Integration of TB and HIV Services: Experiences from the Kericho District Hospital

1. Integration of TB and HIV Services: Experiences from the Kericho District Hospital Charles S. Kiptemas, MBChB, MPH Director South Rift Valley HIV Care & Treatment Program Kenya Medical Research Institute/Walter Reed Project Track 1.0 ART Program Meeting: Willard Intercontinental Hotel, Washington, D.C. August 11-12, 2008

2. Background • Need for integrated TB & HIV services • 1 patients/2 diseases • 2 clinics/2 ques/2 clinicians/2 treatment regimens • “Intensified case finding” – recognized potential for overloading very busy and overwhelmed clinics • Identifying TB in HIV clinic • Identifying HIV in TB clinic • Aim: integrated TB/HIV clinic • Cadre of clinicians capable of treating both diseases in TB clinic • HIV care provided in TB clinic through at least intensive phase • Goal: improved patient care

3. Integrated TB/HIV Clinic (est. July 2005) HIV Clinic In-patient Out-patient TB Treatment Completion • Integrated TB/HIV Clinic • HIV Testing & Counseling (PITC) • HIV Surveillance • HIV Prevention • TB Diagnosis and Treatment (for both • HIV positive and negative • patients) • HIV Care & Treatment (for co-infected • patients) • Co-trimoxazole Preventive Therapy

4. TB/HIV Clinic Characteristics (2005-2007) • Cohort size (n) 1,220 • Age (mean, years) 31 • Female 53% • Pulmonary TB 86% • Sputum positive 41% • PITC 94% • TB-HIV coinfected 54%

5. TB/HIV Clinic Baseline CD4 78% eligible for ART

6. TB/HIV Co-infected Treatment Outcomes* Mean 6-Month CD4 Change (cells/mm3) Care +78 ART +139 TB Treatment Outcome Completed 64% Transferred out 11% Loss to Follow up 14% Deaths 11% * Data presented on subset n=792

7. Intensified Case Finding • Identifying TB in HIV clinic • symptom algorithm • CXR • cough monitors • Identifying HIV in TB clinic • PITC • Contact tracing / case finding • Family who can come to clinic • Future contract tracing to home

8. TB/HIV Clinic Observations • Successful management of co-infected patients with good clinical outcomes. • Successful integration of TB and HIV services at a district hospital setting. • High uptake of TB/HIV collaborative services. • Patients with combined TB/HIV infections may receive benefit from: • primary TB treatment (“care”) alone; • and additionally ART. • Patients with combined TB/HIV infections often present with advanced HIV disease.

9. Limitations/Strengths • Primary Limitations: • Inherent limitations in retrospective chart reviews: • Clinic set-up not designed for systematic research. • Incomplete/missing clinical data. • Strengths: • Advantage of electronic medical record system in TB/HIV clinic where data accuracy can be verified against original clinic record. • Findings should be considered descriptive in nature; however, value of such descriptive data should not be overlooked in the early development of such TB/HIV programs.

10. Recommendations/Way Forward • Integration of TB and HIV services needs to be considered in health facilities in order to improve uptake of collaborative services. • Clinicians treating patients with TB/HIV should be aware of the benefit to HIV infection by treating TB and offering supportive care alone, and additionally ART. • Efforts to identify patients with TB/HIV early in their disease may offer tangible benefit by providing the opportunity to consider early ART. • Further controlled studies are needed to best identify when (and what settings) to initiate ART in patients receiving TB treatment. • The Kenya team plans to roll out integrated TB/HIV clinic experiences from KDH to remaining district level ART treatment facilities in Southern Rift Valley.

11. Acknowledgements • Kericho District Hospital TB/HIV Clinic • Kenya Ministry of Health/NLTP/NASCOP • President’s Emergency Plan for AIDS Relief • Kericho District Hospital - Eunice Obiero • KEMRI – Fredrick Sawe & Jonah Maswai • USMHRP – Doug Shaffer, Tiffany Hamm, Nelson Michael • Brown University – Jane Carter