Integrating HIV and TB services : some evidences, many challenges Lessons learned from Khayelistha , South Africa TB/HIV working group, Addis-Ababa September 2004 MÉDECINS SANS FRONTIÈRES SOUTH AFRICA UNIVERSITY OF CAPE TOWN School of Public Health and Family Medicine

Which model of integration ? HIV/Aids TB ARV follow-up One stop service for TB-HIV co-infected HIV/AIDS TB + ARV TB/HIV TB Tb patients Infectious disease chronic care unit

KHAYELITSHA Township 30 km from Cape Town Population: 400-500,000 60-70% unemployment,mostly informal housing

Evolution of HIV prevalence rate in Khayelitsha ( 1999-2003 antenatal VCT results)

Evolution of TB caseload in Khayelitha ( all TB patients regardless of HIV status) Tb incidence rate in 2003 was 1122/100.000 36% 34 % Source: Cape Town TB Control 2003 .Case load almost doubled between 2000 and 2003 In Metro region EPTB has increased by 187 % in last 4 years Tb incidence rate ( 2003) :1122/100.000

PMTCT: 2003:more than 4 000 women enrolled A tentative to integrate 2 vertical services : HIV/AIDS and TB services in site B ,Khayelitsha 2000: opening HIV/AIDS clinics in public services, next to the TB clinic 2001: first HAART patient … > 1400 patients by now 2002: VCT re-enforced in TB service and easier access to HAART 2003: merging both buidlings and stepwise integration of HIV and TB services -> the busiest TB clinics for the whole Province ( 4800 TB consultations and > 1500 sputa /month) and the biggest ARV clinic for the country PMTCT: 2003:more than 4 000 women enrolled

Objectives of TB/HIV integration For TB patients To stimulate VCT among TB clients To accelerate access to HAART for TB/HIV co-infected To reduce TB incidence among HIV patients To improve TB diagnostic algorithms To increase adherence and cure rate among TB patients by using the Hiv adherence tools For HIV patients To have an easier access to TB diagnosis and treatment To develop a one stop service To benefit from existing TB network to support HIV For the health services To pool TB and HIV staff and integrate training To improve staff morale

To stimulate VCT in TB patients (2003 cohort analysis) 22 % know their status upon arrival 47 % counselled and 87 % accepted a test ( can be compared to 8 % known status and 40 % acceptance rate in Gugulethu, similar township next to Khayelitsha) 63 % co-infection rate

To accelerate access to HAART for TB/HIV co-infected and reduce TB incidence

To reduce TB incidence among HIV patients Annual tuberculosis risk of 38% among all HIV patients regardless of Cd4 not under HAART. HAART reduces TB incidence by 68 %-80 % Impact on individuals but only 11.4 % of TB patients were enrolled for HAART in 2003 n 663 210 45 5 Failure 0.20 (0.17-0.24) 0.44 (0.37-0.52) 0.64 (0.51-0.77) 268 85 1 0.09 (0.07-0.12) 0.18 (0.14-0.23) . 0.00 0.25 0.50 0.75 1.00 3 6 9 12 15 18 21 24 27 30 33 36 Follow-up time in months Pre-ART ART by duration of follow-up pre and post ART Kaplan-Meier estimate of time to first tuberculosis episode

To improve TB diagnostic We are confronted with a totally different TB clinical picture Sub-sample review ( n=109) : Only 18 (16.5%) are smear(+) 53 ( 49 % ) are smear (-) culture (+) 38 (35 % ) are extra-pulmonary forms 63 % of extra-pulmonary TB are diagnosed in HIV clinics Validation of new TB diagnostic algorithm in process A desperate need for a new TB serological test to make nurse confident with sputum (-) diagnostic

TB TREATMENT Regimen 1 or 2 DISCHARGE Smear x 2 FNAB of LN > or = 2cm for TB microscopy (+/- culture and cytology) Amoxycillin 500mg tds x 7 days (or Doxycycline if Penicillin allergic) Smear(s) positive or granulomas on FNAB* TB TREATMENT Regimen 1 or 2 Symptoms and signs resolved, weight stable and smears negative DISCHARGE No sputum produced or smears negative and remains symptomatic CXR 3rd sputum for smear and culture Clinical picture and CXR consistent with active TB as decided by MO TB treatment monitoring CRP, Hb, weight, temperature, Karnofsky and symptoms CXR clear or not consistent with active TB REFER Favourable response Poor response at 8 weeks or earlier if deterioration Pleural effusion > 1/3 hemithorax, tap to exclude empyema and send for protein, ADA, MCS and AFB/TB culture Consider PCP if RR>30, cyanosed, grounglass bilateral infiltrate on CXR Smear or culture positive “PULMONARY PRESENTATION” = Cough > 14 days and/or CXR infiltrate with or without night sweats, recent weight loss or deteriorating level of function *If only one smear is positive then perform CXR and/or 3rd sputum for TB microscopy and culture for corroboration, but start TB treatment regardless

To increase adherence and cure rate among TB patients by using the HIV adherence tools HIV adherence rates much higher than TB rates ( <5 % lost to follow-up at 36 months versus 76 % completion rate) Tb/HIV patients have a completion rate close to 90 % Tb to capitalise on HIV set of adherence tools A new category of CHW : adherence counsellors Change of approach has allowed to space DOTS visits and reduce workload

To develop a one stop service Both building have been merged 2 different patient flows TB non co-infected :2 clinical visit/episode HIV and co-infected :monthly clinical visit A positive impact on TB/HIV patients: Reduced queuing time Improved clinical monitoring Allow adjustment for treatment interactions A negative impact on non-co-infected TB cases

To develop a one stop service: what about the risk of nosoconial infection ? Risk to be balanced with: inherent risk of HIV patients sitting together with undiagnosed TB Multiple contacts in the community Fingerprints would probably be inconclusive

Comparative of TB incidence rates between integrated clinic and a non integrated one in same township (670 patients started on ART between May 2001 and December 2003 followed up until the end of March 2004) 1.00 0.75 Proportion free of new TB episode after enrolment 0.50 0.25 0.00 6 12 18 24 30 Follow-up time in months Integrated clinic .Rate ratio compared to other = 1.02 (0.79-1.32 p=0,905)

To integrate both monitoring system Tentative to integrated clinical follow-up sheets Separate but similar registers Unsuccessful integration of patient cards Separate reporting but electronic HIV reporting will boost electronic TB reporting Rigidity of TB monitoring system

To benefit from existing TB network to support HIV TB: 24 DOTS community health workers to cover 40% of TB caseload HIV: Patient self responsibility , family support and “buddy” system for HIV Community based treatment supporters ( in Gugulethu ratio 1/20) : estimated too costly in the long run see cumulative numbers DOTS CHW: different profile than PWA’s CHW Could be used in “troubleshooting” role

To pool TB and HIV staff and integrate training Pledge to use ARV programme as a tool to re-enforce existing PHC services Tb and HIV staff now able to rotate between services No recruitment out of existing TB service but rather re-enforcement Improved staff morale with improved treatment outcomes New clinical career path for TB staff Renewed doctor’s interest in TB

Discussion : beyond evidence… TB services are geared for chronic care services : folders, cohort monitoring… TB services are public health oriented : standardisation, simplified regimen , coverage , epidemic control… Both treatment require a special attention for adherence ….is there any other option where co-infection is high and staff is scarce ?

Some serious challenges TB program not yet geared towards new forms of Tb presentation in HIV ( sputum (-) and extra-pulmonary presentations) HIV services :clinically oriented with emerging public health practices Tb services : established strategies and relatively rigid public health oriented guidelines for TB A strong political culture human rights oriented in HIV versus a technical culture in TB

Conclusions ” Tackling tuberculosis should include tackling HIV as the most potent force driving the tuberculosis epidemic; tackling HIV should include tackling tuberculosis as a leading killer of PLWH” WHO 2002 ..More a forced marriage than a love story seen the differences of culture How to make the bride attractive ? Major flexibility and criticism about existing practices Risk acceptance on the TB side Less guidelines and more operational research Who will integrate ( swallow?) who ?

Acknowledgements Department of Health, Western Cape Province University of Cape Town Department of Public Health, Infectious Disease Unit, Tropical Institute, Department of Public Health, Antwerp, Belgium Staff of HIV and TB clinic in Khayelitsha who accepted the challenge