Addressing the challenges and successes of expediting TB treatment among PLHIV who are seriously ill: experience from Kenya Masini E & Olwande C National TB Control Program and National AIDS & STI Control Program, Ministry of Health, Kenya

Outline Disease burden 2015 performance Challenges and successes

TB Burden in Kenya 4th cause of death among infectious diseases 81,481 notified cases in 2015

Notified TB cases 1992-2015

Kenya TB Mortality Modelling of mortality among all TB patients ( HIV positive and negative) and among HIV positive. Overall TB mortality has remained unchanged. However, there has been a steady decline in mortality among TBHIV co-infected patients

Key TB HIV indicators 2015 TB patients tested for HIV 95% HIV positive TB patients on CPT 99% HIV positive TB patients on ART 93% HIV positive patients screened for TB 564,723 HIV positive put on IPT (June 2016) 334,838 Kenya has been trailblazer in implementation of TB HIV interventions. The increasing access to IPT, coupled with high ART coverage among PLHIV are among priority interventions aimed at reducing TB HIV co-infection.

TB/HIV - missing cases WHO estimated TBHIV incident cases 2015 40,000 Number detected in 2015 30,012 Detection gap 8,000 Close to a quarter of TBHIV co-infected patients go undiagnosed and untreated

Challenges in confirming TB diagnosis in PLHIV-2015 Number of TB-HIV patients clinically confirmed & empirically treated 12,804 Number of TB-HIV patients on treatment who were bacteriologically confirmed 8,657 Number of TB –HIV patients on treatment with extra-pulmonary TB 4,859 Total number of TB-HIV co-infected patients treatment 26,320 Close to 50% of TBHIV patients are put on treatment without bacteriological confirmation of the disease. Access to more sensitive diagnostics like Xpert in peripheral health facilities still remains limited. TB-LAM assay (point of care urine test for seriously ill people living with HIV) recently approved by WHO for TB diagnosis in PLHIV with severe immuno-suppression is not currently available in public health settings.

Challenges in confirming TB diagnosis in PLHIV-2015 (Deaths among PLHIV on treatment-2015) Overall death rate among TB/HIV co-infected patients 7.7% Death rate among bacteriologically confirmed TB /HIV patients 5.9% Death rate among clinically confirmed & empirically treated TB/HIV patients 9.1% Overall death rate HIV negative TB patients 3.6% The high death rates among TBHIV co-infected patients compared to their HIV negative counterparts suggest challenges & delays in diagnosis and subsequent initiation on treatment. Worse among patients without bacteriological confirmation, who have to undergo additional layers of clinical evaluation for empirical diagnosis to be made. Highlighting the need of increased access to more sensitive TB diagnostics like Xpert and TB LAM especially in peripheral health facilities.

Challenges in confirming TB diagnosis in PLHIV-2015 This data from 3 counties in Kenya that assesses the HIV stage of patients at TB diagnosis. Significant number of patients are diagnosed at advanced HIV stage ,this may explain the earlier slides depicting a disproportionately higher mortality among TBHIV co-infected patients.

Challenges in confirming TB diagnosis in PLHIV-2015

Sub optimal screening of PLHIV for TB Cause of the delays in TB diagnosis and treatment initiation among PLHIV Sub optimal screening of PLHIV for TB Multiple steps in conducting initial patient evaluation at enrolment e.g. baseline laboratory tests and psychosocial preparation Failure to integrate TB/HIV management in other out-patient clinics and IPDs Double stigma from HIV/TB diagnosis Limited access to newer TB diagnostics especially in peripheral facilities  

Successes/opportunities in expediting TB diagnosis and treatment in PLHIV IPT provision to PLHIV has led to more thorough TB screening Gene Xpert is now the first test for TB diagnosis in PLHIV Phase in lateral flow urine lipoarabinomannan assay (LF- LAM) for severely ill patients in the current diagnostic algorithm TB screening has been incorporated into HIV diagnostic algorithm (reducing delays in diagnosis) Task shifting of TB screening in PLHIV on care to peer educators enables this to be done where HCWs may not have adequate time to thoroughly perform this universal testing of TB patients for HIV leads to earlier HIV diagnosis and better management of both conditions.

Successes in expediting diagnosis and treatment over time due to Guideline clarity on management of TB/HIV co- infection Packaged treatment literacy for patients Improved commodity security Improved healthcare worker capacity through training Near complete integration of TB and HIV services at facility

Increasing access to more sensitive diagnosis   129 Xpert equipment in placement. All major HIV hospitals have. Number of Xpert tests done for TB diagnosis among PLHIV increased from 9,947 in 2014 to 79,876 in 2016

Conclusions TB / HIV patients disproportionately bear the brunt  of TB deaths  Challenges in confirming diagnosis compounded by health system related factors delays diagnosis and eventual treatment initiation