1. 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

2. Outline
Disease burden
2015 performance
Challenges and successes

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

4. Notified TB cases

5. 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

6. 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.

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

9. 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.

10. 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.

11. 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.

12. Challenges in confirming TB diagnosis in PLHIV-2015

13. 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

14. 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.

15. 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

16. 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

17. 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