TB programmes and clinics face significant hurdles linking people with TB who they test and diagnose with HIV to other HIV services included antiretroviral therapy (ART) — even when those services are co-located — according to reports at the 2008 HIV Implementers' meeting in Kampala, Uganda.
While there is widespread agreement that these services are essential, programmes are adopting different approaches to TB/HIV service integration — with responses ranging from ‘one-stop’ shops to escorted referrals. But the success of these approaches may vary from setting to setting.
“In our setting, people chose not to go to the ART clinic that was right around the corner…a one-stop shop was not enough,” Dr Mike Kalulu of Lighthouse Trust in Lilongwe, Malawi told the meeting.
It’s becoming increasing clear that providing more convenient access to HIV services is only part of the solution. People with TB diagnosed with HIV also need information, counselling and support to address stigma, disclosure issues and other fears that are a barrier to uptake of HIV treatment and care.
Improving the care of TB patients diagnosed with HIV
More TB programmes and clinics in resource-limited settings are routinely testing people with TB for HIV, but, in order for testing to make a difference, TB patients who test for HIV should also receive prevention services, cotrimoxazole to prevent serious infections, basic care and treatment for opportunistic infections and other HIV-related condition, and eventually ART.
At one time, TB clinics could only make referrals to HIV clinics for those services, but experience has demonstrated that referrals between these separate programmes — often housed in separate facilities — tend to lose high numbers of patients.
“It is not uncommon for HIV-TB coinfected patients to slip through the cracks in the referral system and be lost to follow-up after completion of TB treatment, resulting in lack of timely access to ART and the consequent unfavourable outcomes for both HIV and TB,” wrote Dr Vikas Inamder and colleagues in a poster on the integration of HIV care and support for TB patients in South India.
When it comes to providing HIV care and treatment, including ART, most TB programmes and clinics respond by either trying to make the referral process airtight or by finding a way to deliver some or all of those services on site (either co-location of ART and TB clinics or by providing HIV services within the TB clinic).
Prevention services
After testing for HIV, TB patients need HIV prevention counselling and support just like anyone else — but this service is often overlooked. According to a Population Council survey in three provinces in South Africa, less than 20% of TB clinic patients reported receiving any HIV prevention information (Maphanga).
TB patients who test HIV-negative should receive counselling and services (access to condoms, etc) to keep them that way. It is an integral part of HIV testing and counselling. But if the person tests positive for HIV, it could also trigger a number of other useful interventions, as Dr Reuben Granich of WHO pointed during a discussion on TB/HIV integration.
“When someone has a positive test result, it represents an important prevention opportunity because they all have partners and families who are at risk for HIV. Some countries are now moving to partner testing and actually taking it to the next level in terms of seeing TB patients as a part of a larger family and a larger community,” he said.
The practice in Rwanda can serve as a model.
“For every TB patient that we identify with HIV, a home visit is carried out and at that visit, they do sensitisation to do an HIV test on all the family members that are not yet tested,” said Dr Greet Vandebriel of the International Center for AIDS Care and Treatment Programs (ICAP) during the symposia, “and this has increased significantly HIV testing.”
HIV prevention and testing for the family dovetail nicely with TB contact tracing — another critical intervention for the family’s wellbeing because TB usually spreads within the home. TB clinics serving coinfected populations should thus be equipped to provide these family-based interventions during home-visits. This means training staff, peer educators or community-based DOTS supporters — and providing them with some way of documenting whether the activity was thorough and complete.
This might be facilitated by adapting the ‘Family HIV/AIDS care and treatment enrolment form,” developed by ICAP in Ethiopia. Whenever a person with HIV is diagnosed, they are asked about their other family members. This information is recorded on the form, which includes a box for every family member, a legend the counsellor making the home visit can use to note counselling and testing status for each family member, and whether they are on ART yet or not. The form can easily be amended to include TB elements including whether the family member has been screened for TB, diagnosed and on treatment, or given isoniazid preventive therapy (IPT) to keep household contacts from getting TB.
Cotrimoxazole
There is ample evidence that TB clinics can give cotrimoxazole preventive therapy (CPT) to their clients with TB who test positive for HIV — but as a survey in Uganda has shown, (see PEPFAR TB/HIV Intro article), it doesn’t just happen automatically. Standard operating protocols must be developed, supply chain management systems put in place and health care workers trained to implement and monitor cotrimoxazole provision, as well as ways developed to educate and support the patient.
In Lesotho, Dr Biggie Mabaera of the University Research Co said that last year supported sites were getting between 60-80% of the HIV-positive TB patients onto cotrimoxazole. Dr Mabaera said it would have been higher were it not for stock-outs of the drug — “a problem that has since been rectified,” he said.
Similarly, Dr Fadare Amos Omoniyi of WHO described the rapid rollout of cotrimoxazole at DOTS centres in 12 Nigerian states where WHO and USAID are supporting TB/HIV collaborative services. While attending the TB clinic, cotrimoxazole is provided regardless of CD4 cell count (which most TB facilities aren’t equipped to provide). By the fourth quarter of last year, 84 out of 90 of the DOTS centres in those states had implemented the intervention so that, overall, 79% of TB clients diagnosed with HIV at those 90 facilities were receiving cotrimoxazole from their DOTS centre.
HIV treatment and care, including ART rarely accessed
But that, unfortunately, appears to be the limit of HIV services offered to TB clients diagnosed with HIV in many settings.
“CPT, because it is provided at the DOTS centre, in some cases is actually the only anti-HIV/AIDS treatment that somebody that is dually infected has access to in the course of their TB treatment because of the distance to the ARV centre,” said Dr Omoniyi.
There are relatively few HIV clinics (at present, only about 240 that can dispense ART) spread across the country, serving a population of over 3 million people with HIV, compared to thousands of primary healthcare clinics.
The Population Council survey of TB and HIV clinics in Gauteng, Northwest and Mpumulanga provinces of South Africa made a similar observation: “ART services are offered at far fewer points than TB services, which can be accessed at primary health centres,” wrote Maphanga et al.
In the case of Nigeria, what is even more worrying is that patients aren’t referred to the HIV clinics until the very end of TB treatment, which in that country goes on for up to 8 months.
Many programmes are beginning ART sooner in the hope that it will improve outcomes. But survival is poor even when people with TB and HIV have early access to ART, according to a poster describing the provision of ART to seriously ill in-patients at Nkqubele TB Hospital in the Eastern Cape (Verkuijl). With ICAP’s assistance, since September 2006, TB hospital began staging patients who test positive for HIV. In-patients who have CD4 cell counts below 50 and/or serious stage IV diseases are started on ART while still on the intensive phase of TB treatment (two months for new cases and three months for retreatment cases), while those with CD4 cell counts between 50-200 are prepared for ART, aiming to begin treatment at the nearest ART clinic immediately after discharge (during the less intensive phase of TB treatment).
But even with aggressive treatment, mortality remains high: 16% during preparation for ART and 21% after starting ART (compared to an overall mortality of 24% for the hospital during the same period). (It should be noted that immune reconstitution inflammatory syndrome (IRIS) and drug-resistant TB were a problem in this population).
“Many co-infected are admitted in a very poor clinical condition,” wrote the poster’s authors, and they recommended that ART should be initiated early in any in-patient with less than 100 CD4 cells.
Dr Omoniyi acknowledged that people with TB/HIV in Nigeria often don’t survive to complete the referral to the HIV clinic and make it onto ART, so he recommended that the “available human resources at facilities providing DOTS services — which are mostly at primary healthcare centres that are very close to the people — should be leveraged to provide ARV services for those without access to these services.”
But to achieve this, most countries would have to either use clinical eligibility criteria for ART, (WHO clinical staging) and/or treat all patients coinfected with TB/HIV, since CD4 cell count monitoring is unavailable in most primary healthcare clinics, or invest in strengthening the laboratory and probably the human resource capacity at the primary healthcare level.
This approach works in some programmes (see below)— but it cannot be done everywhere.
For example, using a public health approach, Malawi has set up 200 ART clinics in public and private facilities, often staffed only with trained nurses, and has put 100,000 people on ART — an impressive accomplishment from one of the most resource-challenged countries in the world.
TB treatment isn’t really provided by primary health clinics in Malawi, however. Instead it is initiated at 48 centralised facilities, and treatment continuation is decentralised to 600 facilities. People with TB/HIV automatically qualify for ART, unless they have high CD4 cell counts (and CD4 cell monitoring isn’t widely available).
In Malawi, the goal is to get people onto treatment, and ART is supposed to begin two months after initiating TB treatment. But ART simply cannot be prescribed at the TB continuation clinics that are run by non-medical staff (like social workers/government officials).
So at present in Malawi, people with TB/HIV must be referred to the ART clinics — with mediocre uptake.
“Sixty percent of our TB/HIV patients don’t get on ART,” said Dr Kalulu. It should be noted however that only a few programmes in the world are reporting higher rates (see later in the article).
Disappointing results with co-located TB and HIV clinics in Malawi
But what’s more disturbing, as Dr Kalulu and colleagues discovered, is that results are more or less the same even when an ART clinic is situated in the same hospital as the TB clinic.
The Martin-Preuss-Centre at Bwaila Hospital in Lilongwe, is the country’s first integrated TB/ART facility, opened by the Department of Health and the Lighthouse Trust in 2006. The TB and HIV clinics are actually in two separate wings of the hospital, to assist infection control.
Yet, only 36% of the TB patients with HIV actually complete the referral within the same facility and get onto ART.
To find out why, the team examined the hurdles between the TB clinic and getting on ART.
HIV testing certainly wasn’t the problem. Through routine HIV counselling and testing, the TB clinic was able to determine the HIV status of about 92% of the patients. 68% were HIV-positive.
However, there were problems with retention even within the first two months of TB treatment, with 16% lost to follow-up. Some of these may have chosen to continue to get treatment at their local centres — though Malawi has a transfer system that tries to keep track of TB patients. Some were quite possibly dead, indeed, 2% were known to be dead within the first two months.
The next hurdle to ART was that patients need to have a smear-negative sputum result before admission to the ART clinic to make sure they weren’t infectious — which meant a sputum collection at the two-month visit. Because of the high number of specimens at the lab, patients had to come back for another clinic visit to get their results and referral to the HIV clinic.
Once they had their smear-negative result, they were sent to the hospital pharmacy to pick up their TB meds and directed to go to the ART clinic reception, which is right around the corner. But 30% of the coinfected patients picking up their TB meds simple chose not to go to the ART clinic.
Those who did register at the ART clinic were given a clinical assessment and attended a group education session on lifelong ART, and instructed to return one week later to start ART.
But 44% of them didn’t come back, although a few did straggle in months later.
So co-locating the clinics in the same health facility may not always be enough. However, co-location is not the only way — and in fact, may not be the best way — to provide a ‘one-stop shop.’
One-stop HIV care and treatment provided by the TB clinic
“Even in hospitals where both TB and ART services are offered, they are not offered in the same division. The two services function separately from one another,” the Population Council study noted and the author’s concluded that both HIV clinics and TB clinics needed to be able to provide all the essential TB/HIV services, staffed “with better trained providers who are able to manage and treat both HIV and TB.”
This approach has been adopted by several groups, including MDH, a PEPFAR-supported partnership between Muhimbili University, the Dar es Salaam City Council and Harvard School of Public Health, after the programme noticed that there were poor referral rates between TB facilities and HIV care and treatment centres and concluded that receiving care at two facilities increased the risk of treatment non-adherence (Makubi).
MDH developed the laboratory and human resource capacity within TB clinics to screen TB patients for HIV and then provide those who were positive with full HIV care and treatment, including ART, if the client was eligible.
The TB clinics achieved high testing rates (87%), and as many as 471 out of 552 (86%) of those who were eligible were started on ART and monitored at the TB clinic until the completion of anti-TB therapy, at which time they were referred to an ART clinic.
According to Dr Kalulu, Malawi is now planning to place ART clinicians in the TB clinic —which would also allow the clinic to initiate ART during the first two months of TB treatment rather than waiting until after the client has a confirmed sputum conversion. But it may remain a challenge getting HIV services to people attending one of the 600 local TB treatment continuation sites.
And even if HIV services are integrated into the TB initiation clinics, there must be a referral to the ART clinic one day, when TB treatment is complete.
Directly observed referrals?
Another option, particularly when the HIV and TB clinics are next to each other or under the same roof, is an accompanied referral — where someone is designated to escort the person with TB/HIV from one clinic to another — which was described as a important part of Rwanda’s programme at last year’s Implementers’ Meeting.
It is working pretty well for a rural facility in Mozambique, the Nicoadala Health Center, which houses both a TB and HIV unit, according to a presentation by Dr Anna Scardigli, a TB/HIV technical advisor to ICAP in that country. In 2007, a TB/HIV focal point nurse was established to accompany TB/HIV patients between services within the facility, reinforce their counselling, and improve data collection. During the last quarter of that year, 45/56 (80%) of the TB patients who were unaware of their status got tested for HIV. Twenty-two were positive and 68% of those enrolled into the ART clinic immediately and 87% within the next few months. 53% of the all the TB/HIV co-infected patients have begun ART (which is either efavirenz or abacavir-based).
Referrals could also be escorted by direct observed therapy DOTS workers, trained community members or peer educators. For instance, the TB programme in South India is using TB DOTS supporters to help make effective referrals to ART centres during the intensive phase of TB treatment (although only for ART preparation because ART is usually started after the intensive phase is completed in that country) (Inamder). An advantage of working with a DOTS supporter or community adherence supporter is that the patient will have an ongoing relationship — so there could be more than one opportunity to make an effective referral.
TB/HIV education, support and community sensitisation
Another advantage of having a TB/HIV focal point nurse or peer educator is that every point of contact with the person with TB/HIV provides an opportunity to give them information about ART and support.
Given the large proportion of people in Malawi who made it to the HIV clinic, but chose not to come back for treatment, it is clear that the people with TB/HIV were reluctant to start ART — and this could be because there are low levels of knowledge about TB/HIV in the community, heightened stigma and fear of disclosing HIV status to their family. Dr Kalulu suggested that additional factors could also play a role including the pill burden, fear of side effects — and the belief that “the drugs will make them crave more food [and] there is no food security at home.”
To address these factors, the Lilongwe clinic plans to improve HIV counselling in the TB clinic, and intensify information, education and communication efforts for people with TB/HIV.
The team working with Nkqubele TB Hospital also made several practical recommendations in their poster presentation to ensure continuity of care and avoid treatment interruptions and loss to follow-up after referral:
1) Disclosure to and engagement of treatment supporters in the home (note that this would be facilitated by providing the family-based prevention services mentioned earlier in the article)
2) Adequate referral documentation to the nearest ART site
3) Follow-up with receiving facility
4) Home visits by peer educators, and
5) Promoting community awareness of TB and HIV and efforts to address the stigma related to TB and HIV
Working with local community support groups may be the best way to achieve these aims and retain people with TB/HIV in care. And if there are no such groups locally, other reports at the Implementers’ Meeting described how, with a little support, they can be encouraged to grow (see related article).
Inander V et al. Integrating tuberculosis control with HIV care and support service lessons from Southern India. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract 57.
Maphanga T et al. Exploring models of delivering antiretroviral therapy and integration of ART with TB services in South Africa. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract 1935.
Omoniyi FA et al. Implementation of cotrimoxazole preventive therapy (CPT) at DOTS centers. Experiences from Nigeria. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract 1418.
Verkuijl S et al. Providing HAART to HIV coinfected TB In-patients: Lessons learnt from a TB hospital in the Eastern Cape, South Africa. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract 1138.
Kalulu M et al. Challenges in effective TB/ART Integration and The Riddle of Monitoring Referrals in Routine Public Health Services. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract 675.
Makubi A et al. TB/HIV integration services within the PEPFAR funded MDH HIV/AIDS Care and Treatment Program, Dar es Salaam, Tanzania. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract 1077.
Scardigli A et al. Integration between HIV services and TB services: the experience of a rural health centre in Mozambique. 2008 HIV Implementers’ Meeting, Kampala, Uganda, abstract 1548.