Several studies and posters described the growing uptake of the 3I’s to reduce the burden of TB in people with HIV, especially intensified case finding.11 12
“In terms of intensified case finding, it’s very encouraging that we see many activities happening in many countries. HIV implementers now seem to have embraced this activity. We are still lagging behind what we need to do, but we are on the right track.” said Dr Getahun.
He reported that currently WHO and the CDC are working on a meta-analysis of primary data for TB screening (including twelve data sets and over 30,000 people). The primary question: What is the most sensitive clinical algorithm to screen for culture-confirmed pulmonary TB in people living with HIV? The objective is to develop a standardized evidence-based approach and guidelines for TB screening and prevention (IPT) among PLHIV.
The guideline will contain an algorithm that identifies an individual as a TB suspect, who should then be referred for diagnosis. If they are not a suspect, they should be put on a course of IPT. WHO plans to finalise this analysis in the next two or three weeks at a meeting in Geneva.
One issue raised by several speakers is that scaling up intensified case finding cannot be done successfully without also scaling up TB laboratory capacity.
According to Dr Bernard Langat of the Division of Leprosy TB and Lung Disease in Kenya, to support ICF, his country needs to expand diagnostic capacity (especially fast liquid culture to diagnose smear-negative TB in patients with HIV). “We need to decentralise and it costs money”, he said. Plus there are issues of workload. “For every patient found with active TB, ten are screened with very good screening tools. So the number of smears will be going up and human resources in the lab are definitely an issue.”
Dr El-Sadr agreed that if programmes begin using screening tools that are highly sensitive, but with low specificity, “The amount of work-up that will need to be done on all of our suspects will increase tremendously. We need to think about how we are going to balance using highly sensitive but not specific tools with laboratory capacity to diagnose.”
PEPFAR is willing to provide assistance with laboratory scale-up, according to Dr Amy Bloom of USAID: “ICF is very high up on our radar — then looking at laboratory services to support it.”
Another option might be to simply offer TB treatment to suspects with advanced disease and symptoms of TB. Dr El-Sadr described a study that is in development that would randomise people with advanced HIV disease entering care with very low CD4 cell counts at the time of initiating ART to immediate empiric TB treatment, versus the standard approach of work-up and diagnosis of TB, then followed by treatment. The outcome will be mortality.
But Dr Francois Venter of Johannesburg Hospital stressed that finding TB suspects is not enough, “It’s what you do with them after you’ve found them. We spend a huge amount in South Africa, diagnosing people with TB and then not retaining them in care or rapidly initiating them on therapy. At Baragwanath Hospital in Johannesburg, 50% of the hospitalised patients diagnosed with TB don’t make it to a TB clinic. These are diagnosed patients with fully susceptible TB and they still can’t get to the clinic. The system is failing these patients.”
He complained about all the money being invested in expensive diagnostics and new drugs, saying that there are fairly simple cost effective solutions to these problems.
“Asking for new drugs and new diagnostics is useless. If instead, we had somebody phoning these patients, or actually escorting them to the TB clinics, I bet we would save a hell of a lot more lives,” he said.
The uptake of IPT is still limited (and discussed in a related article in this edition of HATIP); but “of all the Three I’s, infection control still seems to be the most neglected,” said Dr Getahun.
“We’re all well aware of how far behind we are,” said Dr Bess Miller, who is also the chair of the Infection Control subgroup of the TB/HIV Working Group of the STOP TB Partnership.
Dr Miller noted that the WHO is also in the process of finalising TB Infection Control Policy for Health Facilities (a draft copy was finally available for distribution at the meeting). She also said the working group has put together a work plan to address a number of areas.
“The area we’ve been most successful in is training, and human resource development. Between TB CAB and WHO, there have been numerous trainings in every region of the world to train people at the national level in TB infection control. In addition to that, we are developing training materials for health care workers. We also need to have some M&E tools — surveillance of TB among workers in facilities is part of that. Another area we are working on (ICAP has taken some of the lead on this) is developing facility-level materials. We are in the process of developing a manual.”
Dr Miller believes that the responsibility for infection control will ultimately fall on nurses.
“We have hired an infection control nurse, and want to work with the International Confederation of Nurses, and the Association of Practitioners of Infection Control to try to work on nurse behaviours, on an ongoing basis, to monitor infection control.” While the complete package is in development, Miller shared a tool with a basic checklist for nurses to use to monitor basic infection control practices at a facility.
Dr Venter is sceptical this approach will work.
“You try to tell a nurse in Johannesburg that she has to work with open windows in the winter. Even in Africa, it does get cold. Their opposition is rational, because it is an unpleasant place to work in. And they keep telling me that I have to move coughing patients to another area. Seventy per cent of the admissions in my hospital are there for respiratory infections. My sense is that we should just build another hospital for the patients who aren’t coughing. I have yet to visit a hospital in Southern Africa where coughing patients are put in another place. I think we need to take three steps back and think about what is going to work in this situation.”
He cited the TB infection control projects that MSF has pioneered, “but it takes the dedicated passion of a large group of people to implement them in just one area in South Africa, if we have to demand this from the system across the board, it is very difficult.”
Dr Venter believes that an emergency response that includes teams with infection control engineers are needed to make site visits to get facility managers on board, and enforce infection control.
“I agree that infection control is important, but the leadership behind it has been lacking. Recently, 30 healthcare workers died in one year in a hospital north of Tugela Ferry, of MDR TB. If they all died in car accidents we would make compulsory driving lessons for healthcare staff. It just happened quietly and was swept under the carpet. So where is the action? Where is the emergency that WHO declared a few years ago?”
Dr El-Sadr noted that infection control issues do go beyond the scope of the HIV programme. “Facilities have to buy into infection control (even though there are some activities that fall square on the HIV department, like ICF and IPT), but without advocacy and buy-in at the facility level, it is going to be hard for the HIV programme to push a specific agenda.”
Nevertheless, as is so often the case if the HIV programme does not push for infection control, it isn’t clear who will.
Overall, Dr Venter voiced frustration with the implementation of the Three I’s.
“We have to scale beyond the believers. We wouldn’t come to a PEPFAR Implementers' meeting and talk about how we put 120 patients on antiretrovirals and these are the lessons learned. We’d be laughed out of the room. But we do this for TB quite often but that’s not scale, that’s a joke,” he said. “We need more research on operational interventions to make these programmes work, rather than biological or treatment approaches.”
Dr El-Sadr was more upbeat however:
“I always feel like [after] meetings on TB/HIV, that we walk out feeling depressed, but I want to fight this. We’ve really achieved a lot. A few years ago, nobody was being tested for HIV in TB clinics, now in some countries, all the people are being tested and linked to HIV care. I think that even starting to think about screening for TB routinely is great, and the efforts being put into place to improve laboratory capacity, and talking about TB in kids and trying to do IPT in kids [too]. We really should walk out of here encouraged,” she said.