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