1. TB- HIV Collaborative activities in Romania- may 2006 status
NTP Romania
National Institute for Lung Diseases Bucharest

2. Romania Location: Eastern Europe 314,000 square kilometers
22 million inhabitants
41 counties and the Capital city: Bucharest (2.5 million inhabitants)
13 medical universities (6 with over 50 years tradition , 7 are “born” after 1989

3. TB network- epidemiology
Since the 1950s, a strong TB network and centralized data-collection for TB patients has been in place
There are over 800 lung-disease specialists dealing with TB in 189 TB dispensaries, and more than 100 TB inpatient facilities
The bacteriological laboratory network: over 170 bacteriological laboratories
Annually over 20,000 new TB cases, are registered, along with over 4,000 relapses and over 1,000 TB cases in children.
There are about 1,000 MDR-TB cases
The MDR-TB rate among never-treated patients: 2.9 % (Last drug resistance survey ended in 2004)

4. National TB Control Programme
DOTS strategy started to be implemented in 1998 in pilot
Since then, TB-control activities have been continuously reinforced and the TB network was strengthened
WHO technical assistance was continuously provided

5. National TB Control Programme (History)
Main achievements revealed by the WHO Programme Review Mission during April 2005:
Functional TB network, including bacteriological laboratories
Diagnosis and TB treatment free of charge
Computerized data collection system in place
100% population covered by DOTS
An effective supervision- monitoring system in place
Over 70% case detection rate, and 82% success rate for the 2003 cohort
TB-HIV and MDR-TB issues addressed

6. M- intens. and cont. phase
Flow of the TB patients
Periodical
examinations
Suspects
Contacts
GP or other
Medical services
TB Ambulatory
New registered cases
M- intens. and cont. phase
M-cont. phase
TREATMENT M+
intensive phase
G.P. in
rural areas M-
TB Hospitals

7. National HIV/AIDS Control Programme (History)
1984: first AIDS case reported
breakdown in closed children communities, a challenge for public health authorities after 1989
1990: - computerized surveillance system
- 3 major laboratories were equipped in Bucharest for HIV
testing
2000: a national plan for universal access to ARV treatment and care started
2003: the universal access to ARV treatment free of charge was achieved

8. HIV/ AIDS Epidemiology
There are now 9 regional reference centers for HIV diagnosis, treatment, and follow-up.
HIV incidence among the general population:
1.53 % in 2000
1.11 % in 2005
Number of TB cases among HIV-infected persons:
174 in 2004
175 in 2005
Number of HIV cases: 6,433 (cumulative)
Number AIDS cases: 9,825 (cumulative)
Number of persons living with HIV/ AIDS at 31st of December 2005: 11,187

9. HIV Testing for TB Patients

10. HIV testing for TB patients (The project funded by the Global Fund)
Main objectives:
To establish an effective collaboration between NTP and HIV/AIDS Programme
To assess the percentage of HIV-infection among TB patients

11. HIV-Testing for TB patients (The project funded by the Global Fund)
First step: a formal collaboration protocol addressing the
following issues:
Responsible institution and staff
Case-management of HIV-TB patients
Data recording and reporting, exchange of information at central and regional levels
Supply with drugs for both treatment regimens
Supervision

12. Management of TB – HIV patient
Isolation of Smear + patients in TB-network wards
TB treatment is priority in front of HIV treatment
Drug sources: - NTP units for anti-TB treatment
- HIV/ AIDS units for ARV treatment

13. TB District-Level Dispensary Registration Anti-TB Drug prescription
SS -
SS +
Bacteriological laboratory (TB network)
Bacteriological examination
TB suspicion
TB patient
(anti-TB treatment )
HIV-infected person
(ARV treatment)
Counseling
County PHD Laboratory
HIV Testing
HIV/ AIDS regional centers
Initial and periodical evaluation
ARV drugs prescription
HIV +
HIV -

14. Recording and Reporting (forms used)
Notification form for the start of an anti-TB treatment
Filled-in and sent during first 48 hours to the TB county dispensary where the patients is living
Treatment card for TB
During all treatment course
Sent to the TB district-level dispensary when the treatment ends
Notification form for an HIV/ AIDS case
Filled-in with the personal information of the patient and sent to the regional center for HIV/ AIDS surveillance.

15. Recording and reporting (information reported)
Number of TB patients registered
Number of HIV-Tests perfomed for TB patients
Number of positive ELISA tests in TB patients
Number of TB patients confirmed with HIV (Western Blot)

16. Treatment If ARV is not compulsory: Standard regimens for TB treatment
If ARV are necessary:
avoiding the protease inhibitors,
If is not possible: replacement of Riphampicin with Riphabutin
Daily, including during the continuation phase
Duration of treatment: 9 months, instead of 6 months

17. HIV testing for TB patients (The project funded by the Global Fund)
Training of staff from TB network:
For pre and post testing counseling
Case management, recording- reporting, drug supply
150 persons trained from 47 centers (one/county)

19. Results During September 2004- September 2005:
15,474 confirmed TB cases were registered
Out of them: 9,475 were tested for HIV
27 were HIV positive: 0.28 %

20. Difficulties met
The common protocol was not yet endorsed by the public health authorities (Ministry of Health), so it was not sent to the Public Health Departments at county level.
There are few counties that are not reporting systematically
Difficulties in supplying process with HIV tests and materials at national level during 2005

21. Conclusions
Romania is considered by WHO at high risk for TB and at medium risk for HIV
HIV testing for TB patients has been continuously performed during last 2 years, in a continuously increasing proportion
Both Control Programmes are continuously strengthened and an effective collaboration has been started at central and county levels