National TB Program, Cambodia, JICA National TB Control Project

1. National HIV Prevalence Survey Among TB Patients, Jan 2003 As one of supplemental studies of the National TB Survey 2002 National TB Program, Cambodia, JICA National TB Control Project 3rd Global WG on TB/HIV, Montreux, 4-6June, 2003

2. From NTP Statistics

3. Increase in TB detection in the Capital City(from: National TB Statistics)

4. (From Chris Dye)

5. Trend of HIV Sero-prevalence among TB Patients, Cambodia(Crude Prevalence: 92,94 independent studies, 95- National HSS)

6. Why HIV/TB Prevalence Survey? • The HSS by AIDS program provides useful information on geographical and time trends. However • Representativeness is questionable • Hospital base: DOTS has been expanded • Non population based sample allocation • Diagnosis/Categorization errors • Low frequency of blood collection: Severe cases are more likely to be missed

8. Sampling Design(1): 100% v.s. Cluster • Huge variation between facilities was expected from “death” rate during treatment • Hot spots might be missed in cluster sampling • Facilities linked with AIDS treatment service Sampling Design(2): All v.s. Pul(+)New • Technical and moral problems in “Partial participation” :False positive cases • Advocacy issues Conclusion: 100% Sampling for all TB cases who are registered in January 2003

9. Study Design • Anonymous: No Name, No TB Number, De/Re-coding at National Center • Operational Health District, Age, Sex, Nationality, Type, New or Retreatment, Rather precise information on diagnostic process, Reason of Failing to take blood

10. National TB Center HIV Test Sample collection visit & Supervision Supervision Provincial Health Department(24) Overall management in province 50 Centrifuge/Cold Store Center Supervision Blood Transportation 150 Referral and Former District Hospitals with TB Lab in 74 Operational Health Districts Blood collection for own patients Smear results Blood collection visit Smear slides 500+ Health Centers/No doctor, No X-ray, No Microscope

11. Informed consent (Oral)A sheet in local language was provided to staff (English translation) This examination is only for the purpose of examining overall health condition of TB patients in Cambodia including HIV status. You are invited to participate in the survey. If you consent, you will be taken blood with the amount of 5ml, which process does not physically affect your body at all. There will be no side effect with this examination. The result of HIV test will not be informed to you, doctors, health workers, or any people (nobody will know your individual result). It is very important to make a future plan to help more TB and TB/HIV patients in Cambodia. Thank you very much for your understanding. You are entitled to receive a small gift for your participation.

12. Participants Cloth of 1.2$ value Staff Guidance/Training in Phnom Penh 20-40$ handling charge per TB unit and/or Lab Allowance for transportation Dissemination WS Incentives

13. HIV Test • National Reference TB Lab in National Center for TB Control • Test 1: Serodia HIV1/2, FUJIREBIO, Japan • Test 2: Determine HIV1/2, ABBOTT, Japan

14. Result(1) Eligibility 25 (Blood was actually collected) No Blood Collection 2289 (1.0%) Registered and Contacted 23 2264 No Yes 2241 (99.0%) Yes

15. Preliminary result of National Survey of HIV sero-prevalence among TB PatientsJan. 2003, Cambodia

16. TB patients and HIV infectionAge distribution, Jan 2003 National TB/HIV Survey, Jan 2003, Cambodia

17. TB/HIV BurdenGeographical Differences 27/900 (14 provinces+Kep) 9/149 17/173 9/36 (2) 17/159 (3+Pailin) 28/139 (1) Pul+ New Cases, Jun 2003, National HIV/TB Survey, Cambodia

18. TB/HIV in Phnom PenhJan 2003

19. BANTY MEANCHEY SIHANOUKVILLE TB/HIV Hot Spots in Cambodia

20. Finance • Training for Central staff and Supervisors (30): 3,500$ • Training and Guidance for all TB Units (160): 22,000$** • Supervision and Sample collection (Central team): 5,000$ • Local handling charge and local transportation: 15,000$ • Cloth for participants: 3,000$ • HIV test kits, other Lab equipment and consumables, printing etc.: 12,000$ + Technical Assistance by JICA Project Team **:Funded by STB/WPRO, Others were by JICA

21. Lessons learned • To carry out quality study, it is essential to make staff of all levels understand meanings and importance of the study • Although HSS provides good information on HIV/TB trend, periodic prevalence surveys are essential to know whole pictures especially in a country where HIV situation is very different by areas/service facilities • Quality of HIV kits locally available is sometimes questionable

22. Although our primary mission is to assist NTP to expand DOTS, we are proud of completing several quality studies to clarify TB situation in Cambodia. Our achievements are not only the study results but also huge capacity development of NTP staff. We believe that proper policy plans can be developed with scientific evidences by quality studies. Major Studies by NTP since 2000 • National TB Drug Resistance • National TB Prevalence (Tuberculin, X-ray, Smear/Culture) • National HIV/TB • Delay (Behavior Survey) JICA National TB Control Project Team (Mar ’03)