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Overview: HIV Surveillance in TB settings

Overview: HIV Surveillance in TB settings . PEPFAR Office of the US Global AIDS Coordinator Global AIDS Program – CDC/DHHS. Outline. Review global TB-related HIV surveillance estimates Review methodologies for TB-related HIV surveillance

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Overview: HIV Surveillance in TB settings

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  1. Overview: HIV Surveillance in TB settings PEPFAR Office of the US Global AIDS Coordinator Global AIDS Program – CDC/DHHS

  2. Outline Review global TB-related HIV surveillance estimates Review methodologies for TB-related HIV surveillance Focused overview of TB program-related HIV surveillance in resource-constrained settings HIV counseling and testing for all TB patients Advantages and current barriers Adjunct M&E and clinical benefits

  3. Dye’s Onion:Complexities of TB recording & reporting estimated TB cases Inter-sector collaboration all true TB cases IEC cases presenting to health facilities Patient convenience cases presenting to public health facilities cases presenting to DOTS facilities cases correctly diagnosed by DOTS facilities Lab. QA Training, Supervision diagnosed cases reported by DOTS facilities Quality facilities/ services

  4. - 2004 “Diagnostic HIV testing is indicated whenever a person shows signs or symptoms that are consistent with an HIV-related disease or AIDS…This includes HIV testing for ALL tuberculosis patients as part of their routine management.”

  5. Data from Routine Care TB patients tested for HIV on voluntary and confidential basis Testing used to provide surveillance, M&E data, and clinical information for patient management (DOTS) Should become THE standard in countries with generalized HIV epidemics

  6. Global TB facts Data since 1990 (2007 data not yet published) 202 of 212 countries reporting Global incidence (2006): 9.2 million cases (139 per 100,000 pop) 5.1 million cases actually reported Rates (per 100,00 pop) Non-HIV related US: 4 / Europe: 49 /Africa: 363 HIV related (per 100,00 pop) US: <1 / Europe: 1.4 / Africa: 78

  7. HIV prevalence in new TB cases Analytic and consultative estimates 184/212 countries estimate by: PHIV x IRR 1+ PHIV x (IRR-1) PHIV =HIV prevalence in general pop IRR = Incidence rate ratio (TB incidence rate in HIV(+)/TB incidence rate in HIV(-) 13 countries estimated by reported program data 2 by special surveys

  8. Surveillance component Targets set within the framework of the Millennium Development Goals WHO. Global Tuberculosis Control 2008. Surveillance, Planning, Financing.

  9. WHO. Global Tuberculosis Control 2008. Surveillance, Planning, Financing.

  10. WHO. Global Tuberculosis Control 2008. Surveillance, Planning, Financing.

  11. WHO. Global Tuberculosis Control 2008. Surveillance, Planning, Financing.

  12. DOTS TB Epidemic HIV Epidemic

  13. Estimated TB incidence vs HIV incidence 800 600 Estimated TB incidence 400 (per 100K, 1999) 200 0 0.0 10% 20% 30% 40% HIV prevalence, adults 15-49 years

  14. WHO. Global Tuberculosis Control 2008. Surveillance, Planning, Financing.

  15. % of notified TB patient tested for HIV: America – 32% Europe – 46% Africa – 22%

  16. Rationale for HIV Surveillance in TB Patients TB patients as sentinel population For HIV surveillance For HIV mortality surveillance M&E functions Improvement in clinical care

  17. Guidelines for HIV Surveillance in TB Patients WHO. Guidelines for HIV Surveillance among Tuberculosis Patients. 2nd Edition. WHO/HTM/TB/2004.339

  18. HIV Testing of TB Patients Accepted methods for periodic (special) surveys and sentinel surveillance Linked anonymous testing with informed consent Linkedconfidential testing with informed consent Sentinel surveillance and data from routine care amenable to provider-Initiated HIV C & T Unlinked anonymous testing with or without consent no longer justifiable from an ethical standpoint Sputum can be used for HIV testing (Oraquick ®) Not recommended when HIV prevalence in TB patients < 10%

  19. Periodic (Special) Surveys Cross-sectional HIV seroprevalence surveys Should include all newly registered TB cases Use if prevalence unknown Provides a rough point estimate Can be used to calibrate routine data

  20. Periodic (Special) Surveys (2) Advantages Simple, requires little infrastructure Established method Provides reliable estimate with representative sampling May indicate sources of bias from other methods Disadvantages Poor for trends Can be expensive and time-consuming Choice and logistics of samples Ethics of unlinked testing Small sample size Inconsistent if test procedures are poor

  21. Sentinel Surveys TB patients as sentinel group in HIV surveillance Predetermined number of TB patients routinely tested (cross-sectional or as part of routine care) Testing performed in regular and consistent way All TB cases should be included

  22. Sentinel surveillance system * * * * * * * Central surveillance unit * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * • Trends!! • Total?=> can be estimated Sample frame

  23. Sentinel surveillance surveys/systems Advantages Simple and inexpensive Better for trends Focuses on easily accessible patients Often part of HIV sentinel system Disadvantages Representativeness Consistent sampling frame Ethical issues Who is responsible? Inconsistent if test procedures are poor Selection bias

  24. Data from routine TB care (1) Key component of the DOTS strategy Recording and reporting system tracks estimates of TB incidence and prevalence Patient registration system Patient treatment card TB register TB laboratory register Cohort analysis using standard outcomes Individual patient outcomes TB surveillance Program performance

  25. Data from Routine TB Care (2) TB patients tested for HIV on voluntary and confidential basis Testing used to provide surveillance data Should become standard system for TB-related HIV surveillance in countries with generalized HIV epidemics

  26. Revised TB recording and reportingforms and registers – version 2006

  27. Core Elements of TB/HIV surveillance system – data from routine care Cohort analysis Feedback TB register Feedback Lab register Treatment card

  28. Data from Routine TB Care Advantages Results are important for clinical care Public health advantage May estimate burden of HIV-related disease May provide reliable estimates if implemented widely Disadvantages Requires infrastructure Biased if HIV testing rate low Barriers to completeness May reflect access to services Inconsistent if test procedures are poor

  29. Challenges Data collected in TB and HIV clinics not linked Incomplete data Lack of quality data Reporting functions and data analysis weak High staff turnover Lack of dedicated staff Current estimates based on Mathematical modeling

  30. E-capture of TB-related HIV surveillance data Electronic systems facilitate Data capture analysis at sub-district, provincial and national levels Timely and accurate completion of the patient card and register is paramount Foster data use at facility-level, program evaluation and improvement.

  31. Cannot be done without strengthening program (DOTS) Expand HIV testing of TB patients Foster information sharing between NTP, NACP, surveillance programs Target resources and planning Evaluate impact of interventions Improve clinical care Quality assurance (includes laboratory) Internal and external reviews Adjunct advantages of strengthening routine TB-related HIV surveillance

  32. DOT and survival with HIV Survived 56.7% Survived 85.4% Died 14.6% Died 43.3% SCC with DOT SCC without DOT Alwood K. AIDS 1994;8:1103-8

  33. Provision of co-trimoxazole to TB patients Even in the absence of antiretroviral therapy Reduces mortality by 50% Reduces hospitalization by 50%

  34. Concluding remarks HIV surveillance among tuberculosis patients is a key TB/HIV activity Surveillance methods in countries should vary according to the underlying HIV epidemic state Systems that collect TB-related HIV surveillance data should be strengthened and promoted as another tool for HIV surveillance

  35. ANC/PMTCT data validation study Kenya Generalized HIV epidemic National HIV prevalence in ANC clients: 9.4% (2003) Rapid expansion of PMTCT <10 sites (2001) 130 (2003) Hladik. AIDS 2006

  36. Objectives To describe availability and quality of PMTCT data To compare HIV prevalence estimates from PMTCT program data to those from ANC surveillance data To identify determinants for differences between PMTCT and ANC surveillance based HIV estimates

  37. UAT and PMTCT HIV Prevalence by Age Group (all Sites)

  38. Conclusion At most sites PMTCT data over-estimated HIV prevalence compared to UAT data Line list PMTCT data varied in accessibility and quality laborious to use for analysis Factors influencing HIV testing uptake for PMTCT: Gravidity Level of HIV prevalence in the area

  39. PMTCT Counseling Logbook ANCNo PMTCT No Age Marital Status Unigold Determine

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