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

2. Disclosures
No disclosures

3. 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

4. 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

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

6. Why is there a problem? TB HIV
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7. 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

8. 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): e
Odone PLoS One 2014; 9(11): e

9. WHO policy on collaborative activities

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

11. Percentage of new and relapsea TB cases with documented HIV status, , globally and for WHO regions

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

13. 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,
Estimated HIV-positive new and relapse cases
Reported cases
Reported cases on ART

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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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?

21. 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

22. 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

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

24. 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

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

26. 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): e
Hanifa, 4th SA TB conference

27. 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 2
 25
CD4
< 200 1
 350
Number of WHO symptoms
 1 4
TOTAL SCORE + =
Hanifa PLoS One 2017; 12(8): e

28. 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?

29. 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

30. 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

31. 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

32. What matters?

33. Acknowledgements Special thanks to: Aaron Karat Michael Kimerling
Vindi Singh

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