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Integrating HIV and TB delivery: models, results and prospect

Integrating HIV and TB delivery: models, results and prospect. Haileyesus Getahun, MD, PhD, MPH. Stop TB Department World Health Organisation, Geneva. . TB patients tested for HIV (%). Africa. Global. Regions other than Africa. TB patients received ART (%). Regions other than Africa.

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Integrating HIV and TB delivery: models, results and prospect

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  1. Integrating HIV and TB delivery: models, results and prospect Haileyesus Getahun, MD, PhD, MPH. Stop TB Department World Health Organisation, Geneva.

  2. TB patients tested for HIV (%) Africa Global Regions other than Africa TB patients received ART (%) Regions other than Africa Global Africa

  3. Number of facilities providing TB and ART, 2011 ART services are still too centralized and too few

  4. 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

  5. HIV service TB service One-stop service HIV testing ART CPT Condoms HIV testing HIV prevention CPT ART TB screening TB diagnosis TB treatment HIV and TB Services provided together ART TB diagnosis and treatment TB screening IPT TB diagnosis TB treatment TB contact tracing Partially integrated Partially integrated Referral to TB Co-located Adjacent Referral to HIV Models for integrated TB and HIV services delivery

  6. 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.

  7. Referral from TB clinic for HIV testing in India National HIV testing of TB patients increased 23 fold

  8. Referral from HIV clinic for TB diagnosis in India Reference: RNTCP Annual Reports 8% 6% 5% 20% 11% 9% Percent shows out of all PLHIV registered for HIV care (red) and out of all PLHIV referred (blue)

  9. 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 One stop Separate Partial

  10. Results: mixed models in Kenya Percent of TB patients tested for HIV One stop Percent of HIV positive TB patients received ART

  11. 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

  12. Results: One stop service model in Rwanda Percent shows out of all identified HIV positive TB patients nationally Percent ART coverage for TB patients increased five fold

  13. 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 ART Interventions: a. Training to medical officers and TB and HIV staff b. New standard referral forms developed Unknown HIV status 4701 (100%) Eligible for ART referral 396 (100%) Referred for HIV testing 3368 (72%) Referred for ART center 269 (68%) Reached ART center 220 (56%) HIV test done (66%) HIV positive 200 (4%) ART started 105 (27%)

  14. Impact on patient cohorts (Urban HIV clinic, Uganda, Hermans et al JAIDS 2012;60:e29–e35) Objective: establish a one stop TB service in HIV clinic Interventions: 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<0.01

  15. 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)

  16. Practical considerations

  17. More physical space Renovation and restructuring Qualified staff Training Space, staff and training Congested OPD, Kenya Congested OPD, India

  18. 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)

  19. Documentation, monitoring and evaluation • New tools and formats • Simplifying documentation • Computerization needs M and E in a peripheral clinic Overcrowding with paper based M and E Worn out ART register

  20. What needs to be done? Macro level measures Programme level interventions Research and generating evidence

  21. TB Program Drug use Program AIDS Program TB, HIV, drug use and incarceration are intricately linked Prison H Program National level National level National level National level Intermediate level Intermediate level Intermediate level Intermediate level Lower level District level District level Lower level Intermediate level Prison services Drug use services TB clinic ART clinic TB services HIV services • Break up silos and minimize extreme verticality • Joint planning and implementation at minimum • Enhance MOH engagement in prison health

  22. NTP NAP So many questions • Which countries? • At what level? • Will it work? • Who will swallow who? • Competition and turf? • Power imbalance? • Funding and resources? National level National level Intermediate level Intermediate level District level District level TB clinic ART clinic NTP – National TB Program ; NAP – National AIDS Program Integrate the management of TB and HIV programs?

  23. Number of facilities providing TB and ART, 2011 Use the decentralized TB facilities to provide ART using the TB nurses and clinical officers

  24. Task shifting: nurse monitored ART is not inferior to doctor monitored ART (Sanne I, et al, 2010)

  25. 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.

  26. Build and strengthen integrated community based TB and HIV activities

  27. Multidisciplinaryimplementation 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

  28. 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 Summary

  29. Khayelitsha, South Africa – a pioneer clinic

  30. 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

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