How do TB clinic practices obstruct good HIV care?

Researchers from Kenya report that tuberculosis (TB) clinic practices provide a major obstacle to the provision of good HIV care, despite the fact that national TB programes throughout Africa and Asia are being urged to integrate HIV care with TB care. The findings, drawn from a survey of TB clinics in two districts of Kenya, reflect practice in many countries, and were presented to last week's International Conference on Lung Health in Paris.

Siaya and Bonde districts, located on Kenya's border with Uganda, are rural areas with a high HIV prevalence but few HIV-specific clinics. Researchers investigated practices at 59 clinics providing TB care in the two districts in order to identify obstacles to the provision of antiretroviral therapy through these clinics.

Problems

TB clinics are often run as drug dispensing events with no meaningful interaction between staff and patients due to the high number of patients seen in one day. Trying to provide HIV drugs using such a model has never been shown to work, especially during the early months of therapy. The team recommends that the concentration of TB patients into one monthly or weekly clinic should be avoided, and that time needs to be set aside to address issues of dual adherence to TB and HIV treatment.

Confidentiality is also an issue that needs to be addressed, all the way from the physical layout of the clinic to the record keeping system. In many TB clinics patients are seen in a communal waiting room or open ward, and the opportunity for private consultation is almost non-existent. TB/HIV clinics ought to make private consultation available to all patients who need it without making private consultation a clear sign that a patient is HIV-positive.

Surprisingly, HIV testing was not routinely offered in TB clinics despite the fact that 75-80% of TB patients were likely to be HIV-infected, but was instead offered where a suspicion of HIV disease existed. Indeed, only half of facilities were able to offer HIV testing; the remainder had to refer to other clinics.

Even when testing was carried out, healthcare workers rarely learnt the results of a patient’s HIV test and so did not make appropriate referrals or offer contrimoxazole prophylaxis, despite the fact that 50 of the 59 facilities surveyed had the ability to provide treatment for HIV-related opportunistic infections. HIV testing and cotrimoxazole prophylaxis should be available at all TB treatment facilities, the researchers recommend.

A lack of health education for TB patients was also noted, and the use of community volunteers for little other than tracing of TB treatment defaulters was apparent. The role of community volunteers, especially those successfully treated for TB, needs to be considered for treatment supervision and adherence education, and improved co-ordination is needed between home-based care and community TB services. A standardised health education package needs to be provided to all patients too, the researchers say.

Safe drinking water was lacking at all clinics, exposing immunocompromised HIV-positive patients to the risk of waterborne diarrhoeal illness.

Drug supplies were also sporadic. One fifth of facilities had experienced interruptions in drug supply of at least one week in the previous six months, exposing patients to the risk of TB treatment failure. Although only two of the 59 facilities were already offering antiretrovirals at the time of the survey, the number was expected to expand rapidly, increasing the pressure to make drug supply more reliable.

Finally, TB diagnosis itself needs to be speeded up, with improved availability of sputum microscopy through provision of more microscopes and a weekly sputum transport service where microscopes are not available.