But that, unfortunately, appears to be the limit of HIV services offered to TB clients diagnosed with HIV in many settings.
“CPT, because it is provided at the DOTS centre, in some cases is actually the only anti-HIV/AIDS treatment that somebody that is dually infected has access to in the course of their TB treatment because of the distance to the ARV centre,” said Dr Omoniyi.
There are relatively few HIV clinics (at present, only about 240 that can dispense ART) spread across the country, serving a population of over 3 million people with HIV, compared to thousands of primary healthcare clinics.
The Population Council survey of TB and HIV clinics in Gauteng, Northwest and Mpumulanga provinces of South Africa made a similar observation: “ART services are offered at far fewer points than TB services, which can be accessed at primary health centres,” wrote Maphanga et al.
In the case of Nigeria, what is even more worrying is that patients aren’t referred to the HIV clinics until the very end of TB treatment, which in that country goes on for up to 8 months.
Many programmes are beginning ART sooner in the hope that it will improve outcomes. But survival is poor even when people with TB and HIV have early access to ART, according to a poster describing the provision of ART to seriously ill in-patients at Nkqubele TB Hospital in the Eastern Cape (Verkuijl). With ICAP’s assistance, since September 2006, TB hospital began staging patients who test positive for HIV. In-patients who have CD4 cell counts below 50 and/or serious stage IV diseases are started on ART while still on the intensive phase of TB treatment (two months for new cases and three months for retreatment cases), while those with CD4 cell counts between 50-200 are prepared for ART, aiming to begin treatment at the nearest ART clinic immediately after discharge (during the less intensive phase of TB treatment).
But even with aggressive treatment, mortality remains high: 16% during preparation for ART and 21% after starting ART (compared to an overall mortality of 24% for the hospital during the same period). (It should be noted that immune reconstitution inflammatory syndrome (IRIS) and drug-resistant TB were a problem in this population).
“Many co-infected are admitted in a very poor clinical condition,” wrote the poster’s authors, and they recommended that ART should be initiated early in any in-patient with less than 100 CD4 cells.
Dr Omoniyi acknowledged that people with TB/HIV in Nigeria often don’t survive to complete the referral to the HIV clinic and make it onto ART, so he recommended that the “available human resources at facilities providing DOTS services — which are mostly at primary healthcare centres that are very close to the people — should be leveraged to provide ARV services for those without access to these services.”
But to achieve this, most countries would have to either use clinical eligibility criteria for ART, (WHO clinical staging) and/or treat all patients coinfected with TB/HIV, since CD4 cell count monitoring is unavailable in most primary healthcare clinics, or invest in strengthening the laboratory and probably the human resource capacity at the primary healthcare level.
This approach works in some programmes (see below)— but it cannot be done everywhere.
For example, using a public health approach, Malawi has set up 200 ART clinics in public and private facilities, often staffed only with trained nurses, and has put 100,000 people on ART — an impressive accomplishment from one of the most resource-challenged countries in the world.
TB treatment isn’t really provided by primary health clinics in Malawi, however. Instead it is initiated at 48 centralised facilities, and treatment continuation is decentralised to 600 facilities. People with TB/HIV automatically qualify for ART, unless they have high CD4 cell counts (and CD4 cell monitoring isn’t widely available).
In Malawi, the goal is to get people onto treatment, and ART is supposed to begin two months after initiating TB treatment. But ART simply cannot be prescribed at the TB continuation clinics that are run by non-medical staff (like social workers/government officials).
So at present in Malawi, people with TB/HIV must be referred to the ART clinics — with mediocre uptake.
“Sixty percent of our TB/HIV patients don’t get on ART,” said Dr Kalulu. It should be noted however that only a few programmes in the world are reporting higher rates (see later in the article).