Integrated TB-HIV Services at PSI Clinical Social Franchise Network (Myanmar) Dr. Phyu Phyu Swe Health Services Manager (TB) Population Services International/Myanmar 25 July 2012

Presentation outline TB & HIV situation in Myanmar National strategic plan for TB-HIV services integration PSI/Myanmar health service system Integration of TB-HIV service at PSI franchised network Achievement Challenges/Lessons learnt Future plan

TB & HIV Situation in Myanmar CHINA LAOS THAILAND INDIA BANGLA DESH KACHIN SHAN SAGAING CHIN RAKHINE MANDALAY MAGWE BAGO AYARWADDY YANGON KAYIN KAYAH MON TANINTHARYI One of the 41 high TB-HIV burden countries HIV prevalence among TB patients (2010) 10.4% TB prevalence among PLHA (2010) 30-40% Population - 57 millions Regions/States - 14 Townships - 330 Estimated incidence all forms (2010) 384/100,000 pop. Estimated prevalence of TB (2010) 525/100,000 pop. Estimated TB mortality (2010) 41/100,000 pop. (Global TB control: a short update to the 2010 report, WHO, Geneva. 2011) According to 2009-2010 National TB prevalence survey: - TB prevalence is 2 - 3 times increase than previous expectation Detected only 60% Nearly 50% of TB cases detected in survey showed no classical TB symptoms Global TB control, 2011 , HSS 2010

National strategic plan for TB-HIV services integration (2012-2015) Goal: To reduce the burden of HIV-related TB to achieve the 2015 MDG target Plan to scale up to all townships & public hospitals by 2015 Collaborative TB/HIV activities by NTP & NAP started in 2005 in 7 Townships and reached 17 district/township & 1 public hospital in 2011 Based on partial integration and cross referral Scale up plan for 2012-2015 Scale-up 2011 2012 2013 2014 2015 # of new townships per year 17 28 31 70 182 # of new hospitals per year 1 8 24 # of new townships and hospitals 18 36 54 70 182 Cumulative # of townships and hospitals 18 54 109 179 361 Targets by 2015 Impact target the number of TB deaths among people living with HIV is reduced by 50% compared to a baseline of 2004 Coverage targets 100% of TB patients with an HIV test result recorded in the TB register 100% of HIV-positive TB patients receive CPT during TB treatment 100% of HIV-positive TB patients receive life saving ART 100% of PLHIV enrolled in HIV care, including in PMTCT care and in harm reduction services, are screened for TB 100% of eligible PLHIV newly enrolled in HIV care are started on IPT 100% of health care facilities providing services to PLHIV with demonstrable TB infection control practices. 4

PSI/M Health Services System Two tiered social franchise network Case management Health talk Referrer Primary care SQH only SPH only SUN (SQH+SPH) SQH: Sun Quality Health SPH: Sun Primary Health

Sun Quality Health Social Franchise model Technical support Product IECs Affordable services to Health impact Healthy behavior PSI provides quality products with highly subsidized price, technical support and other necessaries like IEC to Sun doctors and then they provide them to consumers with agreed price which is affordable to poor people. PSI/M launched PPM-DOTS program in 2004 with the support of MoH. Unlike the other programs, all services & products related to TB are FOC. Franchiser Franchisee Consumer Monitoring & Supervision Fractional franchise system

Integrated Approach…… PPM-DOTS ART PICT 2001 2003 2004 2007 2008 2009 2010 RH STIs Pneumonia U5 children Malaria

Achievement of PPM-DOTS program 12.1% 7.6% 11.5% 8% NTP + PSI 7.6% NTP only 5.1% 2.3% MIS data

TB-HIV Integration PPM-DOTS STIs RH Referral voucher to PSI/VCT CPT ART PPM-DOTS PICT 2001 2003 2004 2007 2008 2009 2010 STIs Pneumonia U5 children RH Malaria

Provider Initiated HIV Counseling & Testing (2010) PICT Start voucher system HIV prevalence among TB patients – 9% MIS data

Achievement of TB-HIV Integrated Service (1%) (8%) (11%) (21%) (26%) 107 (2%), 1346 (32%),1897 (43%) coverage – 3% of total TB registered case HIV prevalence – about 20% As of April 143 out of 862 SQH clinics provide PICT MIS data

One Stop Service For TB-HIV ART DOTS CPT PICT 7 SQH clinics + 2 PSI/VCT 50 PLHA 143 SQH clinics 862 SQH clinics

Challenges “No ART if we found positive client” (SQHC) Double stigma Time consuming ART inavailability Data burden Client awareness on TB-HIV co-infection Funding for sustainability & expansion “We are busy we can’t afford time” (SQHC) “I dare not face the positive result” ” I don’t need the test” (Client) PSI’s qualitative research on PICT service May 2012

Future Plan Expand PICT to cover 80% of TB registered cases at Sun clinics access the HCT service by 2015 Continue CPT for TB-HIV co-infected patients Integrate ART program to PICT clinics Strengthen ACSM activities Strengthen referral network Sustain collaboration with NTP, NAP and other partners

Thanks