1. Integration of TB and HIV Services A Case Study of Kericho District Hospital
Hellen Muttai, MBChB, MPH
Clinical Care Manager
South Rift Valley HIV Care & Treatment Program
Kenya Medical Research Institute/Walter Reed Project

2. Why Integration? TB Clinic HIV Clinic Patients Programmatic Clinicians
Patient’s hospital time
Double clinics, queues, drug prescriptions, sets of labs, different clinic days
Programmatic
Low uptake of collaborative services
Clinicians
Focusing on individual diseases in one patient

3. TB Treatment Completion
Integrated TB/HIV clinic opened July 2005
HIV Clinic
Out-patient
In-patient
Integrated TB/HIV Clinic
TB Diagnosis and Treatment (for both HIV negative patients
HIV Testing & Counseling (for all TB patients)
HIV Surveillance
TB and HIV Care & Treatment (for co-infected patients)
Co-trimoxazole Preventive Therapy
HIV Prevention
TB Treatment Completion

4. Methods Retrospective TB/HIV Clinic chart review
All patients seen in the clinic during a 18 month period
Advantage of electronic medical records system

5. Achievements Provider Initiated Testing and Counseling (PITC)
Total TB pts seen in 2006: 1226
Tested for HIV- 1155: Testing rate 94.2%
National PITC Uptake- 60% (2006)
Routine HIV surveillance among TB patients
HIV+ 525: Co-infection rate 45.4%
Routine HIV prevention services among TB and TB/HIV co-infected patients
Co-trimoxazole preventive therapy
100% uptake
National Uptake- 87% (2006)

6. Achievements Uptake of HIV Care and Treatment
100% of co-infected patients offered HIV Care and Treatment services
Eligible for ART- 78%
100% (of eligible) started on ART
(56.1% started in course of TB treatment; 22% started after completion of TB treatment)
National ART Uptake-26% (2006)
Clinicians tying the management of both diseases together
Reduction in time spent in hospital by patients

7. TB/HIV Clinic Summary Patients Enrolled = 792 (July 2005 to Dec. 2006)
Characteristic No. %
Female %
Age (yrs, mean/SD) (+12.3)
TB Characteristics
Pulmonary %
Smears done (PTB) %
smear – (smears done) %
Baseline CD4 (cells/mm3)
< % % %
> %

8. Treatment Outcomes for Co-infected Patients
Mean 6-Month CD4 Change (cells/mm3)
Care *
ART *
TB Treatment Outcome
No %
Completed %
Transferred out %
Loss to Follow up %
Deaths %
Total %
p value <0.001

9. Strengths/ Conclusions
PROGRAM/ CLINIC LEVEL
Successful management of co-infected patients with good clinical outcomes
Successful integration of TB and HIV services at a district hospital setting
High uptake of TB/HIV collaborative services
ANALYTIC
Patients with combined TB/HIV infections may receive benefit from:
primary TB treatment (“care”) alone
and additionally ART
Patients with combined TB/HIV infections often present with advanced HIV disease

10. Limitations
PRIMARY:
Inherent limitations in retrospective chart reviews
Clinic set-up not designed for systematic research
Incomplete/missing clinical data

11. Recommendations
Integration of TB and HIV services needs to be considered in health facilities in order to improve uptake of collaborative services
Clinicians treating patients with TB/HIV should be aware of the benefit to HIV infection by treating TB and offering supportive care alone, and additionally ART.
Efforts to identify patients with TB/HIV early in their disease may offer tangible benefit by providing the opportunity to consider early ART.
Further controlled studies are needed to best identify when (and what settings) to initiate ART in patients receiving TB treatment.

12. Acknowledgements Kericho District Hospital TB/HIV Clinic
Kenya Ministry of Health/NLTP/NASCOP
President’s Emergency Plan for AIDS Relief
Kericho District Hospital - Eunice Obiero
KEMRI – Fredrick Sawe & Charles Sigei
USMHRP – Douglas Shaffer, Tiffany Hamm
Brown University – Jane Carter
The Kericho HIV cohort study is an important Epidemiological study with a wealth information unique to HIV in rural, East Africa.
I appreciate the opportunity to present our data today, and I am thankful to many collaborators:
Dr. Debbi Birx is the founder of the Kericho site and remains a strong advocate of HIV research as well as HIV care and treatment now throughout Africa in her new position as the CDC/GAP Director.
Most importantly, I have the honor to work with remarkable Kenyan colleagues and friends who are the backbone of this study and the larger program: particularly, Dr. Fred Sawe, Dr. Robert Kimutai, and Dr. Stanley Kiplangat among others.
Thank you.