1. Integration of TB and HIV Services: Experiences from the Kericho District Hospital Charles S. Kiptemas, MBChB, MPH Director South Rift Valley HIV Care & Treatment Program Kenya Medical Research Institute/Walter Reed Project Track 1.0 ART Program Meeting: Willard Intercontinental Washington, D.C. Track 1.0 ART Program Meeting: Willard Intercontinental Hotel, Washington, D.C. August 11-12, 2008

2. Background Need for integrated TB & HIV services 1 patients/2 diseases 2 clinics/2 ques/2 clinicians/2 treatment regimens Intensified case finding – recognized potential for overloading very busy and overwhelmed clinics -Identifying TB in HIV clinic -Identifying HIV in TB clinic Aim: integrated TB/HIV clinic Cadre of clinicians capable of treating both diseases in TB clinic HIV care provided in TB clinic through at least intensive phase Goal: improved patient care

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

4. TB/HIV Clinic Characteristics (2005-2007) Cohort size (n)1,220 Age (mean, years)31 Female 53% Pulmonary TB 86% Sputum positive 41% PITC 94% TB-HIV coinfected54%

5. TB/HIV Clinic Baseline CD4 78% eligible for ART

6. TB/HIV Co-infected Treatment Outcomes* Mean 6-Month CD4 Change (cells/mm 3 ) Care +78 ART +139 TB Treatment Outcome Completed64% Transferred out 11% Loss to Follow up 14% Deaths 11% * Data presented on subset n=792

7. Intensified Case Finding Identifying TB in HIV clinic symptom algorithm CXR cough monitors Identifying HIV in TB clinic PITC Contact tracing / case finding -Family who can come to clinic -Future contract tracing to home

8. TB/HIV Clinic Observations 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. 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.

9. Limitations/Strengths Primary Limitations: Inherent limitations in retrospective chart reviews: -Clinic set-up not designed for systematic research. -Incomplete/missing clinical data. Strengths: Advantage of electronic medical record system in TB/HIV clinic where data accuracy can be verified against original clinic record. Findings should be considered descriptive in nature; however, value of such descriptive data should not be overlooked in the early development of such TB/HIV programs.

10. Recommendations/Way Forward 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. The Kenya team plans to roll out integrated TB/HIV clinic experiences from KDH to remaining district level ART treatment facilities in Southern Rift Valley.

11. Acknowledgements Kericho District Hospital TB/HIV Clinic Kenya Ministry of Health/NLTP/NASCOP Kenya Ministry of Health/NLTP/NASCOP Presidents Emergency Plan for AIDS Relief Presidents Emergency Plan for AIDS Relief Kericho District Hospital - Eunice Obiero Kericho District Hospital - Eunice Obiero KEMRI – Fredrick Sawe & Jonah Maswai KEMRI – Fredrick Sawe & Jonah Maswai USMHRP – Doug Shaffer, Tiffany Hamm, Nelson Michael USMHRP – Doug Shaffer, Tiffany Hamm, Nelson Michael Brown University – Jane Carter Brown University – Jane Carter