1. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Trends in HIV Seroprevalence among clients with newly diagnosed tuberculosis in health facility settings in four regions of Ethiopia Wubaye Walelgne 1, Zenebe Melaku 1, Dawit Assefa 1, Tesfaye Tefera 1, Sileshi Leulseged 2,Tsigereda Gadissa 1,Tsigereda Kifle 3,Damtew W/Mariam 1, Andrea Howard 2,David Hoos 2 1 ICAP Columbia University, Addis Ababa, Ethiopia, 2 ICAP Columbia University, New York, USA, 3 Dire Dawa Regional Health Bureau, Dire Dawa, Ethiopia December 5, 2011 OWN, SCALE-UP & SUSTAIN The 16 th International Conference on AIDS & STIs in Africa 4 to 8 December 2011, Addis Ababa www.icasa2011addis.org

2. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa OWN, SCALE-UP & SUSTAIN Outline of presentation Background Introduction Methods Results Discussions & Conclusions Recommendations

3. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Background ICAP was founded in 2004 at Columbia University’s Mailman School of Public Health In 2005,ICAP received a cooperative agreement from the U.S. Centers for Disease Control and Prevention (US CDC) to support the national roll- out of HIV services in Ethiopia. Works in partnership with the Federal Ministry of Health (FMOH) and Regional Health Bureaus (RHBs), to support comprehensive HIV services at all hospitals in Oromia and all hospitals and health centers in Dire Dawa, Harari, and Somali regions. Sites are largely rural or semi-urban including hard to reach communities

4. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Columbia University,ICAP in Ethiopia Supports services in a geographic area with a population of more than 34 million. 1.Oromia : 29 million 2.Somali :4.6 million 3.Dire Dawa: 400,000 4.Harari: 200,000 As of October 2011 86 facilities provide TB DOTS with Primary HIV Care 69 of these have both TB & HIV services.

5. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa 5 Introduction According to Global TB report 2011 Ethiopia stands 9 th & 17 th among high burden TB & MDR TB countries respectively. The adult HIV seroprevalence is estimated to be 2.4% in 2010. The TB/HIV co-infection rate is 15% among tested TB patients reported nationally in 2010. However the number of HIV tested TB patients is very small compared to the annual TB case detection(43% tested in 2010). There is no systematically documented report on possible changes in uptake of HIV services among TB patients, particularly with the introduction of a PITC approach. This assessment was conducted to determine the proportion of HIV among clients newly diagnosed with TB and assess the trends in proportion of HIV positivity over time.

6. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa 6 Methods ICAP-Columbia University (ICAP-CU) supports the initiation of TB/HIV integration – implemented in 37 health facilities in Q1 2007, now scaled up to 80 facilities by the end of 2010 At the initiation of HIV/TB integration, the staffs were trained in PITC, point of care HIV testing & Basic TB/HIV Co- management and proper documentation of TB/HIV services. Data on PITC at TB clinics were compiled from site-level registers, after checking for validity and completeness. The aggregate data collected during January 1,2007- December 31, 2010 were analyzed.

7. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Results(1) Of 96,607 new TB patients seen over the four year period, 56,623 (58.6%) were TB patients with unknown HIV serostatus; 52,040 (87.0%) received HIV testing using the Provider Initiated Testing & Counseling (PITC) approach. The proportion of TB patients with unknown HIV serostatus has declined from 95% in 2007 to 43 % in 2010 (P<0.0001). The testing rate among TB patients with unknown HIV status increased from 79.0 % in 2007 to 87.6 % in 2010 (p<0.0001).

8. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Registered TB Patients (2007-10) N= 96,607 Known HIV Status N=39,984 HIV + N=5,543 (13.9%) HIV – N=34,441 Unknown HIV Status N=56,623 (58.6%) Counseled N=52,040 (92%) Tested N=49,287 (95%) HIV + N=3,776 (7.7%) HIV – N=45,511 Not tested N=2753 Not counseled N=4583

9. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa HIV Counseling and Testing in TB Clinics Trends,2007-2010

10. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Proportion of TB Patients with unknown HIV status reaching DOTS Clinics

11. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Proportion of TB patients with unknown HIV status tested for HIV,2007-10

12. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa

13. Results(2) HIV Seroprevalence among TB clients with previously unknown HIV status decreased from 12.5 % in 2007 to 3.4 % in 2010 (P<0.01). No gender differences were noted. Overall, Proportion HIV Positive among all newly diagnosed TB patients (including those with known and previously unknown status) )declined from 13.7% in 2007 to 9.4% in 2010 (P<0.0001).

14. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa

17. 17 Conclusions and recommendations Uptake of testing using the PITC approach is very high. The Seroprevalence of HIV among TB patients declined through time. This finding has also been observed in the national ANC HIV sentinel surveillance where HIV prevalence declined from 5.5% in 2003 to 2.3% in 2009 which suggests that the HIV prevalence in Ethiopia may be declining. Even though the HIV prevalence among TB patients was dropping still this is higher than the general population underscoring the importance of strengthening TB clinic PITC services. The linkage of HIV positive clients identified from TB clinic PITC is still fairly high but needs further strengthening. Further studies will be required to identify the determinants of trends in HIV prevalence & for designing optimal strategies to link HIV positive clients identified from TB PITC

18. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Acknowledgements Federal Ministry of Health Ethiopia Oromia Regional Health Bureau Harari Regional Health Bureau, Dire Dawa City Administration Health Bureau Somali Regional Health Bureau CDC-Ethiopia/PEPFAR Columbia University, ICAP (Ethiopia & New York) All Facility Level Staff All clients in Care at ICAP supported facilities

19. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa References WHO, Provider initiated HIV testing & counseling Guideline,2007 FMOH, National TB/HIV Implementation GL,2008 FMOH, National Counseling & testing guideline,2007 FMOH/EHNRI, Report on the 2009 Round Antenatal Care Sentinel HIV Surveillance in Ethiopia, August 2011 FMOH, Annual TB Bulletin, March 2011 WHO, Global TB report 2011

20. The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa Thank You!!