Taking charge of TB services for people with HIV

Essential activities to reduce the burden of TB in people with HIV known as the Three I’s, (intensified TB case finding, infection control and isoniazid preventive therapy) can be successfully integrated into HIV care facilities according to reports at the HIV Implementer’s Meeting held this past June in Kampala.

A growing number of model projects have developed new tools and systems to implement the Three I’s as an integral part of HIV care — and are calling for the scale-up of these activities at a national level. But several presenters also reported that to scale up and provide sustained and universal access to these services at the different health facility levels responsible for caring for people with HIV, it will take the expansion of laboratory diagnostic and treatment capacity, and closer collaboration with TB programmes, and general health services.

WHO and UNAIDS call for HIV programmes to reduce the burden of TB in their patients

HIV/AIDS programmes have been slow to adequately address the needs of their HIV-positive clients who are at great risk of getting and dying from TB.

“Activities to reduce the burden of TB in people living with HIV… are not sustained and many opportunities are still being missed to reduce the burden of TB morbidity and mortality in people living with HIV,” Dr Alasdair Reid, HIV/TB Adviser to UNAIDS wrote in a poster presentation at the HIV Implementers’ Meeting.

“When we see those interventions that are intended to reduce the burden of TB for people living with HIV, intensified TB case finding, TB infection control and isoniazid preventive therapy, the coverage is very dismal,” Dr Haileyesus Getahun of the Stop TB Department at WHO said in a plenary session on monitoring and evaluation.

“We in the AIDS establishment must accept our responsibilities and acknowledge that to date we have not always fulfilled them,” said Dr Kevin De Cock, Director of the HIV/AIDS Department of WHO during the same plenary. In an effort to change this, the HIV/AIDS Department convened a meeting on the Three I’s in Geneva this April (a report on the meeting can be found in HATIP 112 http://www.aidsmap.com/cms1266280.asp).

And in a meeting a few weeks later, UNAIDS endorsed the WHO meeting’s key outcomes, recommending, among other things, that HIV programmes should be supported “to take increased responsibility for prevention, diagnosis and treatment of TB in people living with HIV, and adopt the goal of reducing TB mortality in people living with HIV” (Reid).

But to move from advocacy to implementation, it will be essential to learn from the handful of HIV programmes with actual experience putting the Three I’s (and other activities to manage TB) into practice on the ground. Several representatives were at the HIV Implementers’ Meeting and described both the challenges and the strategies they have adopted to provide improved services for TB.

ICAP rolls out simple standardised TB screening

Intensified TB case finding can be introduced into almost any level of care by developing and training staff to use a simple checklist screening for the most sensitive symptoms for TB in people with HIV. Although there is still some disagreement about the best group of symptoms to include in such a checklist, common ones include cough, fever, noticeable weight loss, coughing up blood and nightsweats.

The International Center for AIDS Care and Treatment Programs (ICAP) has now helped several HIV programmes in Africa increase TB case detection by introducing TB screening in people with HIV. For example, routine TB screening wasn’t initially a part of the early roll-out of ART in Ethiopia, so ICAP, which supports 42 health facilities in the country, began introducing it for every person with HIV attending five selected hospitals (Dilchora, Hiwot Fana, Jimma, Nekemt and Woliso Hospitals) (Melaku).

To do this, they developed a simple TB screening form, printed on coloured paper for easy identification and retrieval. They trained the staff in those hospitals on how to use the form and the importance of screening, and provided regular clinical mentoring.

All HIV-positive clients are now supposed to be screened at enrolment into care — and screening has indeed gone up from 55% in 2006 to 95% in 2007. During the same period, the proportion of active TB cases diagnosed increased fourfold and ICAP is recommending that formula be repeated throughout the country.

At last year’s Implementers’ Meeting, Dr Greet Vanderbriel of ICAP described a similar approach to introduction of TB screening in Rwanda. At this meeting, she reported that by the second half of last year, TB screening was being performed in 95 (55%) of the HIV clinics in Rwanda, with 85% of the new HIV patients screened. (15% screened positive; 17% of those were subsequently diagnosed as having TB).

The programme isn’t doing quite as well at consistently screening the people in routine care for TB: 71 (42%) of the clinics are doing this, in 59% of their patients. 8% screened positive and 189 (13%) were diagnosed with TB.

Meanwhile, Dr Anna Scardigli, a TB/HIV technical advisor to ICAP, reported that TB screening has been introduced into the Nicoadala Health Centre in Mozambique. 88% of newly enrolled clients have been screened — 7.4% of whom have been diagnosed with TB. And one ICAP poster described the introduction of TB screening in Tumbi Hospital in Tanzania (Maruchu). At the start of 2007, it wasn’t being performed (or at least reported) at all, but by the second half of 2007, 100% of newly enrolled people with HIV were being screened.

ICAP is now focusing on making certain that screening is extended to follow-up visits. In Rwanda, Dr Vanderbriel also said that they hope to expand screening to other HIV service sites (such as voluntary counselling and testing clinics, PMTCT programmes and home based care).

In addition, she added that they are looking at validating the screening tool (to make certain that it is as sensitive as it needs to be) as well as working to perfect recording and reporting practices (which is often inadequate), and fully implement a system to monitor intensified TB case-finding.

Challenges linking TB screening to diagnosis

However in Rwanda, Dr Vanderbriel noted that TB detection among PLWHA was lower than expected. The overall prevalence of TB was 2.2% in 12,179 newly enrolled patients in Rwanda, and even lower in the patients in chronic care. She acknowledged that the low rate could partly be the result of poor recording in the patients’ files and the failure to consistently screen all patients, but the bigger problem is that not everyone who screens positive receives full diagnostic evaluation.

Diagnostic capacity at many health facilities is weak, and the diagnostic work-up to confirm or exclude active TB does not always follow national TB programme guidelines — which may require, and in some countries even rely exclusively, upon expensive chest x-rays for diagnosis.

Chest x-rays are often used in the larger hospitals — and recent studies do suggest they can sometimes pick up sub-clinical cases of TB in people with HIV (Badri). But in many settings, the cost of chest x-ray is a serious barrier to diagnosis, and even where it is free to the patient, clinicians may be loath to order a costly procedure unless they have a very high index of suspicion of TB. Thus, uptake can be low.

This problem isn’t unique to Rwanda. For instance, another poster at the meeting reported on the implementation of a standardised TB screening tool by the MDH partnership between Muhumbili University, the Dar es Salaam City Council and Harvard Medical School. Screening positive should have prompted a sputum examination and continued “evaluation according to the TB diagnostic flowchart of the National TB and Leprosy Programmes.”

MDH screened 17,635 HIV-positive clients for TB. 5302 were determined to be TB suspects based on clinical symptoms and signs.

But the screening results were not acted upon. Among those who screened positive, further diagnostic evaluations were only ordered for 1644 (31%), 35 were diagnosed with TB — which is suspiciously low. Given the high burden of TB in people with HIV, especially atypical TB, it is hard to believe that cases are not being missed. This is far from the universal access to TB diagnostic services that people with HIV need.

There is clearly a need to strengthen TB laboratory services and capacity, and including accessibility to CXR — and some groups are doing this. For instance, one PEPFAR-funded partnership, AMPATH (between Moi University in Kenya and Indiana University) is even performing chest x-rays as part of TB screening in all their newly enrolled patients with HIV.

However, many of smaller facilities where people with HIV receive care (such as primary health clinics) or where people may be screened for TB (since as VCT centres) cannot be equipped with onsite laboratories (not to mention radiology). Sputum specimens must either be sent to a reference lab, or the patients must be sent to the referral hospital for diagnostic evaluation.

Since patients often don’t follow through on these referrals, some programmes are providing escorted referrals. For instance, in Vietnam, only provincial level referral hospitals are equipped to diagnose many cases of TB, so Family Health International in Vietnam has set up a programme to guarantee that 100% of the pre-ART patients receive thorough TB screening and diagnostic evaluation via escorted referrals. However, they noted that infection control in these facilities was an urgent need.

How and where to diagnose and treat TB in people with HIV

If screening leads to TB diagnosis in a person with HIV, another question is how best to then manage their TB treatment.

According to a Population Council survey of clinics in Gauteng, Northwest and Mpumulanga Provinces of South Africa, many HIV clinicians reported that they would rather manage their patients themselves rather than send them to a TB clinic. “They expressed a clear preference for treating and managing co-infected patients rather than referring them elsewhere, as referred patients may not go to referral facilities,” the survey’s authors wrote.

One of the challenges is how to provide people with HIV/TB with care, without increasing the risk of TB transmission to other people with HIV. In Uganda, the Mulago-Mbarara Joint AIDS programme has introduced an integrated TB/HIV clinic for co-infected patients (Mbabazi). Other HIV care clinics have designated a specific day for their clients on TB treatment.

Again this isn’t always possible when HIV is managed by lower level facilities (small clinics, primary health care level). Furthermore, in some countries, the only facilities permitted or equipped to take care of TB cases are TB clinics in referral hospitals — and it can be a challenge to maintain the continuum of care between the HIV services and the TB facilities.

For instance, in Vietnam, there is a highly vertical national TB programme. But according to the poster presentation by FHI, people with HIV who go the TB departments in the provincial level referral hospitals are often met with stigma and discrimination, which negatively impacts outcomes. In addition, when people are going to two clinics for care and treatment, “clinical monitoring and adherence support needs to be intense when on ART and TB medication — especially during intensive TB treatment,” according to the poster’s authors.

While calling for more TB diagnostic and treatment capacity at the local district level, FHI-Vietnam is trying to improve collaboration between the HIV and TB programmes in several ways: by forging formal referral relationships between the two disease areas; setting up “continuum of care coordination committees” at the district and provincial levels with representatives from both programme areas, including a TB clinician on the district ART selection committee, joint training of TB and HIV staff in TB/HIV management and setting up clinical case conferences between HIV and TB physicians to discuss the management of their shared clients.

FHI is also lobbying to get a TB physician to work in the HIV clinic at least one or two days a week (which could permit a TB/HIV day at the clinic so that people don’t have to go to two clinics at once).

Finally, they are working with community home-based care groups and PLWHA support groups to make sure people on ART and TB treatment get intensive adherence support.

Preventing TB

Of course, far more people with HIV present for care at the HIV clinic without active TB disease, and isoniazid preventive therapy (IPT) offers a chance to keep them that way. However, most programmes have little experience in treating people with HIV while they are well — which hinders their ability to target IPT to those for whom it is most appropriate.

In order to better manage such patients by systematically integrating TB and HIV services, the team from Reproductive Health and HIV Research Unit at the University of Witwatersrand in Johannesburg have developed and piloted a set of tools focused on promoting wellness in people with HIV (McCarthy). This includes a pre-ART roadmap — which walks the healthcare provider through the key services, including TB screening and IPT, required by people attending the HIV clinic; a TB/HIV integration register; a “Wellness register” for monitoring IPT; a patient-held record, the clinic record; information, education and communication materials (posters for the clinic staff), and a manual containing standard operating procedures and clinical algorithms.

The team piloted the tools at four sites around Johannesburg between January and March this year. The registers produced some rather interesting data. What was most remarkable was the drop-out rate between certain steps on the pre-ART roadmap. 750, 863 and 864 people tested positive in January, February and March. A similar number had their CD4 cell counts done, and about two-thirds had CD4 cell counts above 200. But only about half returned for their results — only 149 in total.

Even fewer people got tuberculin skin tests (TST) and fewer still came back to have the TST read. Only people with a positive TST result qualify for IPT in South Africa. Around a third of those who did have their TSTs read were positive and all of these started IPT. But this was only a fraction of the total number of people who might have qualified for IPT.

McCarthy and colleagues highlighted TSTs as “the biggest obstacle to the delivery of INH prophylaxis,” but also noted that there was a problem retaining people in care and getting them to return for CD4 test results.

While the tools seemed to work well and generated useful data, it is rather disappointing that so few got onto IPT and were retained in care. Requiring TSTs is clearly a barrier. But the low position of IPT provision on the Roadmap could also be to blame. TB screening is performed right after HIV testing. But rather than giving IPT immediately to those who screen negative, it is deferred until after CD4 cell count monitoring and treatment of other minor complaints.

One argument supporting the provision of IPT is that it could help provide people with early HIV disease with a tangible incentive to remain in care — but clearly if several clinic visits are first required before getting IPT, the opportunity could be lost.

Finally, there was one other major presentation on a large IPT programme in Kenya. However, these data are embargoed until the report is made the World AIDS Conference coming up in Mexico City, this August.