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

Washington D.C., USA, 22-27 July 2012www.aids2012.org

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

Dr Owen MugurungiDirector – AIDS & TB ProgrammeMinistry of Health & Child Welfare

Zimbabwe

Washington D.C., USA, 22-27 July 2012www.aids2012.org

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)

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Achievements

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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

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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

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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

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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

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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 where there are shortage of doctors

• Accreditate primary level health facilities as ART initiating sites to accompany increase in ART uptake.

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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

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Thank you