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TB/HIV Integration at ICAP-Supported Health Facilities

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

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TB/HIV Integration at ICAP-Supported Health Facilities

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  1. TB/HIV Integrationat ICAP-Supported Health Facilities ICAP Data Dissemination Meeting March 4 2008 Andrea Howard and Suzue Saito

  2. 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

  3. 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

  4. Integration of TB/HIV Services A Common TB and HIV Paradigm An Alternative TB/HIV Paradigm National HIV Program National TB Program National TB Program National HIV Program Communication • TB Services • Sputum collection • DOT • Contact tracing • IPT • HIV Services • C&T • CPT • ART • OI Dx & Tx • Adherence • support • PWP Integration of Services

  5. Which model for collaboration? TB HIV ‘One stop service’ for TB patients with HIV Referral HIV TB Partial integration TB/HIV TB HIV Referral

  6. 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

  7. TB Screening in HIV Care Settings

  8. Items in TB Screening Questionnaire for Select ICAP Country Programs

  9. Items in TB Screening Questionnaire for Select ICAP Country Programs

  10. TB Screening Questionnaire - + TB Screening Not a TB Suspect TB Suspect Sputum smear microscopy TB Diagnosis Sputum smear negative Sputum smear positive Sputum smear microscopy Chest x-ray Clinical assessment TB is likely Treat for TB TB is unlikely Treat for bacterial infection or PCP Response No response Reassess for TB

  11. The Data: TB Screening in HIV Care Settings As of December 2008…

  12. 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

  13. 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%

  14. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programs, October-December 2008 % patients n=8,023 n=29,081 n=7,197 n=2,235 n=3,538 n=770 New HIV patients n=5,187 n=2,131 • Tanzania close to SOC target of > 90% • In other countries, many patients are not screened at enrollment

  15. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programsover time % patients n=29,081 n=32,760 n=24,705 n=14,824 n=19,104 n=18,886 n=23,991 n=8,685 New HIV patients Proportion screened for TB has increased over time, but still falls short of SOC target of > 90%

  16. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment programs over time, by country % patients

  17. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment programs over time, by country % patients

  18. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment programs over time, by country % patients

  19. Proportion of HIV patients screened for TB who screened positive at ICAP-supported care and treatment programs, October-December 2008 % patients n=2,095 n=3,619 n=3,441 n=19,610 n=1,458 n=3,855 n=528 n=4,614 Screened patients • Proportion screened positive varies substantially across countries • Results from Moz, CDI, SA may be inflated due to selection bias

  20. Proportion of new HIV patients with a positive TB screen who initiated TB treatment at ICAP-supported care and treatment programs, October-December 2008 % patients na n=259 n=2,371 n=4,596 n=596 n=510 n=637 Screened positive patients • Proportion diagnosed/treated (among those with positive screen) • varies substantially across countries • This may be due to biased screening

  21. Proportion of new HIV patients who initiated TB treatment at ICAP-supported care and treatment programs, October-December 2008 % patients n=8,023 n=29,081 n=7,197 n=2,235 n=3,538 n=770 New HIV patients n=5,187 n=2,131 Proportion diagnosed/treated (among all new patients) is relatively low in all countries

  22. HIV Testing in TB Clinics

  23. Unknown HIV status HIV C&T Onsite Off-site HIV + HIV - • Enroll in HIV care & treatment • Provide Cotrimoxazole preventive therapy • Onsite Offsite

  24. The Data: HIV testing in TB clinics • As of December 2008…

  25. 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

  26. 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%

  27. Proportion of new patients with an unknown HIV status at ICAP-supported TB clinics who were HIV tested, Oct-December 2008 Tested at any clinic Tested at TB clinic % patients n=1,971 n=952 n=240 N=6,054 n=551 n=296 n=11,295 New TB patients n=1,231 Proportion of new TB patients who are HIV tested is relatively high

  28. Proportion of new patients with unknown HIV status at ICAP-supported TB clinics tested for HIV over time % patients n=11,295 n=10,781 n=8,700 n=6,955 n=7,271 n=7,481 n=10,027 n=7,441 New HIV patients • Proportion new TB patients HIV tested has increased over time • For the past three quarters, we have reached the SOC target >90%.

  29. Proportion of HIV tested TB patients at ICAP-supported TB treatment programs who tested positive, October-December 2008 HIV tested at TB clinic HIV tested at any clinic % patients HIV tested TB patients n=189 n=1,752 n=882 n=937 n=292 n=5,888 N=10,185 N=245 Proportion new TB patients tested HIV positive is relatively similar across countries except in Cote d’Ivoire and Ethiopia.

  30. Proportion of HIV(+) TB patients enrolling in HIV care at ICAP-supported TB treatment programs, October-December 2008 % patients HIV positive patients n=31 n=384 n=403 n=360 n=660 n=112 n=2,027 In sites with HIV care and treatment on-site (SA, Rwanda), enrollment in HIV care is universal.

  31. 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

  32. On-Site Location of TB Services is Associated with TB Screening ofHIV-Infected Patients at Enrollmentin HIV Care Programsin 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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.

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