HIV and TB Programme Collaboration

1. Interim Draft Module 8A - September 2008 HIV and TB Programme Collaboration

2. Project Partners • Collaborative project Funded by the United States Agency for International Development (USAID)

3. Module Overview HIV TB • Establish collaboration between TB and HIV/AIDS Programmes • Decrease the burden of TB in Persons Living With HIV and AIDS (PLWHA) • Decrease the burden of HIV in patients with TB International Standard 12 WHO TB/HIV Interim Policy, 2004

4. Learning Objectives Objectives: At the end of this presentation, participants will be able to: • Describe the steps needed for collaboration between TB and HIV/AIDS Programmes • Describe the three “I’s” for TB prevention in PLWHA • Describe at least two models for HIV testing and counselling

5. Background • Tuberculosis is highly associated with HIV infection and with overt HIV disease worldwide • Globally, the percentage of patients with TB and HIV co-infection ranges from: • <1% in low-HIV-prevalence countries • 50–70% in countries with a high HIV prevalence, mostly in Sub-Saharan Africa • What are the percentages of co-infection in your countries?

6. TB and HIV Co-infection in CMCs • The actual burden of HIV in patients diagnosed with TB in CAREC Member Countries (CMCs) is not known • HIV testing and counselling of patients with TB has not been systematically performed • Between 1997 and 2002, a cumulative total of 5,025 TB cases were reported in the CMCs • Of these, 2,962 underwent HIV testing (58.9%) • 785 were HIV-positive, reflecting an overall seroprevalence rate of 26.4%

7. HIV and Tuberculosis • In the absence of HIV infection, the lifetime risk of developing TB disease for persons with latent TB infection (LTBI) is approximately 10%  A person with both HIV infection and TB infection, however, has a 5-10% annual risk of developing TB disease

8. HIV and Tuberculosis (2) • HIV affects the progression of TB disease in the following two ways: • Reactivation of latent TB infection to TB disease, in HIV positive individuals  Preventable through treatment with isoniazid (IPT) • Rapid progression from recent TB infection to TB disease. Primary progression to active TB disease may occur within weeks following infection with M. tuberculosis

9. HIV and Tuberculosis (3) • TB is by far the single leading cause of death in patients dying from AIDS worldwide • Failure to diagnose and treat TB disease promptly in HIV infected patients contributes to premature mortality in AIDS patients and increased TB transmission in the community • Given the global TB and HIV situation, collaboration between national programmes (NTP and NAP) is  highly recommended to ensure control of both diseases

10. Goal and Objectives of Collaboration Goal To decrease the burden of TB and HIV in dually affected populations Objectives • To establish the mechanisms for collaboration between TB and HIV/AIDS programmes • To decrease the burden of TB among people living with HIV/AIDS • To decrease the burden of HIV in TB patients

11. Establishing Collaboration Between TB and HIV Programmes • TB services are a critical entry point for: • The promotion of HIV prevention • HIV testing and care and treatment • Adherence support • Anti-retroviral drug resistance monitoring • Ideally, service delivery should be integrated, providing an accessible continuum of care • Both HIV/AIDS and TB require a chronic disease management approach

12. Steps for Effective Collaboration To establish effective collaboration between programs, the following steps should be taken: Step 1: Set up a coordinating body for TB/HIV activities at all levels Step 2: Conduct surveillance of HIV prevalence among tuberculosis patients Step 3: Joint TB/HIV planning Step 4: Monitoring and evaluation (M&E) of collaborative TB/HIV activities

13. Step 1: Set up a coordinating body for TB/HIV activities at all levels • Important areas of responsibility for the joint coordinating bodies include: • Joint resource mobilisation for TB/HIV activities • Capacity building, including training • Ensuring coherence of communications about TB/HIV • Ensuring the participation of the community in joint TB/HIV activities

14. Step 2: Conduct surveillance of HIV prevalence among TB patients Surveillance provides information for • Increase political, professional and community awareness of: • Magnitude of the problem and reliable information for programme planning and implementation • HIV epidemic and its impact on TB patients • Impact of TB on HIV patients • Justify the argument for the formulation and implementation of a national TB/HIV strategy • Quantify the need for providing anti-retroviral (ARV) treatment to TB patients

15. Step 2: Conduct surveillance of HIV prevalence among TB patients (2) Data Sources and Indicators • The main sources of data are health centers, hospitals and laboratories • Specific HIV related data fields that NTPs might consider adding to TB registers and data collection sources include: • CD4 • Date of ARV initiation • Co-trimoxazole prophylaxis initiation    • In CMCs, how is surveillance for TB and TB/HIV is accomplished ?

16. Step 3: Joint TB/HIV Planning Joint planning and coordinated management is particularly important for: • Joint resource mobilisation • Capacity building • Advocacy • Enhancing community involvement in collaborative TB/HIV activities • Operational research

17. Step 4: Monitoring & Evaluation of Collaborative TB/HIV Activities • M&E provides the means to assess programme and activity: • Quality • Effectiveness • Coverage • Delivery • NTP and NAP Programmes should agree on a core set of indicators and the data collection tools that will be used

18. TB and HIV/AIDS Programme Collaboration Activity

19. Activity: TB & HIV Collaboration • Select a Recorder and a Reporter • You’ll have 15 minutes to address the following 2 questions in your group: • What do you think are the challenges to collaboration between the National TB and HIV/AIDS Programmes? • What strategies can you suggest to address these potential challenges?

20. Decreasing the Burden of TB in Persons Living with HIV/AIDS (PLWHA) TB is unique among the many other diseases affecting PLWHA, because: • It can occur at any stage of HIV disease progression • It remains a life-long risk for PLWHA, even in the presence of anti-retroviral therapy • Remember the three “I’s”: • Intensified TB case finding • Infection control • Isoniazid preventive treatment (IPT)

21. Intensified TB Case-finding in PLWHA • Involves screening for symptoms and signs of TB in settings where PLWHA seek care • TB should be suspected in all sick, HIV infected patients who are not doing well clinically  • Early identification of signs and symptoms of TB followed by pursuit of a confirmed diagnosis and prompt treatment: • Increase the chances of survival • Improves quality of life • Reduces transmission of TB in the community  

22. Intensified TB Case-finding in PLWHA (2) Health staff should be aware that: • Where there is a high prevalence of TB, a considerable proportion of cases may also be HIV sero-positive • In areas with a high prevalence of HIV/AIDS, they should look actively for cases of TB • Signs and symptoms of severe progressive TB are very similar to those of clinical AIDS particularly: • chronic fever • loss of body weight • cough

23. Infection Control • TB transmission frequently occurs in health care and congregate settings where people with TB and HIV may be crowded together • The types of infection control measures to reduce TB transmission can be classified as: • Administrative • Environmental • Personal protection

24. Infection Control (2) • Administrative measures for infection control should include: • Establishing and maintaining systems for early recognition, diagnosis and treatment of TB suspects (particularly those with PTB) • Separation of PTB suspects from others, until a diagnosis is confirmed or excluded • Staff working in congregate settings where persons with TB and HIV reside should receive annual updates on TB infection control

25. Infection Control (3) • Environmental protection should include maximising natural ventilation • Good ventilation helps reduce TB transmission indoors and can be facilitated by opening windows and use of fans where air may be stagnant • Sunlight is a natural source of ultra- violet light, which can kill TB bacilli • HEPA filtration is an effective means of cleaning the air

26. Infection Control (4) • Personal protection should include: • Protection of the HIV positive person from possible exposure to TB, and • Offering isoniazid preventive therapy if eligible • A face-mask decreases the risk that the person wearing the mask can infect other people  Whenever possible, a TB suspect or a TB patient should wear a face mask when moving from one part of the hospital to another

27. Isoniazid Preventive Therapy (IPT) • Preventive TB treatment refers to decreasing the risk of a first or recurrent episode of TB • A first episode of TB may occur in someone exposed to infection or with latent infection • A recurrent episode of TB occurs in someone who has previously had TB

28. Isoniazid Preventive Therapy (2) What is the value of IPT?

29. Treatment to Prevent TB in Persons Co-infected with HIV and TB Rate of active tuberculosis cases per 100 person-years Author/Place/Date Placebo Intervention Pape et al/Haiti/1993 INH, X 1 year 10 1.7 Markowitz et al/USA/1997 INH, X 6 mo 4.7 1.6 Whalen et al/Uganda/1997 INH, X 6 mo 3.41 1.08 INH+RIF, X 3 mo 3.41 1.32 INH+RIF+PZA, X 3 mo 3.41 1.73 Halsey et al/Haiti/1999 INH, 2X/week, X 6 mo - 1.0 RIF +PZA , X 8 weeks - 3.7 INH = Isoniazid ; RIF = Rifampicin; PZA = Pyrazinamide

30. Duration of Isoniazid Prophylaxis and Time of Recurrence of TB Duration of INH prophylaxis Fitzgerald D, Morse MM, Pape JW, Johnson WD Jr CID 2000; 311495-1497

31. Current IPT Recommendations *Interim Caribbean Guidelines for the Prevention, Treatment, Care, and Control of TB

32. Current IPT Recommendations (2) • The use of isoniazid with stavudine (d4T) may increase the risk of peripheral neuropathy • To prevent peripheral neuropathy, administer pyridoxine 25 – 50 mg daily along with the isoniazid • For children, the isoniazid dose is 5 mg/kg bodyweight (max. 300mg daily)

33. WHO/UNAIDS Recommendations on IPT in HIV-Positive Persons • Before initiating a service to provide routine IPT to PLWHA, the following prerequisites should be in place: • Adequate capacity for HIV counselling, which should include information, education and counselling about TB • Sufficient trained health care staff • Linkage between HIV care and TB control services • Good TB control programme with high cure rates and combined default/failure rates at the end of treatment of <10%

34. WHO/UNAIDS Recommendations on IPT in HIV-Positive Persons (2)  Rule out TB before IPT! • IPT should NEVER be initiated in a patient with HIV infection who has signs and symptoms consistent with active TB, or in whom TB disease cannot be safely excluded • IPT is used most safely in asymptomatic HIV infected patients, e.g. those diagnosed early in the course of HIV infection through HIV testing and counselling centres or antenatal clinics

35. Eligibility Criteria for IPT in HIV-Positive Persons • Patient is motivated for IPT after having been educated about the benefits as well as the possible side effects and risks; and • None of the following apply to the person: • Currently ill • Abnormal chest X-ray (even if TB has not been confirmed) • History of alcoholism (or daily alcohol use) • Presence of jaundice or active hepatitis (acute or chronic) • Poor prognosis (terminal AIDS) • History of prior allergy or INH intolerance • Had TB treatment in past two years

36. Monthly Monitoring • Medication should be collected once a month (every four-weeks) • The person receiving IPT should be evaluated by a nurse or physician at least monthly to check three important issues: • Signs and symptoms of TB • Side effects attributable to IPT • Adherence

37. Count Doses to Determine Completion

38. Decrease the Burden of HIV Among TB Patients • Provide HIV testing and counselling • Introduce HIV prevention methods • Introduce co-trimoxazole preventive therapy • Ensure HIV/AIDS care and support • Introduce antiretroviral therapy

39. ISTC Standard 12 In areas with a high prevalence of HIV infection in the general population where tuberculosis and HIV infection are likely to co-exist, HIV counseling and testing is indicated for all tuberculosis patients as part of their routine management. In areas with lower prevalence rates of HIV, HIV counseling and testing is indicated for TB patients with symptoms and/or signs of HIV-related conditions and in tuberculosis patients having a history suggestive of high risk of HIV exposure.

40. What are the benefits of HIV testing for a TB patient?

41. HIV Testing and Counselling • Should be promoted and offered routinely to all TB patients because of the following benefits: • Diagnosis of HIV allows for provision of life saving treatment (Co-trimoxazole prophylaxis and ART) • Allows the patient’s fears to be discussed and provides an avenue for information and advice to be given to the patient • Provides an opportunity to prevent further transmission through receipt of information on: • Measures/behaviours to protect self if uninfected • Measures/behaviours to protect others if infected

42. HIV Counselling and Testing Models • HIV counselling and testing approaches used in different settings in CMCs: • Client Initiated or Voluntary Counselling and Testing (VCT) • Provider Initiated Testing and Counselling (PITC) • Diagnostic • Routine

43. HIV Testing Must Occurin a Variety of Settings Provide ARV treatment to HIV-infected persons Clinics TB Clinics MCH Provide care to HIV-affected persons SRH Hospitals STI Clinics Surveillance Lab workers Health workers Counselors Prevent HIV Infections

44. Why use Rapid Tests? • Easier to use, no need for expensive lab equipment or highly skilled staff • Same visit result: useful for prophylactic regimens for transmission e.g., PEP • Increases the number of people that receive the test result  less transmission!

45. Sample Rapid Testing Algorithm Screen with Determine + Unigold Report as positive Both positive? Yes No Report as negative POS Report as positive Both negative? Yes No 1 positive & other negative? Screen with StatPack Yes Report as negative NEG

46. Summary: ISTC Standard Covered* Standard 12: In areas with a high prevalence of HIV infection in the general population and where tuberculosis and HIV infection are likely to co-exist, HIV counseling and testing is indicated for all tuberculosis patients as part of their routine management * Abbreviated version

47. Summary • For effective TB/HIV Programme collaboration, the following steps should take place: • Set up a coordinating body for TB/HIV activities at all levels • Conduct surveillance of HIV prevalence among TB patients • Joint TB/HIV planning • Monitoring and evaluation (M&E) of collaborative TB/HIV activities • Screening for symptoms and signs of TB is recommended in settings where HIV infected people seek care

48. Summary (2) • Remember the three “I’s” for TB prevention in PLWHA: • Intensified TB case finding • Infection control • Isoniazid preventive treatment (IPT) • All TB patients should be screened for clinical features suggestive of HIV • HIV testing and counselling should be offered to all TB patients