1. 6 th Biannual Joint HIV Sector Review Meeting Nov 11-13,2014 Ministry of Health and Social Welfare Mwanaisha Nyamkara, NTLP Werner Maokola, NACP Nov 11, 2014 1

2. Overview Background Collaborative TB/HIV activities overview Achievements in TB/HIV interventions Challenges in TB/HIV interventions Conclusion 2

3. Introduction TB/HIV co-infection continues to be a public health problem –5-10% risk annually for developing TB Vs 5% in life time among non- HIV –HIV is a risk for drug resistant TB (Lancet 2006;368:1575-1580) –Increased TB mortality despite HAART (JAMA 2008;300:423-430) Global picture: –Up to 13% with TB were HIV + in 2012 (WHO, 2013) Tanzanian context: –PLHIVs developing TB: average 1-2% of CTC attendees (NACP, 2013) –HIV among TB patients: 37% (NTLP 2012) 3

4. Introduction HIV/TB co-infection by geographical regions 2012 4

5. Introduction… Tanzania adopted WHO guidelines for collaborative TB/HIV activities since 2007: Objectives for collaborative TB/HIV activities: Establish and strengthen the mechanisms for delivering integrated TB and HIV services Reduce the burden of TB in people living with HIV and initiate early antiretroviral therapy (the Three I’s for HIV/TB) Reduce the burden of HIV in patients with presumptive and diagnosed TB 5

6. Achievements Establish and strengthen the mechanisms for delivering integrated TB and HIV services –Coordinating bodies at all levels: National level: Biannual Coordinating committee meeting & Bi-annual TWG meeting Regional level: Regional coordinating committee meetings (quarterly) District level: District coordinating committee meetings (quarterly) Health Facility level: TB/HIV data sharing meetings (quarterly) –Integrated TB/HIV service delivery Joint supportive supervision Joint planning (GF NFM) Monitoring of TB/HIV interventions ART in TB clinics Isoniazid Preventive Therapy in HIV clinics 6

7. Achievements… Reduce the burden of TB in people living with HIV and initiate early antiretroviral therapy (the Three I’s for HIV/TB) –Intensified TB Case Finding (ICF) among PLHIVs TB screening during every visit to HIV clinics Presumptive TB evaluated following National TB diagnosis algorithm Average 93% of all CTC attendees in 2013 every quarter –Isoniazid Preventive Therapy (IPT) among PLHIVs Phased implementation First phase: 20 HFs in mid 2011 Scale up phase: Jan 2014 104 HFs with HIV care & treatment services and 10,178 initiated on IPT by June 2014 Target: PT in all HFs with HIV care and treatment services by 2017 –TB Infection Control Administrative, environmental and personal protection measures Consolidated in all health facilities with HIV and/or TB services 7

8. Achievements… 8 Reduce the burden of HIV in patients with presumptive and diagnosed TB –HIV testing and counselling in patients with presumptive or diagnosed TB HIV testing and counselling in all HFs with TB services 82% of all presumptive or diagnosed TB were tested for HIV in 2012 –Cotrimoxazole Preventive Therapy (CPT) for all TB/HIV co- infected patients CPT offered in all HFs with TB services to TB/HIV patients regardless of CD4 95% of TB/HIV co-infected offered CPT in 2012 –ARVs for TB/HIV co-infected patients Policy: TB/HIV patients initiated on ARV within 2 weeks of anti-TB Two models exist: ARV offered in TB clinics (in about 500 HFs) and TB to HIV clinic referral model (in the remaining TB clinics) 73% of TB/HIV co-infected initiated on ART in 2012

9. Achievements… 9 Reduce the burden of HIV in patients with presumptive and diagnosed TB… –HIV prevention interventions in patients with presumptive and diagnosed TB HIV testing and counselling offered in TB clinics Identified HIV positive linked to HIV care and treatment services including option B+ for pregnant women Condom distribution

10. Challenges 10 –National coordinating committee meeting has not been conducted Competing activities Flexibility with regards to the chairperson –Coordination meetings in regional, district and health facility level irregularly conducted Withdraw of donor support (PEPFAR) Planned for support from GF through NFM in high burden regions –Weak integration of TB and HIV programs Sharing of work plans between TB and HIV programs at regional and district levels-not regularly done Under utilization of TB/HIV officers at council level

11. Challenges… 11 –Slow IPT scale up Health providers factors: increased work load, IPT is a research, fear for Isoniazid resistance (Training, mentorship, supportive supervision) Patients factors: pill burden, same drug used for TB treatment, lack of knowledge on IPT benefits (continuous health education) Interrupted INH supplies: availability of INH, supply chain, roles and responsibilities in INH procurement at regional, district and health facility levels (Proper INH supply chain in place, roles and responsibilities defined) –Inadequate implementation of TB infection control measures Lack of willing ness to implement TB infection control measures among HCWs

12. Challenges… 12 –Low ART uptake among TB patients (Target: 100% of TB/HIV co-infected individuals initiated on ARV within 2 weeks of anti-TB) Health providers factors: awareness of new guidelines for the initiation of ARV in TB patients (Training, mentorship, supportive supervision) ? M&E system: Proportion of TB initiated on ART reported quarterly –Inadequate implementation of TB infection control measures Lack of willing ness to implement TB infection control measures among HCWs

13. Conclusion 13 –Need for strengthening coordination of collaborative TB/HIV interventions Conduct National coordinating committee meeting Coordination at regional and council levels (work plans, roles of TB/HIV officers) –Efforts to strengthen and scale up IPT –Increase uptake of ARV among TB patients Increase number of “under one roof” HFs Strengthen referrals