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Transcript of Policy review of HIV and TB guidelines for high HIV/TB burden African countries HIV/AIDS Department...
Policy review of HIV and TB guidelines for high HIV/TB burden
African countries
HIV/AIDS DepartmentWorld Health Organization
WHO 2010 ART guidelines
Target Population ART guideline
HIV+ asymptomatic patients
ARV-naïve individuals
CD4 < 350 cells/mm3
HIV+ pregnant women CD4 < 350 cells/mm3 irrespective of clinical symptoms or WHO clinical stage 3 or 4 irrespective of CD4 cell count
HIV/TB co-infection
ARV- naïve individuals
Presence of active TB, irrespective of CD4 count
WHO 2004 Interim Policy on Collaborative TB/HIV Activities
A. Establish NTP-NACP collaborative mechanisms Coordinating bodies for effective TB/HIV activities at all levels Conduct surveillance of HIV prevalence among TB cases Carry out joint TB/HIV planning Monitor and evaluate collaborative TB/HIV activities
B. Decrease burden of TB among PLHIV (the "Three I's for HIV/TB") Establish intensified TB case finding Introduce INH preventive therapy Ensure TB infection control in health care and congregate settings
C. Decrease burden of HIV among TB patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV/AIDS care and support Introduce ARVs
Use of four-symptoms screening algorithm to rule out active TB and offer IPT
Four symptoms include cough, fever, weight loss and night sweats
Past history of TB and current pregnancy should not be contraindications for IPT
TST or chest radiography are not required
WHO 2010 IPT/ICF Recommendations
Estimated 2009 HIV/TB and HIV burden
Source : 2010 Stop TB global surveillance report, UNAIDS Report on global AIDS Epidemic 2010
Country People with HIV-Figure in
'000 (% of global HIV-
positive people)
People with HIV and TB- Figure in '000 (% of global
HIV/TB burden)
People eligible for
ART at CD4 < 350 cells ('000)
People on ART ('000)
ART coverage
(%)
People living with
HIV screened
for TB ('000)
ART coverage
(%)
Botswana 320 (1.0) 6.8 (0.6) 170 145.2 83 159.1 11700
Ethiopia N/A 34 (2.8) N/A 176.6 N/A 24.1 2403
Kenya 1500 (4.5) 53 (4.4) 710 337 48 14.1 N/A
Lesotho 290 (0.9) 8.7 (0.7) 130 61.7 48 N/A N/A
Malawi 920 (2.8) 27 (2.3) 440 198.8 46 N/A N/A
Mozambique 1400 (4.2) 54 (4.5) 570 170.2 30 24.3 2429
Namibia 180 (0.5) 9.2 (0.8) 93 70.5 76 87.5 17700
Nigeria 3300 (9.9) 87 (7.3) 1400 303 21 195.1 1853
South Africa 5600 (16.8) 290 (24.2) 2600 971.6 37 433.7 23600
Swaziland 180 (0.5) 10 (0.8) 80 47.2 59 8.4 2107
Tanzania 1400 (4.2) 38 (3.2) 660 199.4 30 5.5 153
Uganda 1200 (3.6) 54 (4.5) 520 200.4 39 57.7 N/A
Zambia 980 (2.9) 23 (1.9) 440 283.9 64 N/A N/A
Zimbabwe 1200 (3.6) 48 (4.0) 640 218.6 34 N/A N/A
Total 18470 (55.5) 742.7 (61.9) 8453 3384.1 38 1009.5 61945
Objectives and MethodologyObjectives:
Compare national HIV, TB and HIV/TB guidelines for 14 African countries with recently released WHO ART and HIV/TB guidelines
Methodology:
Main guidelines were collected from the following sources:
National HIV Guidelines
National TB Guidelines
HIV/TB and TB infection control Guidelines
Standard abstraction form was used to review recommendations on:
ART initiation criteria
The Three I’s for HIV/TB
The Three I's for HIV/TB monitoring and evaluation indicators
Source : National HIV, TB and HIV/TB Guidelines
Country National ART guidelines
National TB control guidelines
HIV/TB, ICF, IPT, OI guidelines
TB infection control guidelines
Botswana 2008 2007
Ethiopia 2008 2008 2007
Kenya 2011 2009 2008
Lesotho 2007 2008
Malawi 2011 2007 2008
Mozambique 2010 2008 2010
Namibia 2010 2011 2010
Nigeria 2010 2010 2008 2008
South Africa 2010 2008 2010 2007
Swaziland 2010 2010 2011 2011
Tanzania 2009 2006
Uganda 2008 2010 2006 2011
Zambia 2010 2008 2010
Zimbabwe 2010 2010 2010
* Published guidelines, Drafts, Preliminary drafts
ART initiation criteria in people with HIVCountry (Year of publication
of ART guidelines)Asymptomatic
peoplePeople with HIV and TB Pregnant women
Botswana (2008) <250 Irrespective of CD4 count <250
Ethiopia (2008) <200 <350 <200
Kenya (2011) <350 Irrespective of CD4 count <350
Lesotho (2007) <350 <350 <350
Malawi (2011) <350 Irrespective of CD4 count Irrespective of CD4 count
Mozambique (2010) <250 <350 <350
Namibia (2010) <350 Irrespective of CD4 count <350
Nigeria (2010) <350 Irrespective of CD4 count* <350
South Africa (2010) <200 <350 <350
Swaziland (2010) <350 Irrespective of CD4 count <350
Tanzania (2009) <200 <350 <200
Uganda (2008) <250 <350 <350
Zambia (2010) <350 <350 <350
Zimbabwe (2010) <350 Irrespective of CD4 count* <350
All figures in cells/mm3, Guidelines in white are similar to WHO recommendations.
* Nigeria's TB and HIV/TB guidelines and Zimbabwe's HIV/TB guidelines recommend ART for people with HIV and TB at CD4 count < 350 cells/mm3
ART initiation for asymptomatic people
2010 WHO Recommendation : CD4 count < 350 cells/mm3
≤ 350
≤ 200
≤ 250
Kenya, Lesotho, Malawi, Namibia, Nigeria, Swaziland, Zambia, Zimbabwe
Botswana, Mozambique, Uganda
Ethiopia, South Africa, Tanzania
CD4 Count
• Zambia recommends ART at CD4 count > 350 cells/mm3 if any other stage III or IV illnesses• Ethiopia recommends ART for all extrapulmonary and disseminated TB patients
ART initiation for people with HIV and TB
2010 WHO Recommendation : ART irrespective of CD4 count
Irrespective of CD4 count
CD4<350 cells
Botswana Ethiopia
Kenya Lesotho
Malawi Mozambique
Namibia South Africa
Nigeria Tanzania
Swaziland Uganda
Zimbabwe Zambia
ART initiation for pregnant women with HIV2010 WHO Recommendation : CD4 count < 350 cells/mm3
Irrespective of CD4 count
CD4<350 cells CD4<250 cells CD4<200 cells
Malawi Kenya Botswana Ethiopia
Lesotho Tanzania
Mozambique
Namibia
Nigeria
South Africa
Swaziland
Uganda
Zambia
Zimbabwe
• Malawi, under Option B+, recommends lifelong ART for all pregnant women irrespective of CD4 count
Co-trimoxazole prophylaxis2006 WHO Recommendation : CD4 count < 350* cells/mm3 or WHO stage 3 or 4
CD4< 200 Cells or WHO Stage 3 or 4
Botswana
CD4< 350 Cells or WHO Stage 3 or 4
Lesotho, Namibia, Nigeria
CD4< 350 Cells or WHO Stage 2, 3 or 4
Mozambique, Tanzania, Zambia, Ethiopia**, Zimbabwe
CD4< 200 Cells or WHO Stage 2, 3 or 4
South Africa
Different guidelines followed by different countries
CD4< 250 Cells or WHO Stage 2, 3 or 4
Uganda
All HIV positives
Kenya, Malawi, Swaziland
*Countries may choose to adopt a CD4 threshold of < 200 cells/mm3 **Source: Ethiopia's Co-trimoxazole prophylaxis guidelines, 2006
National policies for HIV, TB and HIV/TB, and the Three I's for HIV/TB
Country ICF IPT TB infection control
Indicators on the Three I's for HIV/TB
Botswana NAP NAP, NTP NAP, NTP NTP
Ethiopia NAP, NTP, HIV/TB NAP, NTP, HIV/TB NTP, HIV/TB HIV/TB
Kenya NAP, OI, NTP NAP, OI, NTP NAP, OI, NTP x
Lesotho NAP, NTP NAP, NTP NAP, NTP NTP
Malawi NAP, NTP NAP, NTP** IC NTP
Mozambique NAP, NTP NAP, NTP NAP, NTP, IC NAP
Namibia NTP NAP, NTP NTP, IC NTP, IC
Nigeria NAP, NTP, HIV/TB NAP, NTP, HIV/TB NTP, HIV/TB, IC IC
South Africa NAP, NTP, IPT NAP, NTP, IPT NTP, IC IPT
Swaziland* NAP, IPT NAP, IPT NAP, IC NAP, IPT, IC
Tanzania NAP, NTP NAP, NTP NAP, NTP x
Uganda NAP, NTP, HIV/TB NTP, HIV/TB NTP, HIV/TB, IC HIV/TB, IC
Zambia NAP, NTP, ICF NTP**, ICF NTP NTP
Zimbabwe NTP, HIV/TB NTP**, HIV/TB** NTP, HIV/TB x
NAP – National ART Policy, NTP – National TB Policy, ICF – National intensified TB case finding guidelines, IPT – National IPT guidelines, IC – TB infection control guidelines, OI – National guidelines on management of HIV-related opportunistic infections
Note: * 2011 NTP for Swaziland recommends Three I's for HIV/TB but do not mention any guidelines ** These guidelines do not recommend IPT
Country ICF IPT TB infection control
Botswana ✓ ✓ ✓
Ethiopia ✓ ✓ ✓
Kenya ✓ ✓ ✓
Lesotho ✓ ✓ ✓
Malawi ✓ ✓ ✓
Mozambique ✓ ✓ ✓
Namibia ✓ ✓ ✓
Nigeria ✓ ✓ ✓
South Africa ✓ ✓ ✓
Swaziland ✓ ✓ ✓
Tanzania ✓ ✓ ✓
Uganda ✓ ✓ ✓
Zambia ✓ ✓* ✓
Zimbabwe ✓ ✗ ✓
Countries recommending the Three I’s for HIV/TB
* Zambia: Preliminary draft on ICF guidelines recommends IPT
Botswana
Ethiopia
Kenya
Lesotho
Malawi
Mozambique
Namibia
Nigeria
SouthAfrica
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe
IPT not recommended
Symptom-based
Symptom-based + sputumsmear microscopy + chest X-ray
Symptom-based + sputum smearmicroscopy + chest X-ray + TST
LEGEND
IPT Initiation criteria
TB screening criteria for IPT2010 WHO Recommendation : Symptom-based screening
Note: The map shows IPT initiation criteria recommended by the most recent guidelines for a country
TB exclusion criteria for IPT initiation2010 WHO Recommendation : Four-symptom screening for cough, fever, weight loss and night sweats
* 2011 TB guidelines for Namibia recommend enlarged lymph nodes as an additional symptom ** 2006 TB guidelines for Tanzania recommend chest pain as an additional symptom *** 2008 IPT guidelines for Nigeria recommend weight loss as an additional symptom, 2010 NTP guidelines do not recommend chest X-ray and sputum smear microscopy
Cough Cough Cough Cough Cough Cough
Night sweats
Fever Fever Fever Fever Fever Fever
Weight loss
Weight loss
Weight loss
Weight loss
Weight loss
Weight loss
Night sweats
Night sweats
Night sweats
Night sweats
Night sweats
Night sweats
Chest pain
Coughing blood
Chest pain
Swelling
LESOTHO NAP 2007
WHO recommendation
SOUTH AFRICA
IPT 2010
ETHIOPIA HIV/TB 2008
ZAMBIA IPT 2010
MALAWINAP 2011
MOZAMBIQUE NAP 2010
TANZANIA** NAP 2009
SWAZILAND NAP 2010
KENYA NAP 2011
Shortness of breath
Loss of appetite
Shortness of breath
Shortness of breath
Loss of appetite
Loss of appetite
Sputum production
Chest pain
Coughing blood
Chest pain
Coughing blood
Enlarged glandsDiarrhoea
BOTSWANA NTP 2007NAMIBIA*
NAP 2010
SOUTH AFRICA NAP 2010
Cough
UGANDA NTP 2010
Cough
Fever
Weight loss
Night sweats
Chest X-ray
Sputum smear
TST
Chest X-ray
Sputum smear
Cough
Fever
Night sweats
Enlarged lymph nodes
Chest pain
NIGERIA*** NAP 2010
Chest X-ray
Sputum smear
Cough
Fever
Weight loss
Enlarged lymph nodes
Abnormal chest
findings
Enlarged glands
KENYA OI 2008 NTP 2009
Chest X-ray
Cough
1. Botswana and Mozambique – No IPT initiation in pregnancy
2. Botswana and Tanzania – IPT not for children
3. South Africa – IPT with ART is a conditional recommendation
4. Lesotho – IPT offered to TB-exposed HIV infected children and at pilot sites where active TB can be ruled out
5. Malawi – Stop IPT when patient is started on ART
6. Kenya and Swaziland– IPT provided in clinics with TB screening, adherence counselling and patient follow-up services
7. Uganda – IPT provided in institutions with adequate human resources, infrastructure, and equipment and logistics
Exceptions to WHO recommendations on IPT
2010 WHO Recommendation : IPT to all irrespective of previous history of TB or current pregnancy and IPT with ART also
recommended
Indicators for monitoring and evaluating performance on the Three I’s for HIV/TB
ICF
Yes No
Botswana
Kenya
South Africa
Tanzania
Zimbabwe
Lesotho
Ethiopia
Malawi
Mozambique
Namibia
Nigeria
Swaziland
Uganda
Zambia
IPT
Yes No
Kenya
Malawi
Nigeria
Tanzania
Zambia
Botswana
Ethiopia
Lesotho
Mozambique
Namibia
South Africa
Swaziland
Uganda
Malawi, Namibia, Nigeria, Swaziland and Uganda have indicators for TB infection control
Limitations
Guidelines may be outdated and/or in the process of being updatedWritten policies may not reflect programme implementation Other guidelines covering ART and the Three I’s for HIV/TB may exist
- Infection control guidelines - Monitoring and evaluation guidelines
Conclusion• Many countries follow the recently released WHO guidelines
- Asymptomatic patients – 8 countries
- HIV/TB co-infected people – 7 countries
- Pregnant women – 10 countries
• Malawi recommends lifelong ART for pregnant women irrespective of CD4 count (Option B+)
• Almost all countries have recommendations on the Three I’s for HIV/TB
• CPT initiation criteria differs widely across countries
• ICF and IPT guidelines specified in both NAP and NTP for many countries
• Many countries have ICF and IPT indicators
• Room for improving monitoring and evaluating progress on TB infection control
Recommendations
ART policy
Revise ART eligibility criteria where necessary
IPT policy
Adapt policies to recommend IPT for all, including pregnant women, previous TB patients and PLHIV on ART
Simplify criteria for IPT initiation
Monitoring and evaluating of the Three I's for HIV/TB
Include indicators on ICF and IPT in National ART Guidelines
Adapt and implement indicators for TB infection control