Integration of TB and HIV Services A Case Study of Kericho District Hospital

1. Integration of TB and HIV Services A Case Study of Kericho District Hospital Hellen Muttai, MBChB, MPH Clinical Care Manager South Rift Valley HIV Care & Treatment Program Kenya Medical Research Institute/Walter Reed Project

2. Why Integration? TB Clinic HIV Clinic Patients Patient’s hospital time Double clinics, queues, drug prescriptions, sets of labs, different clinic days Programmatic Low uptake of collaborative services Clinicians Focusing on individual diseases in one patient

3. Integrated TB/HIV clinic opened July 2005 HIV Clinic In-patient Out-patient Integrated TB/HIV Clinic TB Diagnosis and Treatment (for both HIV negative patients HIV Testing & Counseling (for all TB patients) HIV Surveillance TB and HIV Care & Treatment (for co-infected patients) Co-trimoxazole Preventive Therapy HIV Prevention TB Treatment Completion

4. Methods • Retrospective TB/HIV Clinic chart review • All patients seen in the clinic during a 18 month period • Advantage of electronic medical records system

5. Achievements • Provider Initiated Testing and Counseling (PITC) • Total TB pts seen in 2006:1226 • Tested for HIV- 1155: Testing rate 94.2% • National PITC Uptake- 60% (2006) • Routine HIV surveillance among TB patients • HIV+ 525: Co-infection rate 45.4% • Routine HIV prevention services among TB and TB/HIV co-infected patients • Co-trimoxazole preventive therapy • 100% uptake • National Uptake- 87% (2006)

6. Uptake of HIV Care and Treatment 100% of co-infected patients offered HIV Care and Treatment services Eligible for ART- 78% 100% (of eligible) started on ART (56.1% started in course of TB treatment; 22% started after completion of TB treatment) National ART Uptake-26% (2006) Clinicians tying the management of both diseases together Reduction in time spent in hospital by patients Achievements

7. TB/HIV Clinic Summary Patients Enrolled = 792 (July 2005 to Dec. 2006) Characteristic No. % Female 435 55% Age (yrs, mean/SD) 33.1 (+12.3) TB Characteristics Pulmonary 697 89% Smears done (PTB) 626 90% smear – (smears done) 377 60% Baseline CD4 (cells/mm3) <100 266 36.9% 100-199 166 23.1% 200-349 144 18.0% >350 157 22.0%

8. Treatment Outcomes for Co-infected Patients Mean 6-Month CD4 Change (cells/mm3) Care +78* ART +139* TB Treatment Outcome No. % Completed 507 64% Transferred out 87 11% Loss to Follow up 111 14% Deaths 87 11% Total 792 100% p value <0.001

9. Strengths/ Conclusions • PROGRAM/ CLINIC LEVEL • 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 • ANALYTIC • 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

10. Limitations • PRIMARY: • Inherent limitations in retrospective chart reviews • Clinic set-up not designed for systematic research • Incomplete/missing clinical data

11. Recommendations • 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.

12. Acknowledgements • Kericho District Hospital TB/HIV Clinic • Kenya Ministry of Health/NLTP/NASCOP • President’s Emergency Plan for AIDS Relief • Kericho District Hospital - Eunice Obiero • KEMRI – Fredrick Sawe & Charles Sigei • USMHRP – Douglas Shaffer, Tiffany Hamm • Brown University – Jane Carter