Jeroen van Gorkom KNCV Tuberculosis Foundation

1. TB/HIV Lessons Learned: ProTEST meeting DurbanFebruary 2003 Jeroen van Gorkom KNCV Tuberculosis Foundation

2. Background WHO ProTEST initiative started in 1998 in 6 districts in 3 countries Malawi: Lilongwe district South-Africa: Bohlabela (Limpopo), East-London (Eastern Cape), Cape Town Central District (Western Cape), Ugu-South (KwazuluNatal) Zambia: Lusaka district

3. Specific Objectives Present quantitative and qualitative data on the outcomes of the various interventions including cost-effectiveness and behaviour studies Provide policy recommendations for collaborative TB and HIV programme activities Develop indicators and targets for monitoring and evaluation Develop policy recommendations for expansion of district pilot projects to national programmes Indicate areas for operational research

4. Participants Country teams from the 3 ProTEST project countries Country teams from Mozambique, Tanzania, Kenya, Uganda, Ethiopia. Mentors and partners (CDC, FHI, KNCV, LSHTM, etc.) UNAIDS inter country teams Representatives of development agencies

5. Main Conclusions and Recommendations

6. Interventions Coordination and Collaboration VCT expansion HIV prevention (STI management, condom distribution) Intensifed case-finding TB in VCT centres CPT IPT CPT

7. 1. Improving Collaboration ProTEST projects were successfull in creating collaborative health networks in TB and HIV/AIDS, where none if little existed before, creating collaboration between: Government ? NGOs ? Community Org. Hospitals ? clinics ? home based care TB ? HIV/AIDS programs Researchers ? Implementors

8. 1. Improving Collaboration (cont.) Joint situational analysis critical as starting point Most projects hired additional staff Collaboration at District Level “natural” Collaboration between mid-level and national level TB and HIV/AIDS programs was more difficult to realize

9. Recommendations Collaboration Address problem of insufficient human resources in the implementation of TB and HIV/AIDS care (e.g. lay counsellors) Project approach initially useful After that mainstream TB in HIV/AIDS plan, and HIV in TB plan, ensuring coordination, clear roles and responsibilities Harmonization

10. 2. VCT Expansion All projects Rapid tests and same day result most efficient Lay counsellors doing rapid tests: feasible and efficient Lay counsellors critical for increasing counselling capacity General nurses ready and keen to do counselling when trained and after HIV/AIDS is “normalized”. VCT services fulfilling unmet demand

11. 2. VCT Recommendations Provide access to VCT service for different client groups Use on site rapid HIV testing Promote and implement standardised National Policy Quality Control Establish uninterrupted HIV test supply Accomodate lay staff as counsellors and HIV testers, in the health system and laws

12. 3. HIV Prevention 120,000 clients HIV tested ? 12,000 HIV infections prevented Promotion and implementation of STI screening and treatment as good clinical practice PMTCT included in ProTEST services network Condom distribution Peer support groups; Post-Test Clubs IEC to TB patients and VCT clients Impact measurement difficult

13. RecommendationsHIV prevention Mainstream HIV prevention where and when possible in TB/HIV care network Use M&E indicators of HIV/AIDS program

14. 4. Intensified case-finding tuberculosis Symptomatic screening VCT clients using questionnaire Tuberculosis symptoms in HIV+ clients 2-57% Diagnosis of Tuberculosis in symptomatic HIV+ patients < 1% - 10% Easy, low incremental cost, variable effectiveness

15. RecommendationsICF Promote and implement ICF in all settings where TB/HIV dual infection or disease is bound to be high Monitor outcome of ICF in various settings Collect best practice in use of IEC for ICF in communities and health care settings

16. 5. CPT Implemented in all projects, except Zambia (RCT) “Easy”to implement with low incremental costs Uptake by TB patients variable (12%-61%) Patients taking CPT keen to do so and continue after TB treatment Health workers like to provide it: “We can offer something” BUT Efficacy questioned Eligibility criteria variable depending on presence or absence of Nat. HIV/AIDS Program policy By end of TB treatment 40-82% still using CPT Adherence criteria not standardised

17. 5. CPTRecommendations Standardize monitoring tools WHO and UNAIDS to update the recommendations of the Harare workshop (2001) on the basis of: The evidence base in countries with variable background CTM resistance CPT in the presence of ART/HAART

18. 6. IPT In all ProTEST sites Only asymptomatic “fit” clients eligible “Easy” to add-on, low incremental costs Uptake 23-77% of eligible HIV+ clients Adherence 24-58% Cost-effective Health workers like it: “We offer something” Adherence criteria not standardized Epidemiological impact on TB transmission limited due to low uptake

19. 6. IPT Evidence needed: Cost and C/E of IPT in routine services, comparing different delivery models Feasibility and C/E of lifelong IPT in preventing the first episode of TB Efficacy, feasibility and C/E of lifelong IPT in preventing a recurrent episode of TB Efficacy of IPT in the presence of ART/HAART

20. 6. IPTRecommendations Reinforce the existing WHO policy of 1998. There is no need to review this policy in the light of current evidence Support research into the utility of IPT in a context of ART, its effectiveness and efficacy, both for preventing first episodes and recurrent episodes of TB WHO recommnedations on IPT 1998: For prevention of first ever episode For individuals rather than as a public health benefit As part of package of care for PLWHA When it will not detract from TB programme resources or undermine performance in achieving DOTS. WHO recommnedations on IPT 1998: For prevention of first ever episode For individuals rather than as a public health benefit As part of package of care for PLWHA When it will not detract from TB programme resources or undermine performance in achieving DOTS.

21. Home Based Care Links created in 3/6 projects Identify and refer suspects of TB Support TB treatment and provide DOT Trace treatment interruptors Community IEC on TB ? HIV/AIDS Community health workers keen to take on TB Impact of HBC on TB ICF and Treatment Success not yet well documented, and small scale Recommendation Document impact of HBC on ICF and treatment success.

22. Context Context has changed since 1998 VCT now accepted as major component of HIV/AIDS response HIV/AIDS Care&Support on HIV/AIDS agenda TB in PLWHA thus much higher priority for HIV/AIDS programs

23. Summary High synergy, low incremental cost: Collaboration, networking, referral Intensified Case Finding in VCT and clinical setting Home Based Care => ICF and TB case-holding Feasibility high, low incremental cost, evidence of efficacy conflicting or absent: CPT Feasibility fair, low incremental cost, uptake moderate, effectiveness limited: IPT Inadequate evidence for efficacy and effectiveness in combination with ART: CPT, IPT

24. Challenges Ahead Mainstream TB prevention and care activities in the Care&Support Strategy of the HIV/AIDS programs Mainstream HIV/AIDS prevention and care activities in DOTS programs Human Resource Development (quantity and quality) Monitoring and Evaluation More evidence needed in: CPT/IPT + ART Communicate ? Coordinate ?Collaborate ?Corroborate Consider reading the report