HIV Implementers meeting: June 18, Kigali, Rwanda TB/HIV: Integration of services and stopping the...
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Transcript of HIV Implementers meeting: June 18, Kigali, Rwanda TB/HIV: Integration of services and stopping the...
HIV Implementers meeting: June 18, Kigali, Rwanda
TB/HIV: Integration of services and stopping the newest epidemic—XDRTB
Chakaya J. MKenya Medical Research
Institute/National Leprosy and TB Control Programme, MoH
Contents
• The burden of TB and HIV• The TB-HIV Link• TB-HIV Service provision
• Achievements• Reasons for achievements• Constraints/Weaknesses
• MDR/XDRTB and HIV• TB transmission at health care settings • Conclusions.
The Burden of TB and HIV
NLTP Kenya - TB Case Finding: 1987 - 2006
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
'87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
Year
Nu
mb
ers
of
rep
ort
ed
ca
se
sSmear Positive Pulmonary TB
Smear Negative Pulmonary TB
Extra Pulmonary TB
Retreatment Cases
All TB
ADULT HIV PREVALENCE TRENDS - KENYA
0%2%4%6%8%
10%12%14%16%18%
NationalUrbanRural
National HIV prevalence is 7%
Sentinel Surveillance data
Demographic and Health Survey of 2003
1.25 m Kenyans estimated to be HIV positive
The TB - HIV Link
Kenya, TB Case Finding vs. HIV Prevalence Rates (ANC): 1990 - 2006
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
110,000
120,000
'90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
Year
Nu
mb
ers
re
gis
tre
d T
B c
as
es
s
0
5
10
15
20
25
HIV
pre
va
len
ce
ra
te (
%)
All registered TB cases
HIV prevalence rate (ANC)
Poly. (HIV prevalence rate (ANC))
TB/HIV Services Provision:
What has Kenya Achieved?
0
10
20
30
40
50
60
70
80
90
100
%tested forHIV
% HIV +
% on ART
% on CPT
HIV Testing and Provision of HIV Interventions to TB Patients - Kenya
N=115,000 in 2006
TB/HIV Service Provision Sites -2006
• HIV Testing• Hospital: 244 of 286 Hospitals
• Health Centre: 440 of 613 Health Centres
• Dispensary: 306 of 851 Dispensaries • Other facility: 15 of 51
• Sputum smear microscopy centres: 777 • All TB treatment centres: 1801
• ART Sites: 320
EXPANDING ART TO HEALTH FACILITIES
10
220
70
261
144
348
199
0
50
100
150
200
250
300
350
Nu
mb
er o
f A
RV
sit
es
2002 2003 2004 2005 Jun-06 Mar-07
ADULT ARV sites PAEDS ARV sites
5 Pilot sites
15 Provincial sites
48 District health
facilities
All Districts, some SDHand HC , mission hospitals, NGOs
10
,00
0
14
,00
0 24
,00
0
37
,00
0
44
,00
01
40
0
50
,00
01
80
0
65
,00
0
29
00
70
,00
0
42
00
80
,00
0
60
00
88
,58
9
67
44
12
42
68
10
48
3
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000J
un
-04
Se
p-0
4
De
c-0
4
Ma
r-0
5
Ju
n-0
5
Se
p-0
5
De
c-0
5
Ma
r-0
6
Ju
n-0
6
Se
p-0
6
De
c-0
6
Ma
r-0
7
TOTAL NUMBER OF PATIENTS ON ART
TOTAL CHILDREN
What made it possible for these results to be achieved?
HIV Testing Guidelines
Issued by MoH in Oct 2004Emphasized that not offering HIV testing to persons presenting with a HIV associated illness, including TB is sub-standard carePaved for the way for rapid scale up of DCT (provider initiated HIV testing with opt out option)
Revision of the TB Recording and Reporting System
NATIONAL LEPROSY/TUBERCULOSIS PROGRAMME
MINISTRY OF HEALTH
TB4 - TUBERCULOSIS TREATMENT UNIT REGISTER
The contents of this register are strictly confidentialDisclosure of information in this register is punishable by law
TB Treatment Unit Register - 4 (right hand page)
HIV
Test
Pos./Neg./ND
Partner(s)
Tested for
HIV
Y/N
Referred
BY
Referred
TO
Cotrimoxazole
Preventive
Therapy
Y/N
ART
Y/N
Referred BY:VCT = VCT centreHCC = HIV comprehensive care unitHBC =Home based careSTI = STI clinicPS = Private sectorANC = Antenatal clinicSR = Self referralCI = Contact invitationCP = Chemist/Pharmacy
Referred TO:VCT = VCT centreHCC = HIV comprehensive care unitHBC =Home based careSTI = STI clinicPS = Private sectorANC = Antenatal clinic
NB. Partner(s) tested for HIV (Y/N) = Regular sexual partner(s) of an HIV positive TB case
TB Treatment Unit Register - 2 (left hand page)
DOT
by
Type
TB
P/EP
Type of
patient
CD 4 count (if done)Culture
+/-/ND
X-ray
Y/N
CD4/I CD4/II
DOT during intensive phase:HCW = Health care worker H = House hold member, relative, neighbour, friend, etc.CV = Community VolunteerND = Not Done (self-supervision)
Type of patient:N = NewR+ = smear pos. relapseR- = smear neg. relapseREP = extra-pulmonary relapseF = failureRAD = re-treatment after defaultingTI = transfer in
CD 4 count (if done):Date and result of CD 4 countCD4/I = during first 2 months of treatmentCD4/II = during last 2 months of treatment
Other factors that facilitated TB/HIV Service Provision
• Leadership – the NLTP with support from NASCOP took this to heart and provided the requisite “PUSH”
• Finances – exponential growth in funds dedicated to TB/HIV from:
• PEPFAR• WHO• OGAC• CIDA• GFATM
• Multi-stakeholder involvement.
Was the Health Care System Strengthened?
The Health Care System Inputs
• Human Resources for Health• Staff numbers• Staff Training and Technical support (supervision) • Staff Motivation
• Health physical Infrastructure• Buildings and equipment
• Consumables• Reagents and medicines
• Health Care Management
Human Resource and Verification Exercise -2004
• Quantified HR need Based on staffing norms and not on workload assessment.
• Estimated a need for additional 190 doctors and 1,700 nurses to meet MoH staffing norms
The Partners for Health Reform plus survey 2006
• Aimed at a comprehensive analysis of the HR currently available and required to meet the targets set by PEPFAR and the MDGs in the public and FBO sectors in Kenya
Projected Number of FTE required for TB services in 2005, 2010 and 2015
2005 Doctors 37
Clinical Officers 60
Nurses 1,150
Pharmacy Specialists 5
Laboratory Specialists 140
Radiographers 29
2006 Doctors 59
Clinical Officers 90
Nurses 2002
Pharmacy Specialists 9
Laboratory Specialists 242
Radiographers 50
2007 Doctors 64
Clinical Officers 96
Nurses 2,168
Pharmacy Specialists 10
Laboratory Specialist 262
Radiographers 54
Human Resource for Health – Distribution Disparities
• While dispensaries (the most primary health care facility) comprise over 70% of all public health care facilities only 12.9% of all staff work in these facilities
• HR distribution favors urban versus rural health care facilities
• HR distribution favors high agricultural potential area versus arid and semi –arid areas
Human Resource inputs
• Staff Recruitment• The Intensive Support and Action Countries (ISAC)
and PEPFAR provided 36 additional coordinators to stimulate “action” at high TB/HIV burden districts
• Staff Training in all districts • Technical Support (supervision)
• Developed guidelines/checklist for technical support• Provided targets for each service delivery point• Provided finances for regular technical support• Formed teams of in country technical agencies• Regular support from external agencies
Getting the most out of existing staff- Recognition- Competition- Better productivity?
The 1st Performance Awards, March 2004
The Best PTLC 2003 Award
The 2nd Performance Awards March 2006
The Winning Province 2005
The 2nd performance awards March 2006
The winning facility 2005 award
Did we plan and coordinate well?
• Establishing coordinating committees at all levels √
• While the national steering committee may be functioning well this may not be so at other levels
• Joint planning between TB and HIV programmes still not optimal
• Joint monitoring and evaluation – some improvement – linkages remain weak
• Referral systems – still weak
What elements of the interim policy have we neglected?
o To decrease the burden of TB in PLWH• Intensified TB case finding • Treatment of latent TB infection (TB
Preventive therapy)• TB infection control in health care and
congregate settings • Stakeholders Workshop on TB preventive
therapy, ICF and Infection Control – May 14-15. 2007
Recommendations of the stakeholders meeting
• IPT should not be implemented nationwide yet
• Implementation should be in selected settings
• Congregate settings: prisons, military, children home
• Target groups: HCW, children exposed to open TB
• Done by Health programs/entities with adequate systems and structures especially community support: e.g. EDARP, AMPATH, MSF
• May be carried under controlled research programs
• Community feasibility/benefit studies with district wide approaches encouraged.
• Accompanied by intensified drug resistance surveillance
Recommendations
• ICF – A must and an Immediate GO but with refinement of the ICF tool
• Infection Control – A must and an Immediate GO with adoption/adaptation of international guidelines, training of staff etc
Summary
• Good progress made with HIV testing of TB patients• The proportion of TB patients testing HIV+ declines as
HIV testing expands• While CPT provision is satisfactory but up 15% of HIV
infected TB patients may not be receiving this simple intervention
• 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- too many patients “missing out”
• A less decentralized ART programme may be limiting access to ART for HIV infected TB patients
MDR/XDR –TB and HIV
XDRTB: The South African Experience
• Extensively reported
• Involved young patients ( average age 35 years)
• Nearly 50% had no previous TB treatment
• About 60% were hospitalized prior to the diagnosis of XDRTB
• All were HIV+
• Nearly all (98%) died
The lessons
• MDRTB/XDR-TB• A consequence of sub optimal TB control ( service
coverage, case detection, low cure rates, high rates of unfavorable outcomes)
• HIV infected persons, with their increased tendency to utilize health services at risk of acquiring TB including MDR and XDR TB in health care settings
• When HIV infected persons acquire XDRTB the outcomes are very poor
• Inadequate Infection Control Practices encourage the transmission of TB including MDR and XDRTB
MDR/XDRTB
• Other important factors
• Availability of SLDs in the private sector – amikacin, quinolones and others
• Use/misuse of anti-TB drugs including SLDs by the private providers
• Extent of engagement of all providers
Hospitals Transmission of TB
Clinic Congestion
Ward Congestion
KNH TB among Health Care Workers Study
• Case control study
• Risk factors for TB among Hospital staff
• Carried out in 2005.
Table 3. Multivariate logistic regression model for comparison of KNH staff TB cases and controls by selected characteristics.
Variable
Number (%) Cases Controls
MultivariateAdjusted Odds Ratio (95% CI)
Contact hours <5 hours/day ≥5 hours/day
6 (9)59 (91)
109 (35)202 (65)
Referent6.5 (2.3-18.4)
Work in high-risk location* 27 (42) 87 (28) 2.2 (1.1-4.4)
HIVHIV-infectedHIV-uninfectedHIV status unknown
12 (19)33 (52)19 (30)
2 (1)163 (52)146 (47)
33.0 (5.7-192)Referent
0.6 (0.29-1.2)
Housing Slum KNH low-income Other
11 (17)16 (25)38 (58)
25 (8)49 (16)
238 (76)
4.0 (1.4-11.2)2.3 (1.0-5.1)
Referent
History of BCG:BCG report + BCG scarNo BCG report + BCG scarBCG report + No BCG scarNo BCG report + No BCG scar
48 (84)1 (2)4 (7)4 (7)
283 (92)2 (1)
14 (5)9 (3)
0.3 (0.06-0.98)1.2 (0.07-22.87)
0.3 (0.5-2.04)Referent
Percentages may not add up to 100% due to rounding.* A high-risk location was defined as an area where TB patients received care and included: casualty (emergency department), general medical wards, and the TB clinic.
TB among Health Care Workers at the Kenyatta Hospital, Nairobi
Conclusion
• Integration of TB/HIV services• Only way to effectively deliver services• HIV testing and counseling of TB patients and provision of CPT has
progressed well• Provision of ART to TB patients remains inadequate• Hardly anything major is happening with ICF and TBPT yet• MDRTB/XDRT, the result of suboptimal TB control programmes
coupled with Health facility transmission of TB may pose major challenges for TB care and prevention
• What is needed• Strengthened TB control programmes• Better collaboration with HIV control programmes • Rapid definition key measures for infection control in resource
limited settings and implementation of these measures• Intensified Surveillance for DRTB• Engagement of all care providers
Eyes On the BIG PRIZE
Universal Access to TB/HIV Services by 2010.
Thank You All