The services to reduce the burden of HIV among people with TB are much more self-explanatory. However, some countries and projects were much more successful at scaling them up than others. Some of the successes and failures and ongoing challenges are described below.
1) HIV testing and counselling
Without HIV testing and counselling, countries will never recognise the true scale of the burden of HIV and TB coinfection, and people with TB who are coinfected with HIV will go unrecognised and untreated.
Repeated again and again at the Implementers Meeting, far and away, the most critical enabler for the success of TB/HIV service scale-up at various sites was provider-initiated HIV testing and counselling. Without it, the turn-around in the programme in Kenya, Rwanda, Mulago Hospital and other sites would not have been possible.
“One of the key landmark things that happened in Kenya was setting the policy for provider initiated HIV testing in clinical settings,” said Dr Chakaya. “Before 2004, all of our TB patients were being referred to VCT sites for HIV testing and with a lot of problems. But in 2004, the Minister of Health came up with a policy document on HIV Testing in Clinical Settings which [said] that: ‘if you don’t offer HIV testing to persons presenting with an HIV-associated illness, then you are providing, as a clinician, a sub-standard care.’”
“That statement was extremely prominent in that document, and it made a lot of difference. No clinician wants to offer sub-standard care,” he said, noting that it was reinforced in trainings. “It was a major, major event that really, really paved the way for a lot of testing of TB patients.”
In other countries, however, programmes continue to rely on VCT. Unfortunately, even though it is easy enough for TB clinic staff to recommend VCT, most people don’t follow through on the referral.
“VCT uptake initially was very poor in the Richmond Hospital,” said Dr Uys, “Because we had to use the voluntary counseling and testing approach because of the ethics requirement. It increased temporarily when we increased group counselling sessions but then relaxed unfortunately.”
The proportion of people with TB who actually get tested in the Richmond programme is only 30%. And this is higher than reported by some other posters at the South African AIDS Conference. For instance, after intensive training of nurses by the excellent Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA PLUS) programme, VCT uptake among TB patients more than doubled — but only from 10.1% to 21.2% (Fairall).
The experience of a TB/HIV collaborative programme set up to in Jakarta, Indonesia is also telling.
“There has been some hesitation to introduce testing and counselling for HIV in the TB programme (PPTI), due to the worries that it will become a double stigma, and reduce TB detection, reducing people from coming in for TB treatment,” said Dr Flora Tanujaya, a senior clinical officer for Family Health International in Indonesia
But in September 2004, they set up a VCT site at the TB clinic (and a variety of other collaborative services for people with HIV). But during the first few months, hardly anyone they referred used it (around 14% uptake overall, about 30% among those who attended an HIV education session). So for 2005, they adopted an opt-in approach. Nothing changed. In 2006, they introduced an educational video that increased access to the HIV education session to 100%.
“But still, the uptake for pre-test counselling (and testing) was only around 30%,” she said. “It is time for an opt-out strategy, but we are waiting for the national policy to change.”
Changing the national policy includes changing who is allowed to conduct the HIV test. In some settings, non-laboratory staff (including nurses) are not authorised to perform rapid HIV tests, in others medical staff can perform the test but trained lay counsellors cannot.
HIV programme have in some cases been unwilling to give up HIV testing to TB programmes, resulting in delays in the scale up of collaborative activities. But the conclusion of one roundtable discussion at the PEPFAR/WHO meeting was that HIV testing should be available at every TB microscopy site.
One final point that was often repeated at the HIV Implementers’ and PEPFAR/WHO meeting is that HIV testing should be performed on all TB suspects — not just the TB patients. Several teams noted that other HIV-related conditions often turn out to be the reason why someone is referred to the TB clinic.
2) HIV prevention methods
With training and steady supply of materials, most integration sites were able to introduce and implement comprehensive HIV prevention strategies for their patients.
Aspects that programmes may still need to attend to include providing their clients with, or providing referrals for PMTCT, sexually transmitted disease screening, and family planning services.
3) Cotrimoxazole prophylaxis
Most TB programmes at the conference reported little difficulty in introducing cotrimoxazole preventative therapy, other than occasional supply chain management problems, and a lack of an alternative to cotrimoxazole (such as dapsone) in case of contra-indications in the DRC.
4) HIV/AIDS care and support
TB clinics may need to bring on more staff if they are providing integrated HIV/AIDS care and support services (rather than referring patients to the HIV clinic).
“Counselling and support for patients who are concurrently taking anti-TB drugs and ART requires a lot more support. They usually are very ill and there are more reports of missing pills and trying to switch round the timing for taking medications amongst these patients, so they need a lot more support,” said Dr Wanyenze. “Because there was increased workload in terms of counseling and preparing patients for ART, for example, and for the lab investigations, we had to bring in some additional staff there to help them.”
“We used some of the resources that we received from PEPFAR to hire additional personnel,” she said.
5) Antiretroviral therapy
TB programmes have had mixed success getting their coinfected patients onto ART, depending largely upon whether they rely on referrals to existing ART clinics or are able to initiate it themselves. In the DRC, about 7% of people who were referred got onto ART, while at Kericho District Hospital, 100% did (although for a small proportion it was after they had completed TB treatment.
But for obvious reasons, every TB clinic in high burden countries cannot offer ART right away — so referrals continue to be necessary. But this causes problems when TB clinics are more decentralised than ART clinics.
“Although the absolute numbers of HIV-infected TB patients receiving ART has increased tremendously, the proportion of HIV-infected TB patients not receiving ART is not declining,” said Dr Chakaya. “TB services have been decentralised… but ARV treatment sites have not yet decentralised to the same extent. We believe that may be the major reason why a lot of our TB patients who are HIV infected, are not yet receiving ARV treatment,” said Dr Chakaya.
Another issue is when exactly to initiate ART in people who present with TB and HIV. Policies differ by country, but the system at Kericho District Hospital seemed to work fairly well.
“Initially, on the first day when they are found to be coinfected, we take a baseline CD4 and a baseline work-up and we start them on TB treatment and tell them to come back after two weeks,” said Muttai. Family members or friends are counselled to provide the patient with DOTS.
“At two weeks, we review their HIV results and give them their TB refill. If the CD4 count is very low, we want to initiate ART right away but we give them a minimum of two weeks in order to observe whether they are doing well on their TB meds, and that way if there are any side effects on ART later, you will be able to make a clinical judgement whether it is the TB or HIV meds that are causing it… When they complete their TB treatment then we hand them over to the HIV clinic,” she said.
Continuing to treat someone with HIV and cured TB at the TB clinic could clearly put them at risk of re-exposure to TB, so most programmes recommend referring people on ART to their most convenient TB clinic. But this has proven somewhat tricky in some cases.
“We have had some challenges with the transferring out of patients after they have completed TB treatment,” said Dr. Wanyenze. “They get attached to the clinic and they get a bit uncomfortable with transferring out.”