Addressing challenges in scaling up TB / HIV treatment integration Alison Grant London School of Hygiene & Tropical Medicine Africa Health Research Institute

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What is "integration"? Integrated service delivery is “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.” (WHO 2008 www.who.int/healthsystems/technical_brief_final.pdf)

What is "integration"? Integrated service delivery is “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.” (WHO 2008 www.who.int/healthsystems/technical_brief_final.pdf)

Why is there a problem? TB This Photo by Unknown Author is licensed under CC BY-NC

Why is there a problem? TB HIV This Photo by Unknown Author is licensed under CC BY-NC

Why does TB / HIV integration matter? TB remains the most important cause of death among HIV+ people - TB accounts for around 40% of deaths among HIV+ people - nearly half of HIV+ people with TB at autopsy are not diagnosed during life - improving coverage of TB screening among HIV+ people starting ART reduced 6m mortality in Botswana 5.3% 3.2% 3.0% Historical controls (SOC) Universal TB screen, if symptomatic - tested with microscopy (EC, yellow) - tested with Xpert (EC+X, green) Auld, CROI 2018

Why does TB / HIV integration matter? Among HIV-positive people with TB, ART is a key determinant of successful treatment outcomes Forest plot, 16 studies reporting TB-CFR among HIV+ people by ART status TB case fatality 58% lower with ART Survival among people starting TB treatment, Kenya, N=162,014 HIV+, no ART: worst survival Onyango PLoS One 2017; 12(11): e0188235. Odone PLoS One 2014; 9(11): e112017.

WHO policy on collaborative activities

Integrated TB/HIV care: spectrum of models Legido-Quigley TMIH 2013;18:199-211.

Percentage of new and relapsea TB cases with documented HIV status, 2004-2016, globally and for WHO regions

Integrated TB/HIV care: spectrum of models Legido-Quigley TMIH 2013;18:199-211.

Global number of notified new and relapse casesa known to be HIV-positive, number started on ART and estimated number of incident HIV-positive TB cases, 2004-2016 Estimated HIV-positive new and relapse cases Reported cases Reported cases on ART

Integrated TB/HIV care: spectrum of models Legido-Quigley TMIH 2013;18:199-211.

One facility: one ceiling or one roof? TB/ HIV TB HIV or This Photo by Unknown Author is licensed under CC BY-NC-SA This Photo by Unknown Author is licensed under CC BY-NC

Types of one-provider model "one-stop shop" where both TB and HIV care provided e.g. Khayelitsha, South Africa Kerschberger PLoS One 2012;7(10): e46988.

Types of one-provider model "one-stop shop" where both TB and HIV care provided "TB treats both" i.e. HIV+ people receive TB treatment and ART from TB clinics, e.g. in Rwanda (Ndagijimana PHA 2015;5:209): HIV testing services provided in TB clinics HIV+ people with TB managed in TB clinics at end of TB treatment, HIV+ people transfer to HIV service to continue ART all HIV+ people screened for TB at each clinic appointment home visits for people with TB for TB screening and HIV testing "TB treats both" may help address concerns about TB transmission to HIV+ people in health facilities - but most transmission is from the people with TB who you don't know about, not those you do

Is "one provider" better? Theoretical advantages to one-provider model: for provider: should be more efficient for patient: fewer visits = reduced costs to patients for patients entering HIV care, may accelerate ART start reduced risk of failed referral one data system should reduce risk of drug-drug interactions

Does "one provider" improve outcomes? In practice: several studies report faster ART initiation and / or higher ART coverage with integrated models of TB/HIV care Suthar AIDS 2014;28(suppl 2):S175

Does "one provider" improve outcomes? Evidence that closer integration improves TB treatment outcomes is weaker Suthar AIDS 2014;28(suppl 2):S175 ? too little, too late among people with advanced disease?

What about patients' perspective? Is "one provider" better? What about patients' perspective? still relatively little published about patients' views of integrated care common themes (Ghana, Rwanda, South Africa): separate services necessitating multiple clinic visits and need for more time off work one-provider care more convenient perception of better quality care in one-provider model stigma continues to be an issue Anku Global Public Health 2017, Daftary IJTLD 2013;17:546, Ndagijimana PHA 2015; 5:209

Why do services remain separate? It's complicated..... multiple reasons (Loveday TMIH 2011;16:431) history disease-specific donor funding differential decentralisation differential degree of task shifting e.g. in South Africa, professional nurses can prescribe ART, enrolled nurses cannot; most TB nurses are enrolled nurses this limits the implementation of the "TB treats both" model

Integrated care is not only about ART ART: necessary for TB prevention.... Suthar PLoS Medicine 2012;9:e1001270

ART is necessary, but not sufficient, to prevent TB TB risk remains high among HIV+ people on long-term ART Gupta PLoS ONE 2012;7:e34156

ART + TBPT = better prevention Rangaka Lancet 2014;384:682 TEMPRANO NEJM 2015;373:808

The other Is: intensified case finding Intensified case finding (ICF) for TB: essential to reduce mortality and interrupt transmission WHO four-symptom screen (cough, weight loss, fever, night sweats) easy to do and well accepted high coverage among people with advanced disease may save lives but implementation generally limited screen optimised for sensitivity (79%), lacks specificity (50%) "TB symptoms" are common so universal screening generates a lot of work XPHACTOR Hanifa PLoS One 2017; 12(8): e0181519 Hanifa, 4th SA TB conference

The other Is: intensified case finding Given low positive predictive value of WHO screening tool, in most settings: in task-shifted services, need a system to prioritise testing among people reporting one or more symptoms e.g. from XPHACTOR Risk factor Category Select one Associated points Assigned score ART status Pre-ART  3 ART < 3 months ART  3 months BMI < 18.5 6 18.5 - 24.9 2  25 CD4 < 200 200-349 1  350 Number of WHO symptoms  1 4 TOTAL SCORE + = Hanifa PLoS One 2017; 12(8): e0181519

The other Is: TB infection prevention and control TB notification rate ratio, HCW: adults, 2016 (WHO) Infection prevention and control (IPC): a concern in integrated care systems for TB and HIV but most TB transmission is prior to TB treatment initiation plenty of evidence of TB transmission in health facilities plenty of TB IPC guidelines, poor implementation could we find innovative solutions using whole systems approaches?

A whole systems approach to infection prevention and control for DRTB in South Africa Systems interventions to improve IPC Analysis of IPC policy Contribution of facilities to DRTB transmission Effect of clinic design, working practices on IPC Effect of HCW ideas of risk, responsibility Economic impact of reduced transmission Mathematical modelling: effect on transmission

Could "decongestion" contribute to preventing TB transmission? Systems interventions to improve IPC Analysis of IPC policy Contribution of facilities to DRTB transmission Effect of clinic design, working practices on IPC Effect of HCW ideas of risk, responsibility Economic impact of reduced transmission Mathematical modelling: effect on transmission AHRI surveillance area, KwaZulu-Natal, South Africa: visits to PHCs by adults in one year 39% all clinic visits are for HIV care visits by HIV negative/unknown HIV positive visits by HIV+ people Wende Safari, Kathy Baisley, Alison Grant: unpublished

Conclusions TB /HIV services are now more often delivered from a single facility but the two services often operate independently Limited evidence that integrated services improve patient-relevant outcomes, or that one model is better than another Integrated TB/HIV service delivery may need structural more than local changes One size will not fit all: ? integration with care for other chronic diseases improve accessibility, maintain quality

What matters?

Acknowledgements Special thanks to: Aaron Karat Michael Kimerling Vindi Singh

Addressing challenges in scaling up TB / HIV treatment integration Alison Grant London School of Hygiene & Tropical Medicine Africa Health Research Institute