Improving HIV diagnosis in TB patients: new approaches bearing fruit

Improving HIV diagnosis in TB patients: new approaches

A growing number of programmes in PEPFAR-focus countries have introduced provider-initiated HIV testing and counselling for TB patients, according to reports at the HIV Implementers' Meeting in Kampala, Uganda, but they have taken different approaches to introducing the service.

Some reported good results from training TB clinic staff to directly provide HIV testing and counselling, while in other settings, lay counsellors are being hired on to provide the services at the TB clinic. In other settings, co-location of an ART clinic with a HIV testing and counselling service on-site — with aggressive outreach and education of TB clinic clients—led to fairly good rates of HIV testing, even when TB clinic staff were initially reluctant to refer patients.

The gateway to essential services

HIV testing is the gateway to other services for HIV including HIV prevention services, cotrimoxazole, HIV treatment and care, and, of course, ART — all of which are essential for good long-term outcomes of people coinfected with TB/HIV. But experience has demonstrated that simply referring people with TB — whose survival may depend upon knowing their HIV status — to a stand-alone voluntary counselling and testing (VCT) facility leads to low rates of HIV testing. Many will delay testing, often until it is too late.

Last year, WHO endorsed introducing provider-initiated testing and counselling (PITC) together with expanding voluntary counselling and testing (VCT), releasing guidelines to assist countries to standardise and expand provider-initiated testing and counselling through healthcare facilities (download pdf version of guidelines here).

But how best to provide PITC depends on the local setting so teams working on the ground have had to adapt their approach based upon the available resources (especially human) and support system. It is clear however, that regardless of how HIV testing and counselling is delivered, educating TB staff and people with TB about TB/HIVcoinfection, as the availability of HIV services (preferably on site) increases testing uptake.

Scaling up HIV testing in Tanzania

In Tanzania — where about half of people with TB also have HIV — the Program for Appropriate Technology in Health (PATH) has been working with the Ministry of Health and Social Welfare and the National TB and Leprosy Programme to introduce HTC into the PEPFAR-funded clinics in the regions where PATH works (Makame).

The programme was piloted at three sites in 2005, and began scaling up nationally in 2006. The project started out by recruiting, training and deploying TB/HIV coordinators to the regions and districts, who then trained local healthcare providers using a manual on PITC that had been translated into Kiswahili. By March 2008, PITC was introduced into 9 regions and 31 districts in the country. By the second quarter of 2008, 84.2% of newly diagnosed TB patients were receiving PITC. (Note: other PEPFAR partners are helping coordinate PITC services in other parts of Tanzania —for instance, a poster from ICAP reported that 90-96% of those with unknown status accepted PITC in Tumbi Regional Hospital (Maruchu)).

But according to Dr Mohammed Makame, of PATH, there have been some hurdles along the way. For instance, many TB facilities had no private physical spaces to discretely provide HIV testing and counselling; the supply of HIV test kits was sometimes erratic; and, there was a general shortage of clinicians with knowledge of TB and HIV co-management, continued poor understanding of PITC amongst clinic staff, and a shortage of staff to perform testing and counselling in some facilities.

Employing lay counsellors in Lesotho

In Lesotho, lay counsellors are filling that gap. Dr Biggie Mabaera of University Research Co, (URC) reported on their efforts helping to introduce HIV testing and counselling into TB clinics in 6 out of Lesotho’s 10 districts. When the project started in 2006, TB clinics referred people with TB to ART sites or voluntary counselling and testing centres (VCT) for HIV testing — and only 16% of them followed through on the referral. According to Dr Biggie Mabaera, the TB officers were simply too “overwhelmed with other responsibilities” to provide HIV testing and counselling themselves.

So instead, URC trained lay counsellors who became paid employees providing the service at the TB clinics. Two weeks were spent training on HIV testing and counselling, with further training on tuberculosis symptoms and signs, the relationship between tuberculosis and HIV, and how to record TB/HIV data.

Improvement was rapid. Over the course of 2007, 52% of the registered TB cases were tested for HIV (78% of whom tested HIV-positive), and by the first quarter of 2008, 74% of the people with TB were being tested. One hospital, which had tested less than 1% of its TB patients in 2006, tested 75% of the TB patients in the first quarter of this year after the addition of just one lay counsellor late last year.

One challenge is that the lay counsellors are already being given other responsibilities in these busy clinics. Nevertheless, “lay counsellors - when they are properly supervised can allow facilities to both rapidly expand HIV testing and counselling for TB patients and also implement integrated TB/HIV management. HIV testing and counselling uptake can also be improved by offering HTC right in the TB clinics, rather than by referring patients to the ART clinic or to the VCT centres,” said Dr Mabaera.

Resistance to PITC in South Africa

As reports from the first South African TB Conference (held this July in Durban) will later confirm, many TB clinics in the country are struggling with how to scale up HIV testing. Several presenters at that meeting reported that people with TB refuse to be tested because they do not want to have to deal with having two diseases at once. In light of this, there are lingering concerns about how to introduce PITC and at the same time keep HIV testing voluntary. (Reports from the South African TB Conference will be published over the course of this month).

At the HIV Implementers’ Meeting, Dr Munira Khan of the CAPRISA AIDS Treatment Programme described their attempt to introduce PITC for people with TB at the Prince Cyril Zulu Communicable Disease Centre (PZC-CDC) in eThekwini district in KwaZulu Natal, the district with the highest burden of TB (and with the worst outcomes). HIV coinfection rates in the district are over 50%.

Before the eThekwini HIV treatment clinic was set up with testing and counselling on site, the PZC-CDC also relied on traditional VCT (and had low testing rates). TB programmes have generally driven HIV screening for their clients in other countries, but perhaps given the ambivalence about HIV testing in South Africa, in this instance, the HIV clinic drove the introduction of PITC into the TB clinic.

This proved challenging however.

“Initially the concept of PITC was difficult to promote — particularly amongst the TB staff. And this was reflected in our referral rates, which were low in the first two months,” said Dr Khan. In fact, the TB staff only referred 10% of the TB patients for testing. Since training for the TB staff about HIV coinfection too place, referral rates have increased, but only to 31%. This is still a long way from routine referral for testing.

So to further enhance uptake, the HIV clinic conducted outreach in the TB clinic by putting up posters outlining the on-site HIVservices in the TB waiting areas, and by providing informal health education sessions on hygiene, the link between TB and HIV, TB treatment and adherence, as well as on HIV treatment — all the while, promoting counselling and testing. Additionally, “once it was discovered that many men had difficulty relating to young female counsellors, male counsellors were hired,” said Dr. Khan.

In addition to hiring more counsellors, to further increase capacity to meet increased demand, the counselling space was divided to provide for more private counselling booths. Eventually, the site also began offering ‘group’ pre-test counselling sessions (with individual post-test counselling).

In the 19 months after PITC was first introduced, 2375 new smear positive patients were seen at the TB clinic, 1,457 of these were approached about testing; and 975 (67%) agreed to test.

“We also found that there was a high degree of refusal to test initially,” said Dr Khan. So they conducted a separate study to find out why people didn’t want to be tested. By far, the leading reported reason proved to be that people ‘already knew their status.’ “It is important to note, however, that there was no proof of knowledge of status at this time of contact,” she said, (or that the knowledge was current). ‘Fear of being positive’ (especially among men) and a ‘desire to treat TB first’ were the next most common excuses, followed closely by “no time to wait.” A similar number also reported that they were already on ART.

Improving the quality of the service to test ALL — and not just some — TB patients for HIV

Similarly, a poster presentation from Uganda suggested that understanding the reasons why people choose to test or not, and then improving the quality of the service accordingly, would increase testing (Okot-Chono). Despite it being national policy since 2006, HIV testing in TB patients remains very low in the country, at around 30%. So a questionnaire was administered to four hundred people with TB in five districts. Of those who had not previously tested for HIV, 65% tested after receiving their TB diagnosis. In a multivariate analysis, factors that significantly increased the uptake of HIV testing included ‘feeling that their privacy was observed,’ a short waiting time (under an hour), and education about the importance of HIV testing for people with a recent TB diagnosis (and the links between TB and HIV).

But another study finding was that a large proportion of those diagnosised (over a third) had tested for HIV prior to TB, and didn’t retest. “Patients who were found to be HIV-negative [before their TB diagnosis] need to re-test for HIV before completion of TB treatment, and TB care providers should to be urged “to routinely practice PITC for all TB patients,” the study’s authors concluded.