1. 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

2. 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

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

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

5. Evolution of TB caseload in Khayelitha ( all TB patients regardless of HIV status)
Tb incidence rate in 2003 was 1122/
36%
34 %
Source: Cape Town TB Control 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/

6. 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 women enrolled

7. 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

8. 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

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

10. 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 ( )
0.44 ( )
0.64 ( )
268 85 1
0.09 ( )
0.18 ( ) .
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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 ( p=0,905)

17. 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

18. 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

19. 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

20. 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 ?

21. 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

22. 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 ?

23. 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