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Malawi ProTEST Project: Reducing TB/HIV Burden in Lilongwe

Explore the successful Malawi ProTEST Project pilot activities focusing on reducing TB/HIV epidemics in Lilongwe. Output includes increased stakeholder cooperation, VCT services usage, and community involvement in TB/HIV/AIDS care. Learn about strategies such as reducing HIV transmission and TB reactivation in HIV-positive individuals.

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Malawi ProTEST Project: Reducing TB/HIV Burden in Lilongwe

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  1. Malawi ProTEST Projectpilot activities Malawi National TB Control Programme Durban 2003

  2. Malawi ProTEST Project • Pilot Site, August 1999-July 2002 Lilongwe District population: 1.3 million Urban population: 450,000

  3. Malawi TB Notification Rates

  4. Malawi’s HIV burden National adult HIV rate: 16% Lilongwe antenatal HIV rate: 25% HIV in TB 77% of all TB patients HIV +ve(in year 2000)

  5. Goal of the Malawi ProTEST Project: • To reduce the burden of the TB/HIV epidemics in Lilongwe

  6. Purpose: • To increase the cooperation, coordination and collaboration between TB and HIV stakeholders in Lilongwe And • To increase capacity within initiatives addressing TB/HIV management

  7. Malawi ProTEST Outputs 1. Increase dialogue, cooperation and co-ordination between TB/HIV stakeholders 2. Increase capacity of TB/HIV providers 3. Increased use of VCT services 4. A network of services for People Living With HIV/AIDS 5. Increased community involvement in TB/ HIV/AIDS care 6. Economic evaluation

  8. ProTEST Strategies 1.Reduce HIV transmission 2. Reduce TB transmission • Reduce TB reactivation in HIV+ Good quality VCT (rapid results, care) Screening and treatment STIs Promotion of behaviour change Improved TB case finding TB preventive therapy (isoniazid)

  9. Possible approaches when designing the project: 1. Define ProTEST ‘package’ and introduce all interventions to specific partners Or 2. Develop collaborative TB-HIV activities (incorporating elements of the ProTEST strategy) according to the capacity of each partner * Malawi’s approach

  10. 2 VCT Models in Lilongwe • Free standing (MACRO) • 10 counsellors, 1 lab, 1 receptionist, 1 clinician • Usually clients self-referred • Radio promotion • Rapid-results Jan 2000 • Integrated (TB Hospital) • 2 counsellors, no lab technician, 1 receptionist • Usually clients referred from clinical services • Leaflets, referral • Rapid-results Feb 2001

  11. VCT in Lilongwe (Oct 1999-June 2002) Total: 41,026 clients 22% HIV+

  12. Number of clients accessing VCT at MACRO Rapid results

  13. 2897 clients accessing VCT at TB Hospital (May 2000-June 2002) 2nd Counsellor Rapid results

  14. Client differences between services • Stand-alone • MACRO • Jan 00-Dec 01 • 33,167 clients • Median age 23 years • (21-29) • 22% clients women • <1% decline testing • 16% HIV+ • Hospital based • TB Hospital • May 00-April 02 • 2,368 clients • Median age 32 years • (26-39) • 48% clients women • 9% decline testing • 75% HIV+

  15. Impact of ‘while-you wait’ HIV test results • 4-5 fold increase in clients accessing VCT (service implications) • Proportion of those HIV tested that received their results increased from 70-80% to over 99% • Whole-blood rapid test kits can be performed without a laboratory (policy issue) • Whole-blood rapid test kits have the potential to increase access in rural areas • Issues of QC – both counselling and testing

  16. VCT at Health CentresLogistic difficulties due to lack of onsite testing/rapid-results

  17. Intensified case-finding (TB) • 2 main sites: • 1. VCT clients • 2. Community-based organisations • HBC clients • Through traditional healers • Through private practitioners

  18. TB screening at MACRO • All VCT clients screened for cough >3 weeks • Those with cough referred to clinical officer in MACRO clinic • Cough register • Sputum collection • Sputum transport to lab. (from Nov 00)

  19. TB screening: all clients(Nov 2000-Oct 2001) 14,422 clients 197(1.4%) with chronic cough already under investigation for TB 104asked to submit sputum (onsite at MACRO) 98 submit sputum 25 (<1%) with confirmed TB (173/100,000) 11 AFB+ 14 AFB-/Culture+

  20. TB screening: HIV+ clients only(Nov 2000-Oct 2001) 2,217HIV+ clients 121(5%) with chronic cough already under investigation for TB 85 submit sputum (onsite at MACRO) 15 (<1%) with confirmed TB (677/100,000) 7 AFB+ 8 AFB-/Culture+ Treatment outcomes difficult to trace

  21. TB case-finding through HBC • 6 groups community volunteers trained • Case-finding 2000-2001 • 182 new TB cases diagnosed • Population 300,000 – but not full coverage by volunteers • Referrals reflect number/enthusiasm of community volunteers • 58% completed TB treatment Smear-positive 89 Smear-negative 82

  22. STI screeningMACRO and TB Hospital VCT • Simple STI screening questionnaire for all clients, administered by VCT counsellors • Symptomatic clients referred for treatment • Drugs for STI syndromic management provided

  23. MACRO: STI screeningJan 00-Dec 01 25,788 (99%) clients asked STI questionnaire 601(2%) clients with symptoms suggesting STI 501clients with STI confirmed and treated syndromically after review by clinical officer (9% at TB Hospital VCT)

  24. MACRO STI syndromes treated (501 clients) PID Bubo Warts Urethral Discharge (29%) Genito-urinary symptoms (22%) Genital Ulcers (29%)

  25. IPT: at MACRO (from March 2001) • VCT counsellors • promoted IPT to HIV+ve clients • encouraged HIV+ to visit MACRO clinic for IPT screening • Initially clients could start IPT the same day they learnt their results (after ruling out active TB) • After June 2001 clients asked to come back another day to MACRO to start IPT • Option offered of continuing IPT at DOT centre

  26. MACRO Results (March 2001 to June 2002) • 3377 clients tested HIV-positive • 741 (22%) clients were screened for IPT • 32 (4%) were not started on IPT (symptoms consistent with active TB) • 140 (19%) failed to come to back • 569 (77%) actually started IPT

  27. Adherence with IPT(March-December 2001 cohort) • 446 started IPT (March-Dec 01) • 150 (32%) completed the recommended 6 months duration of treatment

  28. Cotrimoxazole Preventive Therapy in Lilongwe • The Challenge: making CPT available to TB patients in a district where TB treatment is decentralised: • 22 DOT centres • 10 diagnostic centres • Centralised VCT services

  29. CPT recruitment criteria • All TB patients on treatment • HIV positive • No contra indication to sulphur- containing drugs • Living in Lilongwe district • TB patients could start CPT at any point during TB treatment

  30. Map of Lilongwe showing No. of TB patients on CPT in DOTS centres

  31. ResultsApril 2000-June 2002 • 9826 registered for TB treatment (all should be offered VCT) • 1500 (15%) accessed VCT • 225 were HIV-ve, 69 were not tested • 1206 started CPT • Assuming 80% of TB patients in Lilongwe are HIV positive then there were 7860 HIV+ve TB patients during this period i.e.: 15% of HIV positive TB patients started CPT

  32. Sub-group analysis (423 patients, April-Dec 2000):CPT continuation after TB treatment completion • 346/423 (82%) patients completed TB treatment and CPT • 198 (57%) continued CPT after 6 months of completing TB RX • 144 (42%) continued CPT 12 months after completing TB treatment

  33. 123 433 215 461 95 26 47 12 671 31 24 >182

  34. Number of clients attending Lighthouse Clinic(July 00-June 02) New centre ARVs

  35. The care-prevention linkLighthouse: Condom distribution

  36. Care, CPT, HBC Stigma?

  37. Less easy to measure: • TB/HIV Collaboration • Impact of VCT on sexual behaviour/risk • Impact on quality of life • Impact on stigma

  38. Conclusions • A collaborative, capacity-building approach to TB/HIV activities is feasible in Malawi • The ‘ProTEST’ approach has catalysed TB and HIV programme collaboration in Malawi • Collaborative TB/HIV activities established through ProTEST have the potential to impact on TB/HIV epidemiology in order to reduce the TB/HIV burdens

  39. Acknowledgements • Lilongwe ProTEST Partners • Ministry of Health and Population • Norwegian Agency for Development Co-operation (NORAD) • World Health Organisation • London School of Hygiene and Tropical Medicine • Liverpool School of Tropical Medicine

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