It’s time to integrate TB/HIV care on a national scale (part II)

Collaborative TB/HIV services

The remaining collaborative activities constitute actual healthcare services that should be provided to people living with or at risk of either HIV or TB.

“These interventions cannot be taken up by only one programme, it must be both,” said Dr Chakaya. “The TB control programme must do their part and HIV control programmes must do their bits. In terms of who takes the lead for which intervention, I think that activities decreasing the burden of TB among HIV patients should really be up to the HIV control programme while the TB control programme should take care of the activities decreasing the burden of HIV disease among TB patients. That to me makes the most sense.”

But different models have been developed for how the services are delivered in different settings:

1. Setting up a good cross referral system between separate TB and HIV sites, where the provision of TB-related services is primarily through the TB clinics and the HIV-related services mostly through the HIV clinics. Some TB services still must be integrated into the HIV clinics: HIV clinics should still screen people for TB (or assess their current TB status, such as whether they are on TB treatment, etc) and practice good TB infection control. However, people identified by TB screening as being TB suspects (possibly having TB) will need to be referred to facilities that can complete the TB diagnostic process.
2. Partial integration: TB clinics provide some HIV services, but refer patients out for others (such as CD4 testing or ART). This is particularly common where clinics are required by the government to go through a rigorous accreditation process or install security before being able to distribute antiretroviral drugs. In South Africa, accreditation delayed the ability of Richmond Hospital to deliver ART, although it is now accredited to do so. One nice work-around that’s it has developed, to bring ART and other HIV services to TB clinics in outlying areas in Gauteng Province, is a roving clinic with a dedicated staff and pharmacy.
3. Complete integration with one stop shopping for the patient, as at Kericho and  Mulago Hospitals and in Rwanda (see box). For instance, while patients have TB, they receive all their HIV services, including ART, from an existing TB clinic or new combination clinic.

One stop services for TB patients with HIV in Rwanda’s model TB/HIV clinics

These models may have strengths or weaknesses in different settings, or in some instances, may simply be compromises for what can be achieved at a site given the “policy” environment or available resources at the time.

However, it’s important to recognise that at every point along a chain of referrals, whenever a person is referred, there is a risk of losing them. Some programmes have developed systems with active follow-up when making referrals, sometimes using with community-based workers. Even so, it is more difficult to capture and record outcome data on referrals, for instance, in settings where TB clinics have to refer people out to separate sites for HIV testing.

But it does not have to be all or nothing — it may also be possible for HIV or TB clinics to start out with a referral system, and decrease reliance upon referrals gradually as resources and capacity become available to integrate more services in-house.

“As far as the specific models of care go,” said Dr de Cock, “although delivery models may differ, outcomes should be identical: diagnosis of both diseases; successful treatment of tuberculosis to cure or completion, reduction in HIV disease progression and mortality, and a decrease in the transmission of both diseases.”

However, from the presentations at the PEPFAR meeting, it was clear that some approaches to TB/HIV service provision were critical enablers of success.

Services to reduce the burden of TB in people with HIV

HIV programmes in most countries have not been implementing TB-reducing services aggressively.

1) Intensified TB case-finding

Intensified case-finding consists of regularly screening all people with or at risk of HIV (especially in congregate settings like prisons) for symptoms and signs of tuberculosis, referring them for prompt diagnosis and treatment, and doing the same for their household contacts.

“There’s a real opportunity, when people present for HIV care or to the HIV care clinic to collect their ARVs, to actually simply screen them for TB.  We’re not talking excluding TB in this case, we’re simply talking about using a screening questionnaire to see if they are symptomatic and if they are, then entering into the diagnostic process,” said Dr Reid.

HIV screening can be performed quickly and cheaply using a questionnaire asking patients whether they currently are on TB treatment, and if not whether they have any of the following symptoms: usually cough (for more than 2 or 3 weeks), fever, night sweats, recent weight loss, lymphadenopathy.

The screening tool will probably capture too many suspects than too few — since this is only the start of the diagnostic process.  Nevertheless, Dr Willie Were and colleagues from CDC Uganda presented a study at the HIV Implementers’ Meeting showing that a few basic clinical symptoms were highly predictive at identifying TB in HIV-infected patients TB. The analysis involved 71 (3.6%) cases of TB diagnosed out of 1995 subjects. No symptom alone was 100% sensitive, however, a combination of any of the following parameters: cough>3 weeks, fever >1 month, lymphadenopathy, and BMI <18 had a sensitivity of 99%, specificity of 66% and negative predictive value of 100% for TB. During follow-up of patients on ART, the presence of any of cough > 3 weeks or body weakness of > 2 weeks had a sensitivity of 100%, specificity of 66 % and negative predictive value of 100%.

It is unclear why HIV programmes haven’t taken up screening (or at least reporting it), as there are several examples suggesting it is easy enough to implement. Mulago Hospital screened 4835 of its HIV clinic patients, focusing on cough for ≥ 2 weeks, and then looking at other clinical symptoms (fever and weight loss) before entering into the diagnostic process (which includes chest X-ray). 17% were found to have active TB.  Rwanda developed a questionnaire with five questions, and currently screens over 90% of the people in its model TB/HIV clinics (and 76% nationwide). Rwanda is now introducing TB screening into its community based outreach HIV testing and counselling programme (screening up to 68% of the people in the families visited).

Haiti has also implemented TB screening in its VCT clinics by simply assessing whether the client has a cough. 30% of those with cough were found to have active TB, 9% of the all VCT clients overall (Grand’Pierre).

Likewise, TB screening should also be introduced at PMTCT clinics, STI clinics and anywhere else people at risk of TB are likely to gather.

Establishing good referral systems between these sites and tuberculosis diagnostic and treatment centres is crucial however. In several programmes, large numbers of patients were lost between screening and ultimate diagnosis. According to Dr Vandebriel in Rwanda, patients were lost after repeated visits to the TB clinic required for repeated sputum samples, and particularly when they had to pay services charges (e.g., for chest x-rays).

2) Treatment of latent TB infection (isoniazid preventive therapy (IPT)

“Probably the least well implemented activity, and we understand the reason for this, is isoniazid preventative therapy,” said Dr Reid.

If active TB has been excluded, IPT is given to people with HIV and latent infection with Mycobacterium tuberculosis to prevent progression to active disease. However, only about 25,000 people living with HIV are currently being treated with isoniazid for latent TB infection and about 84% of them are participants in the Botswana IPT programme.

Many programmes are afraid of the development of isoniazid resistance, and also lack the capacity to introduce widescale IPT (though why this should be more difficult than cotrimoxazole prophylaxis is unclear). HATIP has described some of the issues surrounding IPT fairly recently (see http://www.aidsmap.com/cms1199982.asp). At the Implementer’s meeting, there were several reports of pilot IPT projects starting in other countries, including Nigeria, and Kenya. However, most countries seem to be waiting for the outcome data from the pioneering Botswana programme, some of which are expected to be released at the World Union TB meeting this November.

3) TB infection control CAN be implemented in the HIV clinics

Likewise, TB infection control is not in place in most settings where people are treated for HIV but this is changing since the XDR-TB outbreak in South Africa.

There has been much criticism of South Africa for the XDR-TB outbreak, with many experts attributing it to a “failure to adhere to DOTS” in its TB programme, a “by product” of weak TB control. There may be some truth to this: overwhelmed by the burden of coinfection, some South African TB clinics have been unable to meet targets for case detection and supervised patient adherence support. Countrywide, TB treatment completion rates are only around 65% and the default rate is 14%. There are also issues with the widespread availability of second-line TB drugs, such as fluoroquinolones in the private sector for less serious medical indications.

But the outbreak may be due in part to the delay in integrating collaborative TB activities — in particular, infection control — into the HIV programme. In the case of last year’s outbreak, 85% of the XDR-TB was due to nosocomial transmission of a single XDR strain — so it did not arise independently in hundreds of patients receiving inadequate TB care. But in the absence of functioning TB infection control, one case of XDR-TB can quickly spread among other people living with HIV because they tend to use health services more frequently.

“There is a lot of undiagnosed TB out there, and that means TB that is continuing to be transmitted in the ART clinics and in the community,” said Dr Reid. “Most of these clinics don’t have TB control policies and people are sitting in those waiting rooms for hours on end to collect their medicines. If one person has TB or worse, XDR-TB, the whole room will likely be infected.”

“There is paradoxically the possibility of worsening the situation in the longer term if we run bad programmes,” said Dr de Cock. “Because ART will keep HIV infected patients alive but vulnerable and susceptible to tuberculosis and also to transmit tuberculosis to others.”

An increased association with HIV and TB drug resistance has also been observed in other countries. For instance, at the Implementers Meeting, Dr Reynold Grand Pierre of Haiti said that the rate of MDR-TB is three times higher among people with HIV in his country.

Many countries, including the Ministry of Health in South Africa have expressed an interest in establishing broad infection control policies, though it is unclear how soon these policies will be put into practice.

In the meantime, HIV clinics can establish infection control strategies based on good work practice and administrative measures. These include: A written infection control plan for each facility, administrative support for procedures in the plan, including quality assurance, staff training, education of patients and increasing community awareness and coordination and communication with the TB programme.

Five steps for preventing TB transmission in HIV care settings (from WHO guidelines)

Services to reduce the burden of HIV among people with TB

The services to reduce the burden of HIV among people with TB are much more self-explanatory. However, some countries and projects were much more successful at scaling them up than others. Some of the successes and failures and ongoing challenges are described below.

1) HIV testing and counselling

Without HIV testing and counselling, countries will never recognise the true scale of the burden of HIV and TB coinfection, and people with TB who are coinfected with HIV will go unrecognised and untreated.

Repeated again and again at the Implementers Meeting, far and away, the most critical enabler for the success of TB/HIV service scale-up at various sites was provider-initiated HIV testing and counselling. Without it, the turn-around in the programme in Kenya, Rwanda, Mulago Hospital and other sites would not have been possible.

“One of the key landmark things that happened in Kenya was setting the policy for provider initiated HIV testing in clinical settings,” said Dr Chakaya.  “Before 2004, all of our TB patients were being referred to VCT sites for HIV testing and with a lot of problems. But in 2004, the Minister of Health came up with a policy document on HIV Testing in Clinical Settings which [said] that: ‘if you don’t offer HIV testing to persons presenting with an HIV-associated illness, then you are providing, as a clinician, a sub-standard care.’”

“That statement was extremely prominent in that document, and it made a lot of difference. No clinician wants to offer sub-standard care,” he said, noting that it was reinforced in trainings. “It was a major, major event that really, really paved the way for a lot of testing of TB patients.”

In other countries, however, programmes continue to rely on VCT. Unfortunately, even though it is easy enough for TB clinic staff to recommend VCT, most people don’t follow through on the referral.

“VCT uptake initially was very poor in the Richmond Hospital,” said Dr Uys, “Because we had to use the voluntary counseling and testing approach because of the ethics requirement. It increased temporarily when we increased group counselling sessions but then relaxed unfortunately.”

The proportion of people with TB who actually get tested in the Richmond programme is only 30%. And this is higher than reported by some other posters at the South African AIDS Conference. For instance, after intensive training of nurses by the excellent Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA PLUS) programme, VCT uptake among TB patients more than doubled — but only from 10.1% to 21.2% (Fairall).

The experience of a TB/HIV collaborative programme set up to in Jakarta, Indonesia is also telling. 

“There has been some hesitation to introduce testing and counselling for HIV in the TB programme (PPTI), due to the worries that it will become a double stigma, and reduce TB detection, reducing people from coming in for TB treatment,” said Dr Flora Tanujaya, a senior clinical officer for Family Health International in Indonesia

But in September 2004, they set up a VCT site at the TB clinic (and a variety of other collaborative services for people with HIV). But during the first few months, hardly anyone they referred used it (around 14% uptake overall, about 30% among those who attended an HIV education session). So for 2005, they adopted an opt-in approach. Nothing changed. In 2006, they introduced an educational video that increased access to the HIV education session to 100%.

“But still, the uptake for pre-test counselling (and testing) was only around 30%,” she said. “It is time for an opt-out strategy, but we are waiting for the national policy to change.”

Changing the national policy includes changing who is allowed to conduct the HIV test. In some settings, non-laboratory staff (including nurses) are not authorised to perform rapid HIV tests, in others medical staff can perform the test but trained lay counsellors cannot.

HIV programme have in some cases been unwilling to give up HIV testing to TB programmes, resulting in delays in the scale up of collaborative activities. But the conclusion of one roundtable discussion at the PEPFAR/WHO meeting was that HIV testing should be available at every TB microscopy site.

One final point that was often repeated at the HIV Implementers’ and PEPFAR/WHO meeting is that HIV testing should be performed on all TB suspects — not just the TB patients. Several teams noted that other HIV-related conditions often turn out to be the reason why someone is referred to the TB clinic.

2) HIV prevention methods

With training and steady supply of materials, most integration sites were able to introduce and implement comprehensive HIV prevention strategies for their patients.

Aspects that programmes may still need to attend to include providing their clients with, or providing referrals for PMTCT, sexually transmitted disease screening, and family planning services.

3) Cotrimoxazole prophylaxis

Most TB programmes at the conference reported little difficulty in introducing cotrimoxazole preventative therapy, other than occasional supply chain management problems, and a lack of an alternative to cotrimoxazole (such as dapsone) in case of contra-indications in the DRC.

4) HIV/AIDS care and support

TB clinics may need to bring on more staff if they are providing integrated HIV/AIDS care and support services (rather than referring patients to the HIV clinic).

 “Counselling and support for patients who are concurrently taking anti-TB drugs and ART requires a lot more support. They usually are very ill and there are more reports of missing pills and trying to switch round the timing for taking medications amongst these patients, so they need a lot more support,” said Dr Wanyenze. “Because there was increased workload in terms of counseling and preparing patients for ART, for example, and for the lab investigations, we had to bring in some additional staff there to help them.”

“We used some of the resources that we received from PEPFAR to hire additional personnel,” she said.

5) Antiretroviral therapy

TB programmes have had mixed success getting their coinfected patients onto ART, depending largely upon whether they rely on referrals to existing ART clinics or are able to initiate it themselves. In the DRC, about 7% of people who were referred got onto ART, while at Kericho District Hospital, 100% did (although for a small proportion it was after they had completed TB treatment.

But for obvious reasons, every TB clinic in high burden countries cannot offer ART right away — so referrals continue to be necessary. But this causes problems when TB clinics are more decentralised than ART clinics.

“Although the absolute numbers of HIV-infected TB patients receiving ART has increased tremendously, the proportion of HIV-infected TB patients not receiving ART is not declining,” said Dr Chakaya.  “TB services have been decentralised… but ARV treatment sites have not yet decentralised to the same extent. We believe that may be the major reason why a lot of our TB patients who are HIV infected, are not yet receiving ARV treatment,” said Dr Chakaya.

Another issue is when exactly to initiate ART in people who present with TB and HIV. Policies differ by country, but the system at Kericho District Hospital seemed to work fairly well.

“Initially, on the first day when they are found to be coinfected, we take a baseline CD4 and a baseline work-up and we start them on TB treatment and tell them to come back after two weeks,” said Muttai. Family members or friends are counselled to provide the patient with DOTS.

“At two weeks, we review their HIV results and give them their TB refill. If the CD4 count is very low, we want to initiate ART right away but we give them a minimum of two weeks in order to observe whether they are doing well on their TB meds, and that way if there are any side effects on ART later, you will be able to make a clinical judgement whether it is the TB or HIV meds that are causing it… When they complete their TB treatment then we hand them over to the HIV clinic,” she said.

Continuing to treat someone with HIV and cured TB at the TB clinic could clearly put them at risk of re-exposure to TB, so most programmes recommend referring people on ART to their most convenient TB clinic.  But this has proven somewhat tricky in some cases.

 “We have had some challenges with the transferring out of patients after they have completed TB treatment,” said Dr. Wanyenze. “They get attached to the clinic and they get a bit uncomfortable with transferring out.”

Ongoing challenges

There are of course various ongoing problems that will continue to limit success of any of collaborative TB/HIV efforts.  For instance, resource-limited countries still need to strengthen their health systems and add to their health workforce. Although assistance from PEPFAR, the Global Fund, DFID and other partners has enabled some programmes to bring on more staff, and other programmes are finding ways to “task shift” activities to new cadres of workers (volunteers and/or paid lay staff from the community), long term and sustainable solutions are needed.

Despite an increase in funding to laboratory scale-up and diagnostics, the capacity to quickly diagnose TB, including smear negative and drug resistant strains continues to be a problem. One roundtable group at the PEPFAR/WHO meeting suggested that HIV programmes might want to consider using some of their funds to improve TB laboratory capacity, since, given the high coinfection rate, there is a good chance that this would improve outcomes in their patients.

Finally, supply chain management needs to be updated and improved to prevent stock-outs of HIV test kits, condoms and cotrimoxazole.

Time to scale up

But at the end of the day (and of the conferences), it was clear, based on the example of Kenya and Rwanda and at several of the pilot sites, that these issues should not stand in the way of immediately implementing collaborative activities.

“I think it’s time we move beyond pilot sites,” said Dr Anand Date of the CDC as we both boarded our plane leaving Kigali. “It’s time to scale up.”

References

Dhlamini N et al. HIV & AIDS, STI, tuberculosis (HAST) integration. 3rd South African AIDS Conference, Durban South Africa, abstract 223, 2007.

Chakaya JM. TB/HIV: Integration of services and stopping the newest epidemic—XDR-TB. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda.

Fairall L. Practical approach to lung health and HIV/AIDS in South Africa (PALSA PLUS):  a best practice model for primary care nurse training in integrated healthcare. 3rd South African AIDS Conference, Durban South Africa, abstract 733, 2007.

Getahun, H. Enablers for nationwide expansion of collaborative TB/HIV activities. Accelerate HIV/TB activities in PEPFAR focus countries. Kigali, Rwanda, 2007.

Grand'Pierre, R et al. HIV/TB integration in a network of VCT centers in Haiti. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda abstract 303.

Loveday, M et al. The awareness and effect of HIV on TB patients and health service provision for TB patients. 3rd South African AIDS Conference, Durban South Africa, abstract 710, 2007.

Mwesigire, D.M A model for integration of TB and HIV care and treatment services in Mulago Hospital, Uganda. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda, abstract 1062.

Muttai HC, Hamm TE, Sigei, CK.Integration of HIV and TB services within the district hospital: experiences from the Kericho District Hospital in Kenya. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda, abstract 678.

Natpratan, C et al. TB/HIV public-private partnership for most-at-risk-groups in Jakarta, Indonesia. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda, abstract 831.

Ndhlovu L et al. Challenges to integrating ART and TB services in Health Facilities in South Africa. 3rd South African AIDS Conference, Durban South Africa, abstract 230, 2007.

Reid A et al. Global progress in implementing collaborative TB/HIV Activities — comparison with the 15 PEPFAR ‘focus’ countries. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda, abstract 1771.

Scott V et al. Evaluation of an integrated HIV/TB/STI strategy in Cape Town. Addressing the challenge of turning the policy of HIV/TB integration into action. 3rd South African AIDS Conference, Durban South Africa, abstract 586, 2007.

Stephens D et al. Integration of tuberculosis (TB) treatment in HIV And AIDS programming. 3rd South African AIDS Conference, Durban South Africa, abstract 445, 2007.

Van Rie A et al. Roll-out of provider-initiated HIV counselling and testing for patients with tuberculosis in Kinshasa, Democratic Republic of Congo. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda, abstract 763.

Vandebriel G. Early results of implementation of a national policy on TB screening in people living with HIV attending ART clinics in Rwanda. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda, abstract 596.

Verkujt SE et al. TB and HIV services integration in TB hospitals at the Buffalo City Local Service Area, East London, South Africa. 3rd South African AIDS Conference, Durban South Africa, abstract 684, 2007

Weyer K et al. Improving access to HIV care for TB patients in South Africa: a best-practice approach. 3rd South African AIDS Conference, Durban South Africa, abstract 362, 2007.

Were W.A et al. Clinical predictors of active tuberculosis in HIV-infected people attending an antiretroviral treatment program in rural Uganda. The 2007 HIV/AIDS Implementers’ Meeting, Kigali, Rwanda, abstract 1280.

Resources

WHO STOP TB Department

http://www.who.int/topics/tuberculosis/en/

The STOP TB Partnership

http://www.stoptb.org/wg/tb_hiv/