While not always conducted on a
grand scale, a number of studies reported both successes and challenges for
TB/HIV integration in different programmes and types of facilities.
Integrated HIV and TB screening services
Dr Sue-Ann
Meehan of the Desmond Tutu TB Centre described how TB screening has been
integrated into HIV counselling and testing services in Cape Town, and how HIV counselling and
testing was taken out into the commun ity in order to reach groups with low
testing rates, particularly men.5
Nine outreach
sites were established (in shipping containers, rented property or mobile
caravans) at non-medical sites in high burden communities.
After going
online, these proved to reach a much larger and notably healthier population. During
2008-2009, 34,287 clients accessed the testing services — 80% of whom were
accessed through outreach, and 47% of these clients were male. 26,262 (95%)
consented to be tested for HIV at the outreach sites— compared to only 6325 who
consented to be tested at the main Desmond Tutu TB Centre Site.
Nine per cent
of the total population tested HIV positive — 8% at the outreach sites and 15%
at the main site. However, only 1093 of the 1997 who tested positive at the
outreach sites accessed HIV care and treatment services, and 588 of the 922 who
tested positive at the clinic site.
Every client
was also given a symptom screen for TB, and 11% turned out to be symptomatic
for TB (10% at the outreach sites, and 17% at the main site). About 187
ultimately received an ‘early diagnosis’ with TB, 142 of whom accessed
treatment.
Among the
clients who tested HIV positive, 529 were symptomatic, only 340 (64%) had a
diagnostic evaluation. 37 (11%)
were diagnosed with TB, and 30 (81%) accessed treatment.
Having both
types of sites proved complementary since the outreach sites could “reach
populations that don’t usually access HIV counselling and testing”, said Dr
Meehan. “However, there are more challenges that exist getting this population
into care.”
Indeed, this is a situation where a strong partnership with patient networks could
improve linkage and retention in care. For example, other community members
could be hired and employed as part of the health team, to provide adherence
and follow-up support. As noted in a previous issue, another outreach group
performing both HIV and TB screening in South Africa assigns each person
who tests positive to an expert patient/community worker —which considerably
improved links to care.
The 'one stop shop' model in Uganda
If diagnosed
coinfected patients do make it into care, they are more likely to be retained
if high quality treatment services for both illnesses can be conveniently
delivered at the same site.
Accordingly, Dr
Sabine Hermans, of Makerere University and the Amsterdam Institute for Global
Health and Development, the Netherlands, reported on the performance of a
‘one stop shop’ model integrated TB/HIV clinic, established at the Infectious
Diseases Institute — a very large urban outpatient HIV clinic serving around
15,000 patients in Kampala, Uganda.6
Previously — even though medical officers
could diagnose TB during routine follow-up visits, the clinic was not
performing TB screening and diagnosis systematically. If a client was diagnosed
with active TB they would have to report to a TB nurse based in the pharmacy,
who provided them with treatment and follow-up.
In December 2008, however, the clinic set up an
outdoor integrated ‘one-stop shop’ TB/HIV clinic in the Institute’s grounds,
where TB suspects and patients diagnosed with TB could access care for both
diseases simultaneously.
A trained team of two medical officers, two nurses and
a nurse-counsellor provided care. Once TB treatment was completed,
the patient would be referred back to the general HIV clinic.
To try to
assess how this one stop clinic is affecting outcomes, data were compared on
ART initiation in clients with active TB in 2009 and 2007 (before the one stop
clinic was established). In 2007, 161 coinfected subjects were identified,
compared to 130 in 2009. Baseline characteristics (CD4 cell count, etc) were
similar at TB diagnosis in both periods.
Fewer treatment-naive TB patients were initiated on
ART in 2009 than 2007 (56 and 66%,p=0.03), but Dr
Hermans noted these were all people with CD4 over 250 (who didn’t
meet the criteria for starting ART during that period). However, in 2009,
significantly more people started ART while they were still on TB treatment
(94 vs 81%, p=0.001). In fact, most clients (60%) started ART during the
intensive phase of TB treatment, as recommended by WHO. The median time to ART
initiation fell significantly from 101 (IQR 63, 204) days in
2007 to 44 (IQR 21, 105) days in 2009 (p=0.01). Most of the early initiation of ART occurred
in patients with CD4 counts below 100 at TB diagnosis.
“When looking at outcomes: overall, survival and
retention improved,” said Dr Hermans. However, this wasn’t due to improvements
in response of those put on earlier ART — there was no significant difference
in survival between ART-treated patients in 2009 and 2007 (83% vs 80%).
In fact, the improvement in survival occurred in the
group of patients who were not initiated on ART: 52% of whom survived in 2009
versus 33% in 2007 (P=0.015).
This improvement in survival certainly
wasn’t explained by those in the lowest CD4 count strata (below 100) who all
died or got lost to follow-up if not started on ART in both time periods. But
there was a marked difference in survival and retention in people with CD4
counts between 100-249, who were not started on ART: 71% in 2009 vs. 25% in
2007.
And yet, given that this wasn’t a randomized controlled study, it is not
clear how much should be made of this finding, particularly as it wasn’t seen
in the next CD4 cell strata (CD4 cells above 250), even though a substantial proportion
of these coinfected individuals also died or were lost to follow-up.
If anything, it underscores the need to implement
the recommendations of the 2010 ART Guidelines — that ART should be started in
all HIV-infected individuals with active TB, irrespective of the CD4 cell count.
A similar analysis at the same facility, only
looking at TB outcomes, was presented as a poster at the meeting.7 An
evaluation in 2007 had found that 30% of of the hospital‘s patients with HIV
who were diagnosed with TB, defaulted after starting treatment. This was
another reason why the outdoor clinic was established. An active tracing system was established and
employed whenever patients missed appointments.
It worked; in 2009, the defaulter rate had fallen to
8%, and treatment completion rates went up from 68% to 81%. Deaths increased
from 2% to 11%, but the poster’s authors wrote that it was probably due to better
tracking of the losses to follow-up, rather than a real increase in mortality.
The researchers also noted that contrary to what other groups have reported,
most of their treatment defaults happened in the first two months on TB
treatment, suggesting that ‘interventions during the first two months could
drastically reduce the number of patients lost to follow-up.”
Screening
but no follow-through
A less optimistic report described the challenges of
trying to introduce routine intensified case finding into ART clinics in Lusaka District, Zambia — which has around 150,000
people on ART care.8
Despite having a high burden of TB and TB/HIV coinfection, in Zambia, the
electronic data system wasn’t designed to collect data on TB screening.
However, the low rates of TB diagnosis in Lusaka
district (just 568 cases diagnosed over a year out of 99,000 people living with
HIV starting ART), suggested that TB symptom screening was not being done
routinely.
Since 2005, the Centres for Infectious Disease
Research in Zambia (CIDRZ)has been working with the Zambian Ministry of Health
trying to implement TB/HIV service integration.
To introduce TB symptom
screening, CIDRZ performed baseline assessments of patient flow and registers
at 17 clinics. They produced a worksheet to improve the quality and consistency
of symptom screening (and link it to the diagnostic work-up). They provided
nurses and clinical officers with intensive training and mentorship on TB/HIV
management over three to four years.
Earlier this year, CIDRZ conducted a file review,
comparing the year from late 2009-10 with the six-month period after that. They
found that documentation of symptoms in the patient files increased from 87 to
93% — suggesting that staff were indeed asking
the patients about their symptoms.
However, the healthcare workers had refused to fill out the TB screening
worksheet because “it was perceived as extra work.”
But without forms, there was no way of telling
whether patients who screened positive had been sent for diagnostic
work-up, and what their outcomes were. The authors suggested development of
electronic data collection might improve reporting.
But it is difficult to understand why the healthcare workers’ refusal to use the worksheet wasn’t picked up and — addressed —
earlier.
Primary health care clinics can integrate TB/HIV services
In stark contrast to such defeatism, a poster from
Dr Kate Clouse and colleagues from the Clinical HIV Research Unit in
Johannesburg, and the University of North Carolina at Chapel Hill, described
rather encouraging results from a cross-sectional study to assess the extent to
which HIV testing and care formed part of the normal clinical practice at a
busy primary healthcare clinic in Johannesburg.
The facility, Witkoppen Health and Welfare Centre has
around 8500 patient visits each month. It is supported by USAID via the NGO
Right to Care, and by the Gauteng Department of Health and private donors. The
clinic has dedicated HIV/TB staff five days a week (including a doctor for
three days). Since 2004, it has been providing ART, with 4200 clients currently
on treatment.
In addition to general HIV services, the clinic
provides TB screening and treatment, pre/postnatal care, general/chronic care,
paediatric care, social services and a pharmacy. Blood for CD4 cell testing is
drawn at the clinic, and sent off-site. Likewise, TB diagnostic services, such
as chest x-ray, microscopy, and culture have to be performed off site.
The clinic had already raised the CD4 threshold for
starting ART to 350 (as the South African Ministry of Health has also recently
done). In addition, it is clinic procedure to offer provider-initiated testing
and counselling to all patients, especially TB suspects, with blood for CD4
cell counts drawn the same day as the positive test results. It is also clinic
policy to screen all patients for TB at every visit, regardless of the reason
for the visit.
Data were collected on 200 patients with suspected
smear-negative TB. Participants were mostly women, 45.2% were unemployed,
almost a third were born out of South
Africa, 28.5% did not attend high school.
Almost half the participants did not know their
status at the time they were tested for TB. All were offered HIV tests and 85% accepted (about 70% of these were tested for HIV on the same day as their
TB test. 63.3% tested positive for HIV).
80% were given a CD4 test on the same day they
tested positive. The median CD4 cell count in the TB suspects was 196, and 140
among those who just tested positive. Among those who already knew their
status, 79.3% were on ART — 36% (n=7) of those who had not yet initiated were
also eligible for ART. 86% among the newly diagnosed were eligible for ART, 70%
of those had initiated ART by the end of data collection, with a median time to
initiation of 26.5 days.
Overall 20% of the suspects were eventually
diagnosed with TB, 90% of whom were co-infected with HIV. Conversely, 42% of the
TB suspects newly diagnosed with HIV did have active TB. Of those who were
eligible, 57.1% initiated ART within a median of 34 days of starting TB
treatment. Note, the clinic also has tracing procedures in place to track down
patients who tested TB-positive so that TB treatment is not delayed.
“The results suggest successful HIV-TB integration
is possible at a high-volume clinic when all the relevant services (TB
screening, TB treatment, HIV counselling and testing and ART) are available on
site,” wrote Clouse et al.