tb/hiv integration at icap-supported health facilities
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TB/HIV Integration at ICAP-Supported Health Facilities. ICAP Data Dissemination Meeting March 4 2008 Andrea Howard and Suzue Saito. Outline. Background and rationale for TB/HIV integration Review of TB screening questionnaire Quarterly reported data on TB screening in HIV care settings - PowerPoint PPT PresentationTRANSCRIPT
TB/HIV Integrationat ICAP-Supported Health Facilities
ICAP Data Dissemination MeetingMarch 4 2008
Andrea Howard and Suzue Saito
Outline• Background and rationale for TB/HIV integration• Review of TB screening questionnaire• Quarterly reported data on TB screening in HIV
care settings• Quarterly reported data on HIV testing in TB
clinics• Challenges of collecting and analyzing
aggregate data• Analysis on site/program level factors
associated with greater TB screening• Q&A
Background
• Up to 80% of TB patients are HIV positive in high TB/HIV prevalence countries
• People with HIV are 50x more likely to develop TB in their lifetime than HIV-negative people
• 1/5-1/3 of all AIDS deaths worldwide are due to TB
Integration of TB/HIV Services
A Common TB and HIV Paradigm
TB Services•Sputum collection•DOT•Contact tracing• IPT•HIV C&T•CPT•ART
HIV Services•C&T•CPT•ART•OI Dx & Tx•Adherence support•PWP•TB screening•TB diagnosis• IPT
HIV Services• C&T• CPT• ART• OI Dx & Tx• Adherence support
• PWP
TB Services
• Sputum collection• DOT• Contact tracing• IPT
National TB Program
National HIV Program
National TB Program
National HIV Program
An Alternative TB/HIV Paradigm
Integration of Services
Communication
Which model for collaboration?
TB HIV
TB HIV
TB HIV
Referral
Referral‘One stop service’ for TB patients with HIV
Partial integration TB/HIV
Rationale for TB/HIV Integration
•TB clinics are an entry point at which HIV-infected persons can be identified and engaged in HIV care
• ART increases survival in HIV-infected persons with TB
• Routine screening for TB in persons enrolling in HIV care is essential to early diagnosis, improved outcomes, and preventing its spread to others in the community and health care settings
TB Screening in HIV Care Settings
Items in TB Screening Questionnaire for Select ICAP Country Programs
Cough Fever Weight loss
Night sweats
Contact with TB
Other
Cote d’Ivoire
√ √ √ √ √
Ethiopia √ √ √ √ √
Kenya √ √ √ √ √Mozambique √ √ √ √ √ hemoptysis
Nigeria √ √ √ √ √ Prior TB
Rwanda √ √ √ √ √
South Africa
√ √ √ √ Chest pain,Swollen nodes
Tanzania √ √ √ √ hemoptysis
Cough Fever Weight loss Night sweats
Contact with TB
Other
Cote d’Ivoire >3 w >3 w >3kg in 1m yes Yes
Ethiopia >2 w >2 w >3kg in 1m >2 w Yes
Kenya >2 w >3 w >3kg in 4w >3 w Yes
Mozambique >3 w >3 w >3kg in 1m >3 w Yes (home treated for TB)
hemoptysis
Nigeria >2 w >2 w Observed >3kg in 4w
>2 w Yes (or long standing cough)
Prior TB
Rwanda >3 w >3 w >3 kg in 4w >3 w yes
South Africa >2 w >2 w Yes >2 w NO Chest pain, swollen nodes
Tanzania >2 w >2 w >3 kg in 1m >2 w NO hemoptysis
Items in TB Screening Questionnaire for Select ICAP Country Programs
TB Screening Questionnaire
TB Suspect
Sputum smear microscopy
Sputum smear positive
Treat for TB
Sputum smear negative
Sputum smear microscopyChest x-ray
Clinical assessmentTB is likely
Not a TB Suspect
TB is unlikely
Treat for bacterial infection or PCP
ResponseNo response
Reassess for TB
+ -TB Screening
TBDiagnosis
The Data: TB Screening in HIV Care Settings
Country Sites supported Sites reportingCote d’Ivoire 23 21
Ethiopia 51 *
Kenya 73 73
Mozambique 35 32
Nigeria 57 57
Rwanda 44 44
South Africa 37 24
Tanzania 77 74
397 325 (82%)
As of December 2008…
Quarterly Indicators• Proportion of new patients screened for active TB at enrollment into HIV
care• Proportion of new patients who were screened for active TB at
enrollment into HIV care who screened positive• Proportion of new patients who screened positive for active TB, were
subsequently diagnosed with active TB and started treatment for active TB disease
• Proportion of new patients who were diagnosed with active TB and started treatment for active TB disease
• Proportion of patients diagnosed with active TB who started cotrimoxazole prophylaxis
• Number of patients eligible for IPT who started it in accordance with national guidelines
Standards of Care (SOC) for TB screening
• All patients enrolled in HIV care and treatment should be screened for TB at their first visit.
– Target: >90%
Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programs,
October-December 2008%
pat
ient
s
• Tanzania close to SOC target of > 90%• In other countries, many patients are not screened at enrollment
n=29,081 n=3,538 n=2,235 n=770 n=7,197n=5,187 n=8,023New HIV patients n=2,131
Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programs
over time
n=8,685 n=14,824 n=18,886 n=19,104New HIV patients n=23,991 n=24,705 n=32,760 n=29,081
% p
atie
nts
Proportion screened for TB has increased over time,but still falls short of SOC target of > 90%
Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment
programs over time, by country
% p
atie
nts
Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment
programs over time, by country
% p
atie
nts
Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment
programs over time, by country
% p
atie
nts
Proportion of HIV patients screened for TB who screened positive at ICAP-supported care and treatment programs, October-December 2008
% p
atie
nts
n=19,610 n=4,614 n=528 n=1,458 n=3,855 n=3,619 n=3,441Screened patients
n=2,095
• Proportion screened positive varies substantially across countries• Results from Moz, CDI, SA may be inflated due to selection bias
Proportion of new HIV patients with a positive TB screen who initiated TB treatment at ICAP-supported
care and treatment programs, October-December 2008
% p
atie
nts
n=4,596 n=510 n=596 n=637 n=2,371 n=259Screened positive patients
• Proportion diagnosed/treated (among those with positive screen)varies substantially across countries
• This may be due to biased screening
na
Proportion of new HIV patients who initiated TB treatment at ICAP-supported care and treatment
programs, October-December 2008
% p
atie
nts
Proportion diagnosed/treated (among all new patients) is relatively lowin all countries
n=29,081 n=3,538 n=2,235 n=770 n=7,197n=5,187 n=8,023New HIV patients n=2,131
HIV Testing in TB Clinics
HIV C&TOnsite Off-
site
HIV +
• Enroll in HIV care & treatment• Provide Cotrimoxazole preventive therapy
Onsite Offsite
HIV -
Unknown HIV status
The Data: HIV testing in TB clinics
• As of December 2008…Country Sites supported Sites reportingCote d’Ivoire 7 7
Ethiopia 51 49
Kenya 73 72
Mozambique 32 32
Nigeria 71 57
Rwanda 29 28
South Africa 2 2
Tanzania NA NA
265 247 (93%)
Indicators
• Proportion of new patients with unknown HIV status at enrollment into TB care who were tested for HIV while in care at the TB clinic
• Proportion of new patients with unknown HIV status at enrollment who test positive for HIV while in care at the TB clinic
• Proportion of new patients diagnosed with HIV while in care at the TB clinic who were subsequently enrolled in HIV care and treatment
• Proportion of HIV positive patients who were started on cotrimoxazole prophylaxis while in care at the TB clinic
SOC for HIV Testing of TB patients
• TB patients with an unknown HIV status or an HIV negative status that is >6 months old should be counseled and tested for HIV during the first 2 months of TB treatment.
– Target: >90%
Proportion of new patients with an unknown HIV status at ICAP-supported TB clinics who were HIV tested, Oct-December 2008
% p
atie
nts
New TB patients n=11,295 n=296n=952 N=6,054 n=1,231n=240n=551 n=1,971
Proportion of new TB patients who are HIV tested is relatively high
Tested at TB clinic Tested at any clinic
Proportion of new patients with unknown HIV status at ICAP-supported TB clinics tested for HIV over time
n=7,441 n=6,955 n=7,481 n=7,271New HIV patients n=10,027 n=8,700 n=10,781 n=11,295
% p
atie
nts
• Proportion new TB patients HIV tested has increased over time• For the past three quarters, we have reached the SOC target >90%.
Proportion of HIV tested TB patients at ICAP-supported TB treatment programs who tested positive, October-
December 2008
% p
atie
nts
HIV tested TB patients N=10,185 N=245 n=937 n=882 n=292 n=189n=1,752n=5,888
Proportion new TB patients tested HIV positive is relatively similar across countries except in Cote d’Ivoire and Ethiopia.
HIV tested at TB clinic HIV tested at any clinic
Proportion of HIV(+) TB patients enrolling in HIV care at ICAP-supported TB treatment programs, October-
December 2008
% p
atie
nts
HIV positive patients n=2,027 n=660n=112 n=360 n=384n=403 n=31
In sites with HIV care and treatment on-site (SA, Rwanda),enrollment in HIV care is universal.
Challenges of Collecting and Analyzing Aggregate Data
• Difficult to pull together data from multiple points of care
• Difficult to establish trend as continuously adding new sites
• Difficult to distinguish whether not recorded = not done or problem with recording
• Standardizing interpretation of indicators across countries
• Incomplete reporting
On-Site Location of TB Services is Associated with TB Screening of
HIV-Infected Patients at Enrollmentin HIV Care Programs
in 6 Sub-Saharan African Countries
AA Howard, S Saito, D Nash, R Flam,B Elul, A Scardigli, B Oyeledun,
A Cunningham, D Hoos, W El-Sadr
Abstract 590, CROI 2009
Study Aims
• To examine trends in the proportion of newly enrolled HIV care patients screened for TB and started on TB treatment between 1/07 & 6/08
• To identify program-level factors associated with greater TB screening at HIV care clinics
Data Sources• Aggregate quarterly data
– Between 1/07-3/07 (Q1) and 4/08-6/08 (Q6)– 238 HIV care clinics (93,935 patients)– 6 countries (Cote d’Ivoire, Kenya, Mozambique, Nigeria, Rwanda,
Tanzania)– 718 observations– TB screening performed using standardized symptom
questionnaire– TB treatment initiation based on national algorithms
• PFaCTS– Cross-sectional structured survey of program and facility
characteristics in 6/08– Site visits and staff queries at 181/327 facilities
Analyses
• Trends over time in mean proportion of newly enrolled HIV care patients– screened for TB using a symptom questionnaire– started on TB treatment– weighted for program size (# patients currently in
care)• Multivariate linear regression to determine
associations of program and facility characteristics with proportion of newly enrolled HIV care patients screened for TB in Q6
Q1 Q2 Q3 Q4 Q5 Q60
50
100
44 44
55 5763
76
Mean Proportion of New HIV Patients Screened for TB, restricted to 58 sites that have 6 quarters of data
(January 2007 - June 2008)
Perc
ent
p=0.016
03/07 06/07 09/07 12/07 03/08 06/080
10
20
43
45 5
6
Mean Proportion of New HIV patients Started on TB Treatment, restricted to 58 sites that have 6
quarters of data (January 2007-June 2008)
Perc
ent
p=0.016
Conclusions• Routine TB screening using a simple symptom questionnaire results in
a substantial number of HIV+ persons being diagnosed and treated for TB at enrollment in HIV care
• Sizable improvement in screening coverage was achieved over time
• Co-locating TB treatment services with HIV care and treatment services could result in increased TB screening and case finding among patients enrolling in care
• Further efforts are needed to– Define individual risk factors for TB in those enrolling in HIV care– Elucidate which characteristics and combination of symptoms are associated
with diagnosis of TB– Rigorously validate the screening questionnaire
Acknowledgements
Y Wu, G Vandebriel, C Casalini,H Yahaya, Z Samoei, D N’Dabian,H Broul, M Sheriff, F Alvim, F Oronsaye,V Mugisha, H Nuwagaba-Biribonwoha, ICAP Country Directors, ICAP Program Directors, site staff, Ministries of Health and partner organizations in Cote d’Ivoire, Kenya, Mozambique, Nigeria, Rwanda and Tanzania.