tb and hiv: coordinating care (philippe clevenbergh)

8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)

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TB and HIV: Coordinating Care

The example of the Integrated HIVCare program in Myanmar

41st Union World Conference on Lung Health, 11-15

November 2010, Berlin, Germany

P Clevenbergh, MD, PhD

Head of The Unions Office in Myanmar


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Myanmar


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Myanmar

TB: incidence 400/100,000 population per year

HIV: prevalence of 0.7% in adult population

wide variation among groups (Most at risk groups: up to 30%)

about 240,000 HIV infected people nationwide

70% of HIV-infected patients will develop a TB during their

life-time

often as the first serious opportunistic infection

major cause of mortality and morbidity

10% of newly diagnosed TB patients are co-infected with

HIV with huge variations across locations (up to 30%)


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HIV epidemics is contributing to an increase in TB casesfurther fueling the TB epidemics

TB disease is the major cause of death of HIV infectedpatients

However, usually two national programs with little

links/interactions

TB

HIV

TB/HIV deadly combination


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WHO recommended TB/HIV collaborative

activities

3 Is Intensive case finding (both ways)

HIV screening in TB patients

HIV screening among family members of TB/HIV patients

TB screening for family of TB patients TB screening for HIV-infected patients

Isoniazid Preventive therapy

To reduce the risk of TB disease in HIV patients

Infection control procedures

To stop the spread of TB among HIV patients

Concerns about MDR/XDR TB


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Introduction

Program started in May 2005 with the agreement of the Ministry of

Health, MoU signed with MoH in September 2007

Collaboration between MoH, NAP, NTP, WHO and The Union

Sponsored by 3 Diseases Fund (2011), YADANA consortium(2014), Global Fund (2015)

Located in Mandalay, Lashio, Taunggyi, Pakokku (population 2.3

million people)

Expanded to all HIV-infected patients, suppression of geographiccriteria for enrolment


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Objectives of the IHC program

Provide comprehensive and integrated HIV care including

antiretroviral therapy to TB-HIV co-infected patients and their families(spouses and children)

Strengthen TB-HIV collaborative activities with NAP and NTPprograms by developing and implementing policies regarding the

minimum package of care that should be available to TB, TB-HIV, andHIV-infected patients

Field test TB-HIV collaborative activities implemented by bothTuberculosis and HIV/AIDS control programs

Develop the capacity of the public health sectorto take care of itsHIV-infected patients

Promote HIV, TB and TB-HIV awareness and prevention in the

community


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Activities of stakeholders (1/4)

National Tuberculosis Program (NTP)

Manages TB diagnosis and treatment, including recording and reporting

Entry point for diagnosis of HIV: counselling and testing (PICT) of TBpatients, HIV rapid tests

Coordinates referral to HIV treatment and care services for TB/HIVpatients and family

Assess TB disease in PLWH

National AIDS Program (NAP) Coordinates the program by providing supervision, monitoring and

evaluation.

Supports HIV VCCT in the NTP (provides HIV tests, training/qualitycontrol)

Provides educational session for the general population

Addresses stigma, increases advocacy

Provides HIV VCCT and STD/STI screening and treatment in STD clinics

Supports People Living With HIV (PLWH) network, advocacy and social

mobilization Screen PLWH for TB symptoms and refer to TB OPD


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Township Health Centres (TSHC)

Delivery of TB diagnostic and treatment services, HIV counselling and testing for TB patients and spouses/children of

HIV/TB patients

Provision of CPT before IHC enrolment

Provision of IPT

Provision of information and educational material on HIV, and condoms topatients attending their centres

Follow-up of chronic care for HIV-infected patients

Recording and reporting of TB/HIV activities

Tertiary Care District Hospital, Medical Units

Provision of specialized HIV care (ARVs, OIs prevention and treatment,) for inpatients and outpatients

Recording and reporting

Linkage with township health centres for defaulters retrieval


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Laboratories MGH/MTH/PHL/TBH/PGH

Support biological follow-up of HIV-infected patients including CD4count

Quality control of HIV test and CD4 count

Culture ofMycobacterium tuberculosis of Smear negative TB/HIV andscreening PLWH

Drug store/pharmacy

Management of central and sub-stocks

Recording and reporting

Social Workers

Adherence counselling sessions

Home visit for defaulter retrieval

Help for social problems


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People living with HIV (PLWH) self-help groups

Advocacy and educational campaigns Support of other PLWH for adherence counselling, education,

Helping in HIV OPDs

TB symptoms screening using WHO questionnaire, IPT screening

Distribution of facial masks

Link with social workers and township health centres for defaultersretrieval.


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Circu


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Description of the services

Dark blue arrows and blue boxes: places where the patients can seektuberculosis

diagnosis (NTP)

Light blue boxes: place where the patients receive TB treatment (NTP) Red arrows and red boxes: places where the patients access HIV counselling and testing

with same day test and result (NTP)

Yellow box: place where the patients receive comprehensive HIV care and treatment

including OI prevention and treatment, antiretroviral drugs, biological follow-up and CD4

Brown arrows and boxes: places where PLWH are actively screened for TB symptoms

and TB disease using questionnaires, sputum microscopy, chest X ray and culture (NTP)

Pink boxes and arrows: defaulters'tracing activities by Basic Health Staff, Social

Workers, and Peers

Light green boxes: places where HIV prevention is available: health education materialand condoms (NTP)

Orange boxes: places where Cotrimoxazole/Isoniazid Preventive Therapy is distributed

(NTP)

Dark green box: places where the NAP is taking care ofpre-ARTHIV infected patients


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Patients flow Mandalay

UMTBC HIV

OPD

STD clinic

Pre-ART pts

TB OPD

TSHC (TB/HIV pts)

Medical wards

Admitted pts

7 TSHC HIV

OPD

MGH OPD

MCH OPD

MTH OPD

Entry point Care and

treatment

Decentralization

in, by, andwith the public sector


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Methods: HIV testing register


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Number of adult TB patientsregistered

Number of TB patients offeredHIV test

Number of TB patientsHIV tested

Number ofHIV co-infectedpatients

Number ofspouses/children ofTB/HIV patients offered HIV

test

Number of spouses/children ofTB/HIV patients HIV tested

Number ofHIV infectedspouses/children

Recording of TB/HIV activities at township

health centres


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Methods: HIV positive register at township level


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Facial mask for patients

Help us to stop transmission of TB from a patient to

another by wearing a facial mask


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Summary sheet


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LTF/d f lt t i f f TB k PLWH


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LTF/defaulters tracing form for TB key person, PLWH

network, Social workers


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Care and treatment

HIV OPDs: capacity approximately 7500 patients in MDY

GOV clinicians MO, AS, HS: 1 GOV MO responsible for

each OPD, usually + 1-2 AS. OPD starts with the GOV MO

IHC facilitators: 1-3 facilitators per OPD

GOV nurses/pharmacists: 2-3 nurses per OPD

(1 pharmacist) for drug delivery

PLWH network: 1-3 volunteers/ OPD

in, by, andwith the public sector


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TB/HIV activity at Township level


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2009 Report for IHC program

total percentageTotal TB Patients registered

Adult 2991

Children 768

Patient Offered for Testing 2830 95%

Patient tested for HIV 2610 87%

Patient with positive result 803 31%

Relative offered for testing 499 62%

Relative tested For HIV 430 86%

Relative with positive result 263 61%

TOTAL HIV infected 1066


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2009 Report for IHC enrollment

Before Enrollment

Total percentage

Total HIV positive patients 1066

Patients enrolled 832 78%

Patients expired before enrollment 34 4%

patients not enrolled 159 15%

No residential form 10 102 64%

Transferred out 4 3%

Not willing to enroll 18 11%

Other 35 22%


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2009 Report for IHC enrollment

After Enrollment

Patients enrolled 832Patients received CPT 981

Patients received ART 543 65%

Patient expired after enrollment 47

Patients expired on ART 61


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One third of TB cases are due to HIV co-infection

TB clinic is an efficient entry point to enter an HIVcare program

Many HIV-infected patients are diagnosed late,when symptomatic

Spouse testing yield many additional HIV-infected patients, usually asymptomatic

E ll f TB/HIV i f d i


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Enrollment of TB/HIV co-infected patients

34%

TB t i l ti t HIV t t


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TB outcomes in relation to HIV sero-status

Higher mortality among TB/HIV co-infectedrou 3% vs 15%


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Risk factors of an unfavorable TB outcome for all TB/HIV

co-infected patients

Risk factors AdjustedOR

95% CI p

Not having access to HIV careprogram 4.26 (3.41 5.32) < 0.01

Old age (above 44 years) 1.49 (1.07 2.08) 0.02

Category II TB treatment 2.43 (1.67 3.56) < 0.01


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Risk factors of an unfavorable TB outcome for co-infected

patients accessing HIV care program

Risk factors AdjustedOR

95% CI p

Old age (above 44 years) 2.18 (1.28 3.72) < 0.01

Female gender 1.50 (1.00 2.23) 0.05

Underweight (BMI 18) 1.91 (1.28 2.86) < 0.01

Not started on ART 2.82 (1.87 4.26) < 0.01

Baseline CD4 count 100 cells/l 1.89 (1.24 2.89) < 0.01

Moderate anemiaSevere anemia

1.983.29

(1.17 3.34)(1.93 5.60)

0.01< 0.01

A history of prior TB 3.33 (2.03 5.47) < 0.01

T t l ll t ti t d T t l ti f ll f


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Total enrollment patients and Total active follow up of

IHC program in Myanmar (MDY +PKK +TG + LS)

Total

Total everenrolled patients

6448

Active follow up 4897

Total patientsever started

ART

4650

Active follow upon ART

3702


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ART outcomes of IHC program in Myanmar

(MDY + PKK+ TG+ LS (Sept 2010)

Conclusions (1/2)


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Conclusions (1/2)

Recognition: After > 5 years of implementation the IHC

program is a success and is seen by the medical society at

national and international scale and by the United NationsAgencies as extremely effective. Pioneer program in

Myanmar.

Sustainability: The IHC program brings together health

authorities at local, national and international level and

ensures the capacity building across the sectors.

Networking: The IHC program relies on the collaboration

of various participants including township health centres

staff , PLWH self-help groups, and social workers

Expansion: Thanks to the organisation and the policies put

in place, the IHC program is technically sound to be

scaled up


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Acknowledgements

Myanmar National AIDS Program

Myanmar National Tuberculosis Program

Medical and Para-medical teams in Mandalay General

Hospital and Mandalay Teaching Hospital

Township Medical Officers

People Living With HIV Network Spectrum

WHO Myanmar, TB and HIV Dpts

Union's HIV Department


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Sponsors:

This program is jointly supported by

Thank you!


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Thank you!

tb and hiv: coordinating care (philippe clevenbergh)

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