Integration of TB and HIV Services: Experiences from the Kericho District Hospital

Charles S. Kiptemas, MBChB, MPH

Director

South Rift Valley HIV Care & Treatment Program

Kenya Medical Research Institute/Walter Reed Project

Track 1.0 ART Program Meeting: Willard Intercontinental Track 1.0 ART Program Meeting: Willard Intercontinental Hotel, Washington, D.C.Washington, D.C. August 11-12, 2008

Background

• Need for integrated TB & HIV services

1 patients/2 diseases

2 clinics/2 ques/2 clinicians/2 treatment regimens

“Intensified case finding” – recognized potential for overloading very busy and overwhelmed clinics

- Identifying TB in HIV clinic

- Identifying HIV in TB clinic

• Aim: integrated TB/HIV clinic

Cadre of clinicians capable of treating both diseases in TB clinic

HIV care provided in TB clinic through at least intensive phase

• Goal: improved patient care

HIV Clinic In-patient

Integrated TB/HIV Clinic • HIV Testing & Counseling (PITC) • HIV Surveillance• HIV Prevention• TB Diagnosis and Treatment (for both HIV positive and negative patients)• HIV Care & Treatment (for co-infected patients)• Co-trimoxazole Preventive Therapy

TB Treatment Completion

Integrated TB/HIV Clinic (est. July 2005)

Out-patient

TB/HIV Clinic Characteristics (2005-2007)

• Cohort size (n) 1,220

• Age (mean, years) 31

• Female 53%

• Pulmonary TB 86%

• Sputum positive 41%

• PITC 94%

• TB-HIV coinfected 54%

TB/HIV Clinic Baseline CD4

0

5

10

15

20

25

<50 51-100 101-200 201-350 > 350

CD4 Distribution

%

78% eligible for ART

TB/HIV Co-infected Treatment Outcomes*

Mean 6-Month CD4 Change (cells/mm3)

Care +78

ART +139

TB Treatment Outcome

Completed 64%

Transferred out 11%

Loss to Follow up 14%

Deaths 11%

* Data presented on subset n=792

Intensified Case Finding

• Identifying TB in HIV clinic

symptom algorithm

CXR

cough monitors

• Identifying HIV in TB clinic

PITC

Contact tracing / case finding

- Family who can come to clinic

- Future contract tracing to home

TB/HIV Clinic Observations

• Successful management of co-infected patients with good clinical outcomes.

• Successful integration of TB and HIV services at a district hospital setting.

• High uptake of TB/HIV collaborative services.

• Patients with combined TB/HIV infections may receive benefit from:

primary TB treatment (“care”) alone;

and additionally ART.

• Patients with combined TB/HIV infections often present with advanced HIV disease.

Limitations/Strengths

• Primary Limitations: Inherent limitations in retrospective chart reviews:

- Clinic set-up not designed for systematic research.

- Incomplete/missing clinical data.

• Strengths: Advantage of electronic medical record system in TB/HIV

clinic where data accuracy can be verified against original clinic record.

Findings should be considered descriptive in nature; however, value of such descriptive data should not be overlooked in the early development of such TB/HIV programs.

Recommendations/Way Forward

• Integration of TB and HIV services needs to be considered in health facilities in order to improve uptake of collaborative services.

• Clinicians treating patients with TB/HIV should be aware of the benefit to HIV infection by treating TB and offering supportive care alone, and additionally ART.

• Efforts to identify patients with TB/HIV early in their disease may offer tangible benefit by providing the opportunity to consider early ART.

• Further controlled studies are needed to best identify when (and what settings) to initiate ART in patients receiving TB treatment.

• The Kenya team plans to roll out integrated TB/HIV clinic experiences from KDH to remaining district level ART treatment facilities in Southern Rift Valley.

Acknowledgements

• Kericho District Hospital TB/HIV ClinicKericho District Hospital TB/HIV Clinic

• Kenya Ministry of Health/NLTP/NASCOPKenya Ministry of Health/NLTP/NASCOP

• President’s Emergency Plan for AIDS ReliefPresident’s Emergency Plan for AIDS Relief

• Kericho District Hospital - Eunice ObieroKericho District Hospital - Eunice Obiero

• KEMRI – Fredrick Sawe & Jonah Maswai KEMRI – Fredrick Sawe & Jonah Maswai

• USMHRP – Doug Shaffer, Tiffany Hamm, Nelson MichaelUSMHRP – Doug Shaffer, Tiffany Hamm, Nelson Michael

• Brown University – Jane CarterBrown University – Jane Carter