Integration of TB and HIV/AIDS: A Practical Approach Past ......TB integration into HIV programmes can be achieved through several approaches • Joint planning between national TB

Integration of TB and HIV/AIDS:

A Practical Approach

Past lessons and future direction

Presented at TAC meeting, Johannesburg

10 August 2011

NESRI PADAYATCHI

Deputy Director CAPRISA

Hon lecturer Department of Public Health Medicine, UKZN

OVERVIEW of TB-HIV integration

Why?, challenges, priorities, consequences

• Background

• Strengths

• Weaknesses

• Opportunities

• Threats

• Approach to integration

• Summary

BACKGROUND

(WHY integrate TB + HIV services)

• TB - leading cause of

morbidity and mortality in

HIV/AIDS patients

• TB – an important marker of

advanced HIV infection

• Lack of clarity on how best

to use ART in TB HIV co-

infected patients

• Effective mechanism of

identifying patients eligible

for HAART ( 500 000 who have low

CD4 counts from 6m HIV+ in a country of

50m people?)

0

100

200

300

400

500

600

700

0

5

10

15

20

25

30

35

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

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HIV

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(%

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The HIV and TB epidemics

in South Africa

Red Line = TB case notification rateBlue Line = Antenatal HIV prevalence

Source: South African Department of Health

STRENGTHS

• Support for TB-HIV integration:

Political will

Scientific evidence

TB care infrastructure already exists

HIV prevalence

Effect of HAART in patients with TB

A5221/ STRIDE1 CAMELIA 2 SAPiT3

N 806 660 429

SitesAfrica, Asia, S Am, N

AmCambodia S. Africa

Arms Imm vs 8-12 wk Imm vs 8 wk Early vs 8-12wk

Endpt Death Death Death

Mean CD4 77 25 150

1Havlir; 2Abdool Karim CROI 2011; 3Blanc IAC 2010

WEAKNESSES

• Limited resources

Space constraints

Overwhelming an already overburdened system

?HCW will

RESOURCES: Put our money where

our mouths are!

We join multitudes who have determined that this epidemic cannot be overcome without a concerted

and co ordinated effort

GROUP pre test COUNSELLING

INDIVIDUAL Post test counselling

More Weaknesses

• Monitoring and evaluation: poor quality of routine health

system data

15 registers in some clinics viz., TB, MDR TB, HCT, TB- HIV, MTCT,

ART .........

• Logistically complex and not sustainable: Some clinics use separate

stationery; Clinicians consult 2 sets of notes for TB-HIV integration

• Nosocomial transmission

Tugela Ferry: initial XDR- TB‘outbreak’ thought to be due to nosocomial

transmission

Concerns about housing HIV infected with TB patients

• Risk of transmission is higher from unknown infected TB patients not on

treatment

• Once co-infected patients are stable and adherent to treatment implement

a ‘step- down ‘ approach

OPPORTUNITIES

• Existing health care infrastructure

• Re- think the existing service delivery model

OPPORTUNITY: change service

delivery models!

Although this announcement did not address the complexity of TB-HIV service delivery, it provided an opportunity to

address and rework service delivery models

GROUP PRE TEST COUNSELLING

Threats• Stigma and discrimination

Disclosure of HIV status continues to be an obstacle to care and prevention –few

disclose to their primary sexual partner

• ARV’s classified as schedule 5 Threat to NIMART

• Stockouts

of essential drugs

HIV testing kits

• Inadequate laboratory support

slow lab turnaround times

• TB- HIV services not offered daily

• Dysfunctional and fragile health systems Inadequate referral pathways

• Lack of ownership of the programme Unclear roles and responsibilities

Fear of change

Inadequate skills

Approaches to integration

TB integration into HIV programmes can be achieved through several

approaches

• Joint planning between national TB and AIDS programme e.g.

- Shared policies, strategies, training manuals

- Provide basic TB and HIV training for all primary health workers

• District focal persons should be responsible for both TB and HIV service

delivery including surveillance, monitoring and reporting rather than having

two parallel and vertical systems for TB and HIV

• Progress could be achieved if there was programme coordination, planning,

budgeting

• and resource allocation could be decentralised to the district level

Treatment Integration models

• Model 1: Cross referrals between HIV and TB

service points TB/HIV services are linked by a referral system-commonest model

• Model 2: Partial Integration e.g. TB and HIV services

in the same facility or synchronised same day

appointments Partial Integration is achieved by deliberate effort by health

professionals to ensure that services can be delivered on the same day

• Model 3: Provision of TB and HIV services under the

same provider eg The Sizonq’oba Study

• TB and HIV services (Counselling and testing for HIV, ART, TB

screening and treatment) are provided in the same room by the same

staff

CAPRISA SAPiT Model

• Sm+ (on site) patients recruited from adjoining Municipal

TB clinic

• Municipal clinician commenced TB treament

• CAPRISA: Individual pre and post test counselling

• Modified govt ART preparedness training X 3

• Randomised for ART by CAPRISA clinician

• Used Municipal system for DOT for TB and ART

• HIV data, paper and electronic database, TB electronic

with CAPRISA access

POST SAPIT: Integration at the

adjoining municipal clinic

• Tried model 3 –one clinician managing TB-

HIV

Long waiting times

Clinician overworked

• NOW, model 2 – same clinic, different

clinicians managing TB and HIV, same

electronic database

Shorter patient waiting times

Less confusion

Malawian Model

Lilongwe -2007 (Phiri et al Trop med. Aug 2011)

• Collaboration between govt. and NGO

• Custom built centre – 3 units TB, HIV testing, HIV unit

• No doctors, clinical officers (3 yr training), nurses, health surveillance assist

-10wk training pub hth)

• Flow: Front desk (registration ) - Hlth Surv Asst. (symptom check list, health passport hiv status –

if not documented – ref grp pre test counselling and rapid HIV testing in TB unit – sputum

test –return for result in 3 days with TREATMENT GUARDIAN

Smear -, CXR – reviewed by clinical officer – ref to HIV unit

TB+ HIV+: TB + cotrim commenced same day (paper based register and TB master card),

appointment for . Ref to HIV unit for CD4 (TAT 2 wks), WHO staging, appt for results +

counselling

If ART eligible, ART counselling, TB clin officer initiates ART.

After completing TB treatment, ref to HIV unit for ongoing ART.

HIV unit: electronic data base with prompts to screen for TB – TB data entered manually

retrospectively

SUMMARY

• TB-HIV integration: a mechanism to identify 0.5 million

who are most in need of care from the 6m HIV+

• Scientific data supporting integration of services

• Fragile health system – under-resourced, poor M+E

• Opportunities exist to change the current service delivery

model – be innovative !

• Several models of integration – try one!

• Threat: lack of ownership by HCW

nature29

‘Mobilise all our resources and alliances until this war is won’

MANDELA, XIII international AIDS conference