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Integrated HIV Services at a TB clinic, Tanzania, 2006–2008

Integrated HIV Services at a TB clinic, Tanzania, 2006–2008 . International AIDS Conference Vienna, Austria, July 18–23, 2010 Sylvester Nandi, M.D., M.Sc Centers for Disease Control and Prevention Tanzania. Background: United Republic of Tanzania. Population ≈ 41 million

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Integrated HIV Services at a TB clinic, Tanzania, 2006–2008

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  1. Integrated HIV Services at a TB clinic, Tanzania, 2006–2008 International AIDS Conference Vienna, Austria, July 18–23, 2010 Sylvester Nandi, M.D., M.Sc Centers for Disease Control and Prevention Tanzania

  2. Background: United Republic of Tanzania • Population ≈ 41 million • Adult HIV prevalence = 5.7%* • TB case notification (all forms) = 63, 400** • HIV prevalence among TB patients = 41%** *Tanzania HIV and Malaria Indicator Survey, July 2008 **National Tuberculosis and Leprosy Program, 2008

  3. Scale up of TB/HIV Collaborative Activities in Tanzania • In July 2005, Tanzania piloted implementation of TB/HIV activities in three districts (Temeke, Iringa Urban and Korogwe) • The pilot interventions included: • HIV testing and counseling among TB patients in TB clinics • Referral to HIV clinics for enrollment into HIV care • Provision of cotrimoxazole prophylaxis (CPT) • Initiation of antiretroviral therapy (ART)

  4. Preliminary Findings

  5. Need to Increase Access to HIV care • High HIV testing acceptance rate but low uptake of care and treatment services among HIV-infected TB patients • Ministry of Health and Social Welfare (MOHSW) wanted to find a way to improve uptake of the interventions • MOHSW decided to pilot integration of HIV care and treatment within TB clinic • Temeke TB clinic was chosen as the pilot site

  6. Temeke Hospital • District Hospital located in Dar es Salaam • Number of outpatients / day = 1200–1500 • Hospital services: • Out- and inpatient medical, surgical, pharmacy and laboratory for children and adults • Separate clinics for HIV/AIDS, TB, STI, VCT

  7. Temeke Pilot: Integration of HIV Services in a TB Clinic • Introduced pilot HIV services in Temeke TB Clinic in July 2006 • All HIV-infected TB patients at Temeke TB clinic and 36 satellite TB clinics eligible • HIV care and treatment services for duration of TB treatment (6–8 months) • Option to continue TB treatment elsewhere

  8. Objective of Temeke Pilot To increase access to early HIV care and treatment for HIV-infected TB patients

  9. Study Methods • Inclusion criteria: All TB patients (adults and children) registered between July 1, 2006–June 30, 2008 • Quantitative: • Retrospective medical record review (TB registers, paper and electronic charts) • Qualitative: • Focus group discussion with six healthcare workers at Temeke TB clinic

  10. Results: District TB Register Reviews 7724 patients registered for TB treatment 6411 (83%) tested for HIV 1313 (17%) not tested for HIV 3029 (47%) HIV-infected 3382 (53%) HIV-negative 1363 (45%) enrolled in HIV services 1666 (55%) not enrolled in HIV services

  11. Enrollment in HIV Care in Temeke TB Clinic 1363 HIV-infected TB patients enrolled in HIV services during TB treatment 821 (60%) participated In Temeke Pilot 542 (40%) registered at other HIV clinics 670 (82%) medical records located 151 (18%) medical records not located

  12. Description of Participants (N=670) and HIV Services Provided • 422 (63%) participants referred from satellite TB clinics following HIV diagnosis • Male : Female ~ 1:1 • Median age: 34 years (range: 1–72 years) • CPT received by 642 (96%) participants • ART during TB treatment: • 478 (71%) were eligible for ART based on Tanzanian guidelines • 387 (81%) of those eligible received ART

  13. Median Time: HIV Diagnosis and Pilot Enrollment (n=596) Event Median Time IQR Start of TB Treatment 1 day 0–10 days HIV Diagnosis 0 days 0–4 days Enrolled in HIV Care In Temeke TB Clinic

  14. Median Time: ART Eligibility • and Initiation Event Median Time IQR Enrolled in HIV Care In Temeke TB Clinic 15 days 0–32 days ART eligibility determination (n=570) 15 days 10–24 days ART Initiation (n=396)

  15. Retention in HIV Care (N=670) • 616 (92%) participants remained in pilot for the duration of TB treatment • 54 (8%) did not remain in pilot • 36 patients died • 16 lost to follow-up • 2 transfers • 70% (428 of 616) transitioned to separate Temeke HIV clinic after end of TB treatment

  16. CD4 Count Monitoring

  17. Type of TB and Treatment Outcomes (N= 670) • Type of TB: • Extrapulmonary: 126 (19%) • Pulmonary Smear – Positive: 312 (47%) • Pulmonary Smear – Negative: 232 (35%) • TB Treatment Success = 612 (92%)

  18. Healthcare Worker Interview Findings • Felt comfortable providing HIV services • Appreciated closer monitoring of both TB and HIV care and treatment • Identified challenges: increased patient visits and space limitations • Supported expansion to other TB clinics

  19. Limitations • Incomplete data in medical records • No participant interviews • No assessment of overall low enrollment in HIV care and treatment

  20. Conclusions • TB clinicians were able to provide appropriate HIV services • Provision of HIV services in Temeke TB clinic resulted in early enrollment in HIV care and early initiation of ART • Successful integration of HIV services in TB clinic is possible • Low level of enrollment in HIV services among HIV infected TB patients remains a challenge

  21. Recommendations • Consider TB clinic as an additional site for HIV service delivery • Further studies needed to understand: • patient experience with integrated care • barriers/ challenges associated with low enrollment into HIV care among HIV-infected TB patients

  22. Acknowledgments • MOHSW, Tanzania • Dr. Saidi Egwaga • Dr. Sode Matiku • Dr. Mwanaisha Nyamkara • CDC – Tanzania • Dr. Gilly Arthur • Dr. Eunice Mmari • Dr. John Vertefeuille • Dr. Zahra Mkomwa (former CDC) • Temeke Hospital, Tanzania • Dr. Neema Kapalata • Dr. Edward Masika • HARVARD Team in Tanzania • CDC – Atlanta • Dr. Anand Date • Dr. Surbhi Modi • Ms Monita Patel (former CDC) The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

  23. Thank You Temeke TB Clinic Waiting Area

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