Use of surveillance data to improve patient care

1. Use of surveillance data to improve patient care Dr Alwyn Mwinga TB/HIV Surveillance Workshop Addis Ababa 22 September 2004

2. Outline of presentation • Surveillance • TB surveillance • HIV surveillance in TB patients • Methods • Benefits to both programs

3. Surveillance Disease surveillance - usually carried out with the purpose of obtaining information about the pattern of disease in a community. Data collected can be used for purposes such as planning interventions targeted for specific groups, monitoring the trends of infection to assess the impact of interventions on disease occurrence.

4. Surveillance • Surveillance either done in specific target groups (antenatal women for sentinel surveillance), as special studies or population based (DHS, DHS+) • Surveillance seen more as a public health tool. • Not routinely used for patient management.

5. TB Disease Surveillance • Surveillance of TB well established through the use of specific forms and registers • TB diagnostic and treatment registers • Monitoring of TB program done through quarterly reports and Cohort analysis. – acts as a barometer for the performance of the program. • Patient level data collected at service delivery point • Data aggregated at District level • Gender, age group, type of TB (smear results, site, new, relapse • Cure, default, death rates.

6. Use of TB Surveillance data • Cohort analysis - acts as a barometer for the performance of the program. • Quarterly notification rates used for drug distribution.

7. HIV surveillance in TB patients • Initially recommended by WHO in 1994 guidelines • Cluster sampling and unlinked anonymous surveys • Routine HIV testing of TB patients not widely used in resource limited settings • VCT advocated as entry point to HIV/AIDS care for preventive therapy (IPT, CTX, PMTCT, STI) services.

8. HIV surveillance in TB patients • Factors leading to increased interest in collaborative TB/HIV activities • Advocacy for access to ART as a human right • Availability of ‘affordable’ generic drugs • Global initiatives to increase access to treatment (3 x 5, Emergency Plan) • Increased resources (GF, MAP, Emergency Plan) • HIV testing for TB patients promoted as part of good clinical care.

9. TB/HIV collaboration • Anecdotes from last two days • “Forced marriage, not a love match” • HIV is more “sexy” • “old doctors” vs. “younger, more energetic” • Historically, increased focus on TB in late 1980’s and 1990s due to recognition of interaction between two conditions. • Collaborative activities benefit both programs - “marriage of convenience”

10. HIV surveillance methods in TB patients • Generalized HIV epidemic (HIV >1% in pregnant women) • Routine HIV testing in TB patients • Concentrated HIV epidemic (HIV > 5% on sub-population , IDU, SW, MSM) • Sentinel/special surveys, routine data • Low –level HIV epidemic • Periodic (2-3 yrs) sentinel surveys

11. Surveillance in generalized epidemic • Routinely collected data of HIV testing in TB patients with modification of TB data collection forms to include • Referral for counselling and testing • HIV status • Referral for ART • Provision of Cotrimoxazole • Consideration of confidentiality issues with this approach.

12. Benefits of HIV surveillance in TB patients • HIV program • Identifies PLWHA who are likely to be eligible for ART • Useful for planning for drug requirements (ART) • Established data collecting and monitoring system in existence in TB program (Malawi experience using NTP system to collect data).

13. Benefits for TB program • Provide understanding of impact of HIV on outcomes in cohort analysis • Stratify cohort analysis by HIV status • Smear conversion rate at two months • Relapse rates • Death rates • Default rates • Identify any changes needed in management of HIV+ TB patient

14. Benefits for TB program • Provide evidence for re-evaluating global targets • How feasible is the 85% cure rate in areas with high HIV prevalence? • Evaluate referral systems or quality of care • Acceptance rates for HIV testing (quality of counselling, staff attitudes to provision of routine counselling and testing) • Referral for ART • Provision of cotrimoxazole

15. Benefits of HIV surveillance • Analysis of impact of cotrimoxazole on mortality. • Analysis of impact of ART on mortality, related to time of starting ART. • Referral to care after TB treatment (ART, cotrimoxazole) • Ability to monitor trends on a quarterly basis

16. Conclusion • HIV testing should form part of the routine management of TB patients with mutual benefit to both program areas. • Data of HIV surveillance can be evaluated and used to improve the care of the co-infected patient. • Discussion needed on where to record HIV data – confidentiality and stigma issues