Policy review of HIV and TB guidelines for high HIV/TB burden African countries

Policy review of HIV and TB guidelines for high HIV/TB burden

African countries

HIV/AIDS DepartmentWorld Health Organization

WHO 2010 ART guidelines

Target Population ART guideline

HIV+ asymptomatic patientsARV-naïve individuals

CD4 < 350 cells/mm3

HIV+ pregnant women CD4 < 350 cells/mm3 irrespective of clinical symptoms or WHO clinical stage 3 or 4 irrespective of CD4 cell count

HIV/TB co-infectionARV- naïve individuals

Presence of active TB, irrespective of CD4 count

WHO 2004 Interim Policy on Collaborative TB/HIV Activities

A. Establish NTP-NACP collaborative mechanisms Coordinating bodies for effective TB/HIV activities at all levels Conduct surveillance of HIV prevalence among TB cases Carry out joint TB/HIV planning Monitor and evaluate collaborative TB/HIV activities

B. Decrease burden of TB among PLHIV (the "Three I's for HIV/TB") Establish intensified TB case finding Introduce INH preventive therapy Ensure TB infection control in health care and congregate settings

C. Decrease burden of HIV among TB patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV/AIDS care and support Introduce ARVs

Use of four-symptoms screening algorithm to rule out active TB and offer IPT

Four symptoms include cough, fever, weight loss and night sweats

Past history of TB and current pregnancy should not be contraindications for IPT

TST or chest radiography are not required

WHO 2010 IPT/ICF Recommendations

Estimated 2009 HIV/TB and HIV burden

Source : 2010 Stop TB global surveillance report, UNAIDS Report on global AIDS Epidemic 2010

Country People with HIV-Figure in

'000 (% of global HIV-

positive people)

People with HIV and TB- Figure in '000 (% of global

HIV/TB burden)

People eligible for

ART at CD4 < 350 cells ('000)

People on ART ('000)

ART coverage

(%)

People living with

HIV screened

for TB ('000)

ART coverage

(%)

Botswana 320 (1.0) 6.8 (0.6) 170 145.2 83 159.1 11700

Ethiopia N/A 34 (2.8) N/A 176.6 N/A 24.1 2403

Kenya 1500 (4.5) 53 (4.4) 710 337 48 14.1 N/A

Lesotho 290 (0.9) 8.7 (0.7) 130 61.7 48 N/A N/A

Malawi 920 (2.8)  27 (2.3) 440 198.8 46 N/A N/A

Mozambique 1400 (4.2)  54 (4.5) 570 170.2 30 24.3 2429

Namibia 180 (0.5)  9.2 (0.8) 93 70.5 76 87.5 17700

Nigeria 3300 (9.9) 87 (7.3) 1400 303 21 195.1 1853

South Africa 5600 (16.8)  290 (24.2) 2600 971.6 37 433.7 23600

Swaziland 180 (0.5)  10 (0.8) 80 47.2 59 8.4 2107

Tanzania 1400 (4.2) 38 (3.2) 660 199.4 30 5.5 153

Uganda 1200 (3.6) 54 (4.5) 520 200.4 39 57.7 N/A

Zambia 980 (2.9)  23 (1.9) 440 283.9 64 N/A N/A

Zimbabwe 1200 (3.6)  48 (4.0) 640 218.6 34 N/A N/A

Total  18470 (55.5) 742.7 (61.9) 8453 3384.1 38 1009.5 61945

Objectives and MethodologyObjectives:Compare national HIV, TB and HIV/TB guidelines for 14 African countries with recently released WHO ART and HIV/TB guidelines

Methodology:Main guidelines were collected from the following sources: National HIV Guidelines

National TB Guidelines

HIV/TB and TB infection control Guidelines

Standard abstraction form was used to review recommendations on: ART initiation criteria

The Three I’s for HIV/TB

The Three I's for HIV/TB monitoring and evaluation indicators

Source : National HIV, TB and HIV/TB Guidelines

Country National ART guidelines

National TB control guidelines

HIV/TB, ICF, IPT, OI guidelines

TB infection control guidelines

Botswana 2008 2007

Ethiopia 2008 2008 2007

Kenya 2011 2009 2008

Lesotho 2007 2008

Malawi 2011 2007 2008

Mozambique 2010 2008 2010

Namibia 2010 2011 2010

Nigeria 2010 2010 2008 2008

South Africa 2010 2008 2010 2007

Swaziland 2010 2010 2011 2011

Tanzania 2009 2006

Uganda 2008 2010 2006 2011

Zambia 2010 2008 2010

Zimbabwe 2010 2010 2010

* Published guidelines, Drafts, Preliminary drafts

ART initiation criteria in people with HIVCountry (Year of publication

of ART guidelines)Asymptomatic

peoplePeople with HIV and TB Pregnant women

Botswana (2008) <250 Irrespective of CD4 count <250

Ethiopia (2008) <200 <350 <200

Kenya (2011) <350 Irrespective of CD4 count <350

Lesotho (2007) <350 <350 <350

Malawi (2011) <350 Irrespective of CD4 count Irrespective of CD4 count

Mozambique (2010) <250 <350 <350

Namibia (2010) <350 Irrespective of CD4 count <350

Nigeria (2010) <350 Irrespective of CD4 count* <350

South Africa (2010) <200 <350 <350

Swaziland (2010) <350 Irrespective of CD4 count <350

Tanzania (2009) <200 <350 <200

Uganda (2008) <250 <350 <350

Zambia (2010) <350 <350 <350

Zimbabwe (2010) <350 Irrespective of CD4 count* <350

All figures in cells/mm3, Guidelines in white are similar to WHO recommendations.

* Nigeria's TB and HIV/TB guidelines and Zimbabwe's HIV/TB guidelines recommend ART for people with HIV and TB at CD4 count < 350 cells/mm3

ART initiation for asymptomatic people

2010 WHO Recommendation : CD4 count < 350 cells/mm3

≤ 350

≤ 200

≤ 250

Kenya, Lesotho, Malawi, Namibia, Nigeria, Swaziland, Zambia, Zimbabwe

Botswana, Mozambique, Uganda

Ethiopia, South Africa, Tanzania

CD4 Count

• Zambia recommends ART at CD4 count > 350 cells/mm3 if any other stage III or IV illnesses• Ethiopia recommends ART for all extrapulmonary and disseminated TB patients

ART initiation for people with HIV and TB

2010 WHO Recommendation : ART irrespective of CD4 count

Irrespective of CD4 count

CD4<350 cells

Botswana Ethiopia

Kenya Lesotho

Malawi Mozambique

Namibia South Africa

Nigeria Tanzania

Swaziland Uganda

Zimbabwe Zambia

ART initiation for pregnant women with HIV2010 WHO Recommendation : CD4 count < 350 cells/mm3

Irrespective of CD4 count

CD4<350 cells CD4<250 cells CD4<200 cells

Malawi Kenya Botswana Ethiopia

Lesotho Tanzania

Mozambique

Namibia

Nigeria

South Africa

Swaziland

Uganda

Zambia

Zimbabwe

• Malawi, under Option B+, recommends lifelong ART for all pregnant women irrespective of CD4 count

Co-trimoxazole prophylaxis2006 WHO Recommendation : CD4 count < 350* cells/mm3 or WHO stage 3 or 4

CD4< 200 Cells or WHO Stage 3 or 4

Botswana

CD4< 350 Cells or WHO Stage 3 or 4

Lesotho, Namibia, Nigeria

CD4< 350 Cells or WHO Stage 2, 3 or 4

Mozambique, Tanzania, Zambia, Ethiopia**, Zimbabwe

CD4< 200 Cells or WHO Stage 2, 3 or 4

South Africa

Different guidelines followed by different countries

CD4< 250 Cells or WHO Stage 2, 3 or 4

Uganda

All HIV positives

Kenya, Malawi, Swaziland

*Countries may choose to adopt a CD4 threshold of < 200 cells/mm3 **Source: Ethiopia's Co-trimoxazole prophylaxis guidelines, 2006

National policies for HIV, TB and HIV/TB, and the Three I's for HIV/TB

Country ICF IPT TB infection control

Indicators on the Three I's for HIV/TB

Botswana NAP NAP, NTP NAP, NTP NTP

Ethiopia NAP, NTP, HIV/TB NAP, NTP, HIV/TB NTP, HIV/TB HIV/TB

Kenya NAP, OI, NTP NAP, OI, NTP NAP, OI, NTP x

Lesotho NAP, NTP NAP, NTP NAP, NTP NTP

Malawi NAP, NTP NAP, NTP** IC NTP

Mozambique NAP, NTP NAP, NTP NAP, NTP, IC NAP

Namibia NTP NAP, NTP NTP, IC NTP, IC

Nigeria NAP, NTP, HIV/TB NAP, NTP, HIV/TB NTP, HIV/TB, IC IC

South Africa NAP, NTP, IPT NAP, NTP, IPT NTP, IC IPT

Swaziland* NAP, IPT NAP, IPT NAP, IC NAP, IPT, IC

Tanzania NAP, NTP NAP, NTP NAP, NTP x

Uganda NAP, NTP, HIV/TB NTP, HIV/TB NTP, HIV/TB, IC HIV/TB, IC

Zambia NAP, NTP, ICF NTP**, ICF NTP NTP

Zimbabwe NTP, HIV/TB NTP**, HIV/TB** NTP, HIV/TB x

NAP – National ART Policy, NTP – National TB Policy, ICF – National intensified TB case finding guidelines, IPT – National IPT guidelines, IC – TB infection control guidelines, OI – National guidelines on management of HIV-related opportunistic infections

Note: * 2011 NTP for Swaziland recommends Three I's for HIV/TB but do not mention any guidelines ** These guidelines do not recommend IPT

Country ICF IPT TB infection controlBotswana ✓ ✓ ✓

Ethiopia ✓ ✓ ✓

Kenya ✓ ✓ ✓

Lesotho ✓ ✓ ✓

Malawi ✓ ✓ ✓

Mozambique ✓ ✓ ✓

Namibia ✓ ✓ ✓

Nigeria ✓ ✓ ✓

South Africa ✓ ✓ ✓

Swaziland ✓ ✓ ✓

Tanzania ✓ ✓ ✓

Uganda ✓ ✓ ✓

Zambia ✓ ✓* ✓

Zimbabwe ✓ ✗ ✓

Countries recommending the Three I’s for HIV/TB

* Zambia: Preliminary draft on ICF guidelines recommends IPT

Botswana

Ethiopia

Kenya

Lesotho

Malawi

MozambiqueNamibia

Nigeria

SouthAfrica

Swaziland

Tanzania

Uganda

Zambia

Zimbabwe

IPT not recommended

Symptom-based

Symptom-based + sputumsmear microscopy + chest X-raySymptom-based + sputum smearmicroscopy + chest X-ray + TST

LEGENDIPT Initiation criteria

TB screening criteria for IPT2010 WHO Recommendation : Symptom-based screening

Note: The map shows IPT initiation criteria recommended by the most recent guidelines for a country

TB exclusion criteria for IPT initiation2010 WHO Recommendation : Four-symptom screening for cough, fever, weight loss and night sweats

* 2011 TB guidelines for Namibia recommend enlarged lymph nodes as an additional symptom ** 2006 TB guidelines for Tanzania recommend chest pain as an additional symptom *** 2008 IPT guidelines for Nigeria recommend weight loss as an additional symptom, 2010 NTP guidelines do not recommend chest X-ray and sputum smear microscopy

Cough Cough Cough Cough Cough Cough

Night sweats Fever Fever Fever Fever Fever Fever

Weight loss

Weight loss

Weight loss

Weight loss

Weight loss

Weight loss

Night sweats

Night sweats

Night sweats

Night sweats

Night sweats

Night sweats

Chest pain

Coughing blood

Chest pain

Swelling

LESOTHO NAP 2007

WHO recommendation

SOUTH AFRICA

IPT 2010

ETHIOPIA HIV/TB 2008

ZAMBIA IPT 2010

MALAWINAP 2011

MOZAMBIQUE NAP 2010

TANZANIA** NAP 2009

SWAZILAND NAP 2010

KENYA NAP 2011

Shortness of breath

Loss of appetite

Shortness of breath

Shortness of breath

Loss of appetite

Loss of appetite

Sputum production

Chest pain

Coughing blood

Chest pain

Coughing blood

Enlarged glandsDiarrhoea

BOTSWANA NTP 2007NAMIBIA*

NAP 2010

SOUTH AFRICA NAP 2010

Cough

UGANDA NTP 2010

Cough

Fever

Weight loss

Night sweats

Chest X-ray

Sputum smear

TST

Chest X-ray

Sputum smear

Cough

Fever

Night sweats

Enlarged lymph nodes

Chest pain

NIGERIA*** NAP 2010

Chest X-ray

Sputum smear

Cough

Fever

Weight loss

Enlarged lymph nodes

Abnormal chest

findings

Enlarged glands

KENYA OI 2008 NTP 2009

Chest X-ray

Cough

1. Botswana and Mozambique – No IPT initiation in pregnancy

2. Botswana and Tanzania – IPT not for children

3. South Africa – IPT with ART is a conditional recommendation

4. Lesotho – IPT offered to TB-exposed HIV infected children and at pilot sites where active TB can be ruled out

5. Malawi – Stop IPT when patient is started on ART

6. Kenya and Swaziland– IPT provided in clinics with TB screening, adherence counselling and patient follow-up services

7. Uganda – IPT provided in institutions with adequate human resources, infrastructure, and equipment and logistics

Exceptions to WHO recommendations on IPT

2010 WHO Recommendation : IPT to all irrespective of previous history of TB or current pregnancy and IPT with ART also

recommended

Indicators for monitoring and evaluating performance on the Three I’s for HIV/TB

ICF

Yes No

Botswana

Kenya

South Africa

Tanzania

Zimbabwe

Lesotho

Ethiopia

Malawi

Mozambique

Namibia

Nigeria

Swaziland

Uganda

Zambia

IPT

Yes No

Kenya

Malawi

Nigeria

Tanzania

Zambia

Botswana

Ethiopia

Lesotho

Mozambique

Namibia

South Africa

Swaziland

Uganda

Malawi, Namibia, Nigeria, Swaziland and Uganda have indicators for TB infection control

Limitations

Guidelines may be outdated and/or in the process of being updatedWritten policies may not reflect programme implementation Other guidelines covering ART and the Three I’s for HIV/TB may exist

- Infection control guidelines - Monitoring and evaluation guidelines

Conclusion• Many countries follow the recently released WHO guidelines

- Asymptomatic patients – 8 countries

- HIV/TB co-infected people – 7 countries

- Pregnant women – 10 countries

• Malawi recommends lifelong ART for pregnant women irrespective of CD4 count (Option B+)

• Almost all countries have recommendations on the Three I’s for HIV/TB

• CPT initiation criteria differs widely across countries

• ICF and IPT guidelines specified in both NAP and NTP for many countries

• Many countries have ICF and IPT indicators

• Room for improving monitoring and evaluating progress on TB infection control

Recommendations

ART policy Revise ART eligibility criteria where necessary

IPT policy Adapt policies to recommend IPT for all, including pregnant

women, previous TB patients and PLHIV on ART

Simplify criteria for IPT initiation

Monitoring and evaluating of the Three I's for HIV/TB Include indicators on ICF and IPT in National ART Guidelines

Adapt and implement indicators for TB infection control

Thank you…