A National Program Manager’s Perspective on HIV/TB Integration

1. A National Program Manager’s Perspective on HIV/TB Integration Dr Owen Mugurungi Director – AIDS & TB Programme Ministry of Health & Child Welfare Zimbabwe

2. Background • Zimbabwe is ranked 18/ 22 high burden TB countries • 70% of deaths in 15-44 years are due to TB-HIV (1990-2008) • Gradual decline in deaths since ART introduction in from public sector facilities (2004 –2008, Dlodlo et al, 2011)

3. Achievements

4. Achievements (2) • Nationwide access to TB treatment: integration of TB treatment services with general health services strengthened the DOT system • Treatment success rate (2009) - smear+ve: 78% - smear-ve: 74% - EPTB: 80% • New TB screening tool : for improved case detection. First piloted by PSI (2005), then rolled out nationally in 2009. - PSI centers account for 35% of HCT testing in Zimbabwe • TB Case management training now includes HIV

5. Collaborative Activities • The Union& Two cities Health Service are piloting in 3 urban clinics: • Feasibility of integrating HIV CT and TB services: HCT, antiretroviral treatment (ART) and TB services • Households contact screening for TB and ART enrolments (ART initiations are nurse-centred with support from clinical medical officers) • Initial results (2008-2011): • ART initiation among HIV-positive TB patients have been higher in study sites vs. national data: 1,779 ( 80%) vs. 29,361 (38%) • 111(16%) partners of HIV-positive TB patients were traced and HIV tested; 101 (91%) were HIV-positive and all were initiated on ART • ART retention is encouraging; at least 70% of patients started on ART in 2008 at all 3 clinics were still alive and on ART after 30 months

6. Collaborative Activities (2) • PSI leveraged funding for active TB case finding through TB REACH Wave 2 - Improved early TB case detection by integrating LED microscopy and GeneXpert within PSI’s network of 17 HCT clinics - Intensified active case finding at the community level through mobile, and mhealth referrals follow up • Initial results (2010-2011) - 123,109 screened for TB, 5,634 suspected cases identified and 443 new cases of TB (395 smear+ve TB cases & 48 Gene Xpert +ve cases) - Active referral tracing of identified TB cases at HCT centres using SMS messaging to ensure follow up and treatment initiation • Ongoing Operations Research: Assess impact on patient access to care usingXpert MTB/RIF assay technology

7. Challenges • Low ART coverage among HIV+/TB patients (only 44% of HIV+/ TB patients were initiated on ART) • Lack of decentralization of ART initiation to lower level primary clinics as they are not accredited i.e. currently there 606/1560 (39%) health facilities offering ART countrywide of which 144 are ART initiating sites • ART initiations are mostly doctor driven • Reluctance to IPT for HIV + • Health workers and policy makers are reluctant to introduce Isoniazid Preventive Therapy (IPT) for HIV+ patients due to fears of Isoniazid mono-resistance/ anticipated poor capacity to exclude TB • Inadequate funding for coordination meeting at district level • Despite WHO recommendations for TB/HIV coordination meetings at all health levels these are only functional at national level

8. Recommendations • Integrate ART initiation with TB treatment services in order to scale up ART uptake among HIV-positive TB patients • Advocate for nurse-led ART initiation especially in remote settings wherethere are shortage of doctors • Accreditate primary level health facilities as ART initiating sites to accompany increase in ART uptake.

9. Recommendations (2) • Strengthen TB diagnosis among patients in HIV clinics with tools such as Gene Xpert and pave way for introduction of IPT • Improve funding mechanism efficiency to facilitate TB/HIV coordination meetings at lower levels of the health care system • Continue close collaboration with implementing partners in TB/HIV and leverage funding through TB REACH and other mechanisms to increase TB case detection rate

10. Thank you