

• Hospital-based screening for both TB & HIV– Enhanced TB screening in the HIV clinic– Routine HIV testing for TB inpatients &

outpatients– Concurrent TB and HIV screening of medical

inpatients– Integrated TB and HIV care and treatment

TB Screening

• Criteria for TB screening– Patients with cough >2 weeks – Other clinical evaluation: fever, weight

loss, …• Diagnosis

– Laboratory• Sputum smears: patients with productive cough• Biopsy/aspiration: Extra-pulmonary TB

– Microscopy (ZN or auramine)– Recently started doing culture

– X rays

Linkage to Care

TB HIV Action

Pos Pos TB/HIV Clinic

Pos Neg TB Clinic

Neg Pos HIV Clinic

Neg Neg Prevention counseling

CD4 testing & prep for ART starts in ward for very ill patients

Mulago TB/HIV Clinic

• Clinic runs one day a week – Within the TB unit (in Mulago hospital)

• Patients referred to HIV clinic after completion of TB treatment

• Patients receive TB and HIV care – Basic care package and other non-ART

care

– Anti-TB: 2HERZ/6EH

– ART: Combivir + Efavirenz• A few patients on triomune

TB/HIV Clinic Procedures

• Seen monthly or more frequently when needed

• Laboratory tests– CBC: Baseline & every 3 months– CD4: Baseline & every 6 months– Sputum smears: Baseline, 2, 5 & 8

months• SOPs and data collection tools

cover TB and HIV care and treatment aspects

Results (1)

• August 2005-April 2007

• TB patients received RTC: 2,651 – HIV prevalence among tested patients:

33%

– 96% accept testing

• TB sputum smears in medical wards: 1,869 – 587 (32%) sputum positive

– 379 (65%) of sputum Pos co-infected with HIV

Results (2)

• Screened for TB in the HIV clinic: 4,835– Number with TB disease: 807

• 724 (15%) - sputum positive

• 83 - X ray & other clinical criteria

• 706 received care in the TB-HIV clinic– 92 transferred out after completion of Tb

treatment

• 327 initiated ART within the TB-HIV clinic

Challenges/Gaps

• Increased resources for treatment • Diagnosis of extra-pulmonary & smear –

ve TB • Counseling & support for both TB

treatment and ART more complex• Incorporate TB contact tracing• Transfer out after completing TB

treatment – some patients are uncomfortable with this

Conclusions

• Integration of TB/HIV services feasible• Detects a significant number of

TB/HIV co-infected patients • Need to strengthen

– Diagnosis for smear –ve and extra-pulmonary TB

– Adherence counseling, support & monitoring for concurrent TB treatment and ART

Acknowledgements

• PEPFAR/CDC

• National TB and Leprosy program

• Mulago Hospital and Complex

• TB unit

• MJAP Staff