|
The Union’s Integrated HIV Care for Tuberculosis Patients Living with HIV/AIDS (IHC) programme is being field tested in five countries with financial support from the European Commission, the United States Agency for International Development (USAID) and the Yadana project operated by TOTAL.
Benin
From 2005 to the end of 2008, The Union collaborated with the Ministry of Health (MOH), the National Tuberculosis Programme (NTP) and the National AIDS Programme (NAP) of Benin on IHC. An IHC office was inaugurated in Benin’s capital, Cotonou, to oversee and coordinate activities.
Activities were implemented in 20 TB diagnostic and treatment centres (DTCs) in all regions of the country. All DTCs offered HIV testing to their TB patients, and provided cotrimoxazole prophylaxis. The NAP accredited several DTCs as antiretroviral (ARV) prescribing sites. DTCs located near an existing NAP site referred patients eligible for antiretroviral treatment (ART) to that site. Stocks of rapid HIV tests and antiretroviral medications purchased by the project were handed over to the NAP, which distributed them to the DTCs and committed to continue supplying them after the project ended in November 2008. DTCs that are not located near a NAP laboratory were provided with equipment and consumables for performing manual CD4 cell counts.
By the end of 2008, over 100 health care workers (doctors, nurses, laboratory technicians) received specific HIV training. TB patients diagnosed with HIV were placed on cotrimoxazole prophylaxis and, when eligible, started on antiretroviral therapy shortly after the diagnosis of their TB. More than 3,500 TB patients have benefitted from HIV diagnosis and care over the last three years in Benin under the IHC programme
The success of IHC activities in the 20 pilot sites has encouraged the NTP to expand TB-HIV activities nationwide. All DTCs in Benin now routinely offer HIV testing to TB patients.
 Democratic Republic of Congo (DR Congo)
The Union is collaborating with the National Tuberculosis Programme (NTP) and the National AIDS Programme (NAP) of the Democratic Republic of Congo (DRC) to develop a programme for Integrated HIV Care for Tuberculosis Patients Living with HIV/AIDS (IHC). Activities are implemented at the primary health care centres involved in TB control and are supervised by technical experts based at the provincial level, who are in turn supervised by their national level colleagues based in Kinshasa.
The first phase of the IHC programme was implemented in 23 TB diagnostic and treatment centres (DTCs) in two provinces: 13 in North Kivu, the eastern part of the country, and 10 in Bas Congo, the western part of the country. Activities in North Kivu continue within the framework of the second phase of the IHC programme funded by the European Commission.
IHC introduced HIV screening and management of co-infected TB patients by health care staff in charge of TB services. Co-infected patients are started on cotrimoxazole preventive therapy (CPT) and if eligible, also on antiretroviral treatment (ART). IHC has also introduced CD4 cell count measurement at all sites using a simple and robust technique using light microscopes for sputum smear microscopy. Each patient’s CD4 cells are measured to assess eligibility for antiretroviral therapy. Patients are monitored using the cohort analysis system used for TB patients and HIV drugs are supplied to them through the same controlled supply chain as the TB drugs. These services are also extended to family contacts of co-infected TB patients.
The survival rates of the 2007 and 2008 cohort patients on ART from North Kivu are of respectively 79 and 81% at 12 months; respectively 16 and 11% of the patients died, and 0 and 1% were lost to follow up. These results are comparable to those obtained by the successful programs elsewhere in Africa.
The recognition and excellent performance of the model developed by The Union in collaboration with the national programmes has encouraged the HIV/AIDS stakeholders to advocate its nation-wide adoption with the Ministry of Health in order to offer treatment to the largest possible number of patients.
IHC Strengths in 2009 in DRC
IHC represents the basis for interesting operational research with the Ministry of Health in DRC and provides an opportunity within the strategic framework of strengthening the health system to assess the IHC approach to training and supervision as well as health service delivery at no cost for patients and communities.
Myanmar
IHC in Myanmar began in 2005 in five townships of Mandalay district. Following the signing of a Memorandum of Understanding with the Ministry of Health in September 2007, activities expanded to all seven Mandalay townships and the city of Pakokku. The programme is based on collaboration between The Union, the Ministry of Health, National AIDS Programme (NAP), National TB Programme (NTP), and the World Health Organization (WHO).
TB patients diagnosed with HIV are placed on cotrimoxazole prophylaxis and, when eligible, are started on antiretroviral therapy (ART) at the completion of the intensive phase of tuberculosis therapy. HIV counselling and testing services are also offered to the spouses and children of TB/HIV co-infected patients.
IHC has experienced significant growth since 2005 - more than 6000 adult TB patients have been tested for HIV, of which one third have been diagnosed with HIV infection. The number of patients enrolled in IHC now stands at 1,400 from an initial figure of 379, with an inclusion rate of 40-50 patients per month. In the past three years, the number of patients taking ARTs has risen to 700 from 190, with an 89% survival rate amongst those who are on treatment, facilitated by regular follow up.
IHC has demonstrated the capacity of the National Tuberculosis and AIDS Programmes, physicians in teaching hospitals, and primary health care facilities in townships, to collaborate and provide accessible, acceptable and affordable diagnostic and treatment services for TB-HIV co-infected patients and their HIV-infected relatives.
Uganda
The Union is working with the National Tuberculosis and Leprosy Programme (NTLP) and the National AIDS Control Programme (NACP) on TB and HIV collaborative activities in Uganda.
The Union, through its Integrated HIV Care for Tuberculosis (TB) patients living with HIV/AIDS (IHC) project, implemented a two-phased operational research program in five districts of Uganda from May 2006 to September 2008. Phase 1 was an exploratory qualitative knowledge, attitudes, practices and beliefs study which focused on identifying barriers to TB/HIV collaborative activities at four levels: provider, health facility, patient and community. Phase 1 results were used to develop a protocol for an epidemiological second phase cross-sectional study, which focused on identifying patient, provider and facility factors influencing uptake of HIV testing among TB patients. Study results were disseminated nationally and internationally to various stakeholders, Ministry of Health (MoH) TB and HIV control programs, donor partners and at district level to health workers involved in service delivery through conferences, meetings and publications. The results have helped both the MoH and partners to identify strategies to improve the implementation of collaborative TB/HIV services.
In May 2007, the Uganda mission of the United States Agency for International Development (USAID) obligated funding to the TB Control Assistance Program (TB CAP) to support Ministry of Health and districts in Uganda to deliver integrated services for TB and HIV and to strengthen Community Based Directly Observed Therapy-Short course (CB-DOTS). The Union is the coordinating partner for TBCAP in Uganda.
The goal of the program is to decrease the burden of TB among people living with HIV/AIDS (PLWHAs) and the burden of HIV among notified TB patients. TB CAP operates within the existing Ministry of Health and district health systems and supports the implementation of national policies and guidelines on TB/HIV. The main output areas are:
• Increased capacity at the national and district level to improve TB/HIV coordination, management and leadership.
• Improved quality of CB-DOTS and TB/HIV collaborative activities, including TB infection control.
• Technical Assistance provided to USAID TB Implementing partners and United States Government President’s Plan for Emergency AIDS Relief (PEPFAR) partners in order to scale up TB/HIV collaborative activities and strengthen CB-DOTS.
• National TB and Leprosy Programme supported to strengthen coordination of the Multidrug-Resistance (MDR) response at the national level.
TBCAP provides both technical and financial support to the National TB and Leprosy Programme and twelve supported districts, namely Kampala, Mukono, Kayunga, Mpigi, Soroti, Bukedea, Mbale, Manafwa, Kiboga, Hoima, Masindi and Bulisa. Technical assistance is provided to sixteen USAID TB Implementing and PEPFAR partners.
There have been improvements in TB and TB/HIV indicators since the beginning of TBCAP. In eleven supported rural districts, HIV testing among TB patients increased from 43% (2007) to 70% (2008); Cotrimoxaxole prophylaxis among TB/HIV co-infected patients increased from 50% (2006) to 87% (2007) and TB treatment success rate increased from 43% (2006) to 71% (2007). In Kampala district, Uganda’s capital, targeted efforts, including improved follow up of TB patients on DOT and improved TB recording and reporting have contributed to improved treatment success rates from 16% (2006) to 73% (2007).
The Union/TB CAP builds on partnerships at all levels to improve existing TB and HIV services and is working closely with the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and other Uganda Stop TB partners to support MoH to improve guidance to districts and partners on the implementation of TB/HIV activities.
Zimbabwe
The Union collaboration to further strengthen Integrated HIV Care for Tuberculosis Patients with HIV/AIDS (IHC) with the Health Services Departments of the City of Bulawayo and the City of Harare started in September 2007. The main objective of IHC is to develop innovative strategies for feasible and sustainable TB-HIV services that could be replicated by other local authority health departments and district health services in the country and outside Zimbabwe.
Three municipal clinics were chosen to implement TB-HIV-related activities and operational research. They were accredited as antiretroviral treatment (ART) initiating sites in August-September 2008 by the Ministry of Health and Child Welfare. In the first year of enrolment, 639 and 280 co-infected TB patients and their HIV-positive and ART eligible family contacts were commenced on ART in Bulawayo and Harare, respectively. Uptake of provider-initiated testing and counselling for HIV has steadily increased at all sites where also all eligible patients are commenced on cotrimoxazole preventive therapy. |
