1. TB and HIV integrated services at Martin Preuss Centre in Lilongwe, Malawi : “The Lighthouse Trust initiative” Dr Sam Phiri Executive Director Lighthouse Trust, Malawi

2. The Lighthouse Trust Initiative Centre of Excellence for integrated continuum of HIV Prevention, Treatment, Care and Support 2 clinics: 1. HIV counselling and testing – 4, 000 clients/month 2. ART service provision 10,000 patient visits/month > 13, 500 patients alive on ART Integrated with TB, FP, STI, and PMTCT 3. Home- and community-based care 4. Capacity building National trainers in HTC, ART, palliative care Supports MOH in Supervision, mentoring and coaching

3. Martin Preuss Centre Located near bus station in Lilongwe, Malawi’s capital Malawi’s first integrated TB/HIV clinic (opened 2006) Purposeful building design to reduce infection transmission: – Outdoor waiting areas – External sputum submission unit – Separate TB & ART wings Collaboration between DHO and Lighthouse Trust

4. Martin Preuss Centre: front

5. Sputum submission process

6. TB Section

7. TB registry: HIV and TB services Largest TB registry: 3,600 patients per year ~ 30% of patients complete treatment at MPC Services provided by TB officers and clinical officers Standardized TB monitoring tools including HIV status, ART & CPT Opt-out provider-initiated HIV Testing & Counseling (HTC) for TB suspects and TB patients

8. TB registry: HIV and TB services CPT provided immediately following HIV diagnosis to all TB patients Standard TB regimen (6 months, rifampicin throughout) All HIV-positive TB patients initiated on ART regardless of CD4 count within TB registry as early as 2 weeks ART follow-up visits managed by TB clinical officers

9. TB registry: Outcome measures TB Patients registered 200820092010 Registered 441033472602 HIV status ascertained 91%95%96% TB cases managed at MPC HIV infected in need of ART 997 (77%)741 (71%)492 (62%) Initiated on ART 447 (45%)419 (57%)263 (53%) Total TB patients on ART 738 (57%)719 (69%)562 (71%)

10. ART clinic: HIV and TB services Electronic patients management system 7,032 patients on ARVs: 280 new per month Routine screening for TB among HIV+ patients at every ART follow-up visit since June 2009 Positive sputum cases are managed in the TB registry Patients on ART continue ART during intensive phase of TB treatment Patients on ART collect TB drugs within ART wing

11. TB cases in ART clinic N% ART patients 13,009 TB screened 12,80098 TB confirmed8337 On TB treatment79595 Incidence of TB is 7% per year Between June 2009 and September 2010

12. MDR TB PATIENTS CURRENTLY ON REATMENT

13. Challenges Protocol issues: – Data between paper and electronic records – Patient flow for TB/HIV co-infected patients Patient barriers: – High pill burden and side-effects – Complexity of information especially HIV+ individuals Case detection of M/XDR cases: – Delay in getting culture results – Lab infrastructure – Home Based Isolation difficult to monitor

14. Lessons learned Near complete ascertainment of HIV status is possible Training TB clinicians in ART management increases ART uptake Record HIV information for better clinical management of TB suspects and TB patients Monitoring and evaluation of integrated services requires time and effort, but can be done! – Training and consistent supervision is key

15. Next Steps Design and pilot a new EDS module for management of TB/HIV patients – Patient flow Strengthen our system to identify and follow up TB defaulters Intensify information and education sessions among TB patients

16. Acknowledgement