HATIP asked a panel of experts with experience in TB/HIV in concentrated epidemics about lessons learned implementing individual TB/HIV services in these settings. One repeated theme was the importance of conducting pilot studies and then using the results to leverage policy change. Another was the importance of HIV surveillance among TB patients.
The ability of the TB programme to test TB patients for HIV has been crucial to the success of TB/HIV collaborative services, according to Dr Beena Thomas of the Tuberculosis Research Centre in India who said that now that the programme had gotten past that “unnessary apprehension about HIV testing” there has been “speedy progress to where we can talk about integration of services.”
On HIV testing and counselling for TB patients as a collaborative activity : The current policy in India is for routine referral of all TB patients for HIV testing in settings implementing the intensified package; this works well where there are almost as many HIV testing and counselling centres as microscopy centre (and they are collocated).
But in other settings not yet implementing the intensified package, 'selective referral' is recommended — as per WHO guidance, in which all TB patients should be evaluated for HIV risk factors, and referred for testing if any are present.
“In many ways, if you have HIV testing available in the same health facility or in an accessible location, routine referral for HIV testing is easier to implement than selective referral,” said Dr Dewan. “One observation from India is that HIV risk assessment is very difficult to implement in typical, crowded outpatient settings; privacy is limited, risk-assessments can be time-consuming, providers are uncomfortable asking about HIV risk behaviours, females are routinely accompanied by family members, and monitoring of selective referral is not usually possible,” Dr Dewan told HATIP.
One has to wonder about the accuracy of such risk assessments in this context. However in a study where selective referrals took place simultaneously with a population-based survey of HIV infection among TB patients, about 82% of the expected HIV-infected population were identified by selective referral.23 However, this was only one sample and may not be representative of the entire country. Furthermore, risk assessments may not pick up the risk factors of wives who are unaware of their partner’s risk behaviour.
Another concern is whether people with active TB who have to travel to be tested for HIV will bother to do so when they are ill.
“The whole concept of HIV testing sites is problematic and an important barrier to care that needs to be addressed even in low HIV-incidence settings,” said Dr Varma. He cited a recent study that he was engaged in, in Cambodia, which found that people were half as likely to get tested when the HIV testing site was more than 15 minutes from the TB clinic as when onsite testing was available.24
“Even when there are relatively few HIV-positive patients, the consequences of HIV infection among TB patients are so important, and the mortality rate so high, that universal provider-initiated HIV testing and counselling is recommended in all the countries we work with [Thailand, Cambodia, Vietnam],” Dr Varma said. “HIV testing within TB care settings is an important measure to remove the barriers of referral to special VCT centres, and normalising HIV testing in this manner needs to continue to be pushed.”
Dr Thomas believes that the pre- and post-test counselling in VCT may actually be stigmatising, and is a disincentive to testing. “Why have we made HIV screening among TB patients such a big issue, with pre-test counselling, post-test counselling? But if there is still the wide consensus that counselling is required, this facility should be made available at TB clinics as well, [and not] confined only to HIV clinics. HIV and TB services need to be integrated to be patient friendly with them being accessible and available, preferably in the same premises.”
On the provision of cotrimoxazole : Although the pilot study by Raizada et all reported that in the pilot study cotrimoxazole was started in almost all the TB patients with HIV who were not already on it, the Joint Review found that cotrimoxazole was not always available at the general health facilities in many states. Adherence could have been better in the pilot study as well. Overall 351 (48%) collected more than 60% of the number of monthly cotrimoxazole pouches provided. The authors added that “anecdotally, we observed that the on-site availability of cotrimoxazole at primary health centres appeared to motivate providers to assess the HIV status of TB patients.”
Dr Varma agreed that dispensing cotrimoxazole at TB clinical settings improves uptake.
On the provision of ART to people with HIV on TB treatment: Linking of HIV-infected TB patients to ART is the greatest challenge we have in TB/HIV collaboration today,” according to the RNTCP site .
“For ART, the need to refer from TB to HIV care settings results in delays and losses to follow up,” said Dr Varma. “For example, in Vietnam a recent review of PITC scale-up to 14 provinces showed: 78% received cotrimoxazole preventive therapy, 59% were successfully referred to HIV care facilities, 24% had a documented CD4 cell count, and 27% received antiretroviral therapy during TB treatment.”25
However, losses during the referral process are only half the story. “In operational research in India conducted by TRC Chennai and NTI Bangalore, most HIV-infected TB patients actually did reach the ART centres in the study districts, but there was a gap between reaching the ART centre and initiating ART. Simply put, just reaching the ART centre is not enough… so perhaps we need to go back and understand the patient's perspective better,” said Dr Dewan.
India plans to both expand the number of ART centres and decentralise many of the ART functions (such as the decentralisation of ART screening and ART refills and care to those already on ART) to “Link ART centres” at the sub-district levels where service needs are greatest. These will be situated at select ICTCs that have detected and referred more than 50 patients at any ART centre.
Linkages to HIV services in low HIV prevalence districts are especially poor — and even in high prevalence districts, the ART centres are still centralised at the district hospital level.
Dr Haileyesus Getahun of WHO’s STOP TB Department told HATIP that the Joint Monitoring Mission of India’s Revised National TB Control Program also found that “access of ART to HIV-infected TB patients is still limited and dismal in most instances. The ongoing efforts to decentralise ART services and functions are very encouraging and need to be aggressively pursued. But as we all know in many of these countries — including in India — there are more TB diagnosis and treatment facilities than ART facilities. Therefore, using the existing and decentralised TB services and facilities for expanding HIV prevention and treatment services including ART for the millions of patients and clients attending these services should be now explored and aggressively pursued."
Dr Swaminathan agreed. “We need to explore ways of decentralising ART in order to reduce delays and improve access for patients. However, the challenge is not just the delivering the medicines but also clinical management, staging of HIV, CD4 testing etc. India has a good primary health care service network - doctors are not always in place but nurses, lab technicians and pharmacists are. One of the strengths of the TB control programme is that it operates through the general health care services.”
“It may be worth piloting an ART decentralisation exercise - as was done for cotrimoxazole and PITC in a few districts. We could even explore the possibility of having a patient-selected `DOT provider` or an `accompagnateur` from the village being a treatment supporter. We will learn important lessons and can then go forwards,” she concluded.
According to Green, in Indonesia, “a small but increasing number of community health centres offer VCT and are able to manage ART, at least following initiation at a referral hospital. This reduces waiting times. In addition, a number of old dedicated 'lung clinics' have set up HIV services, again offering VCT and ART management. Several continue to treat patients on ART after their TB treatment has finished, to ensure continuity.”
He added that “an increasing number of prison clinics are able to manage both TB and HIV including ART —and some even encourage prisoners to continue treatment at the clinic after release, at least to complete TB treatment.”
On HIV prevention among TB patients: The Policy on Collaborative Activities recommends that TB programmes should develop and implement targeted comprehensive HIV prevention strategies for their patients (or link to HIV/AIDS partners or non-governmental organisations (NGOs) with prevention programmes), offer STI screening, referrals to programmes to prevent mother-to-child transmission and so on. However, effectively targeting these services may be more of a challenge in concentrated epidemics.
India’s National Framework suggests that key RNTCP field staff and all general health care providers should ‘generate awareness’ amongst their TB patients. It leaves more specific prevention interventions to NGO partners. As Dr Getahun suggests however, the availability of so many TB service facilities affords a great opportunity for expanding HIV prevention services. The RNTCP site notes that it is developing partnerships with NGOs such as the Avahan Initiative, a large-scale HIV prevention project, primarily to deliver enhanced TB screening services for commercial sex workers, injection drug users, men who have sex with men, and other marginalised populations who may face access barriers in the general health system. Perhaps these partnerships should be bidirectional, with Avahan and other NGOs getting the TB programme to add HIV prevention to its portfolio of services.
On the 3 I’s: HATIP has previously reported on the important work being conducted on intensified case finding in India and in a US CDC regional study in Thailand, Cambodia and Vietnam. Dr Varma told HATIP that the results of this study are now in press. Findings included that chronic cough is insufficiently sensitive as an initial screening question, but a combination of symptoms can be quite sensitive; and that sputum liquid culture will be required in the majority of symptomatic persons in order to reliably diagnose TB.26 The results from this study have been incorporated into new guidelines in all three countries and the feasibility of adding significantly more liquid culture diagnosis is being assessed.27
Isoniazid preventive therapy is in the pilot project stage in all 3 countries as well, according to Dr Varma. Likewise, India is also planning an operational IPT study at five ART centres, and performing a clinical research study to determine an optimum regimen (isoniazid alone versus isonizid plus ethambutol) and duration of treatment.
“TB infection control is nascent, with some trainings held and development of revised guidelines underway,” said Dr Varma.
According to RNTCP sources, TB facilities in India tend to be older, well-ventilated buildings but the same is not true for all ART centres that were installed into existing medical colleges. These centres are frequently very crowded during morning clinic hours, serving hundreds of HIV-infected persons within a few hours. Meanwhile, HIV testing and care centers often fail to perform triage that would promote infection cotnrol according to findings of the Joint Mission. As in other countries, TB transmission is almost certainly occurring in these HIV service facilities.
However, there have been some improvements. Nationally, infection control guidelines are being revised and there has been an increase in staff training in infection control. The Joint Review observed good practices of TB infection control measures in some ART centres which had open and well-ventilated environments and a system of triage of TB suspects for prompt diagnosis. However, these improvements need to be made consistently across the entire NACP.
Green told HATIP that conditions are similar in Indonesia. “Counselling rooms are often enclosed, and if ventilation is provided, it is as often likely to increase the risk for the counsellor as to decrease it. PLHIV are increasingly being used for counselling and peer education, and are thus at significant risk. As noted, waiting areas, particularly in modern facilities (including urban community health centres) are often enclosed with little ventilation, and with sick people having to wait for hours.”
“Airborne infection control is tough, but national guidelines are under preparation,” said Dr Dewan. “With infection control, however, policy is the easy part. Perhaps implementation success can be achieved by making airborne infection control measures part of universal precautions, by building environmental requirements into building codes and standards for health care facilities, and by synchronising efforts with infection control efforts required for pandemic influenza. There's no need to train the same health care facility staff once for pandemic influenza and again for TB infection control activities when many of the same day-to-day measures apply to both.”
Green agreed: “Avian flu and flu A (H1N1) —swine flu — are adding to the list of other more urgent challenges which face countries like Indonesia with concentrated HIV epidemics. Yet the infection control measures are similar. Could we not at least try to take advantage of these epidemics to raise the level of awareness of cough etiquette and general healthy living, which could benefit TB infection control?”
Green also highlighted something everyone else neglected to mention: “HIV is mainly concentrated here among drug users, and these tend to end up in congregate settings: rehab centres and the prison system. The prisons in which they end up are usually three to four times over capacity, so the risk of a TB epidemic is high. On the plus side, many are airy and well ventilated, the prison management and staff are generally informed about HIV and TB, and the clinic staff are well aware of the risks. Again, an increasing number of prison clinics are able to manage both TB and HIV including ART - and some even encourage prisoners to continue treatment at the clinic after release, at least to complete TB treatment.”
“Rehab centres are another matter, with smaller numbers but often equally crowded. Management may not have any training or knowledge of either HIV or TB, and rarely have any medical staff. I suspect this will be the next challenge, especially following a recent Indonesian Supreme Court decision requiring first-time drug-use offenders to be offered rehab.”