Post on 08-Apr-2018
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
1/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
2/55
Myanmar
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
3/55
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%)
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
4/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
5/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
6/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
7/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
8/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
9/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
10/55
Activities of stakeholders (2/4)
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
11/55
Activities of stakeholders (3/4)
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
12/55
Activities of stakeholders (4/4)
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.
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
13/55
Circu
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
14/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
15/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
16/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
17/55
Methods: HIV testing register
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
18/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
19/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
20/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
21/55
Methods: HIV positive register at township level
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
22/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
23/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
24/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
25/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
26/55
Facial mask for patients
Help us to stop transmission of TB from a patient to
another by wearing a facial mask
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
27/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
28/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
29/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
30/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
31/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
32/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
33/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
34/55
Summary sheet
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
35/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
36/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
37/55
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
38/55
LTF/d f lt t i f f TB k PLWH
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
39/55
LTF/defaulters tracing form for TB key person, PLWH
network, Social workers
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
40/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
41/55
TB/HIV activity at Township level
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
42/55
TB/HIV activity at Township level
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
43/55
TB/HIV activity at Township level
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%
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
44/55
TB/HIV activity at Township level
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
45/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
46/55
Enrollment of TB/HIV co-infected patients
34%
TB t i l ti t HIV t t
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
47/55
TB outcomes in relation to HIV sero-status
Higher mortality among TB/HIV co-infectedrou 3% vs 15%
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
48/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
49/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
50/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
51/55
ART outcomes of IHC program in Myanmar
(MDY + PKK+ TG+ LS (Sept 2010)
Conclusions (1/2)
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
52/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
53/55
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
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
54/55
Sponsors:
This program is jointly supported by
Thank you!
8/7/2019 TB and HIV: Coordinating Care (Philippe Clevenbergh)
55/55
Thank you!