1. Mean Chhi Vun, MD, MPH NCHADS Director mchhivun@nchads.org Cambodia’s Experience on the Scale-Up of Collaborative TB/HIV Activities The 15 th Core Group Meeting of the TB/HIV Working Group, November 3-4, 2009, Geneva

2. Demography and Health Status in Cambodia Total pop. In 2008 = 13,69 million* Male to Female sex ratio is 93.5* Age group 15-49 is 47.9%** (estimated total female pop. = 2,98 million) Rural pop. (85%) and Urban pop. (15%)* Annual Growth rate = 1.81%* (estimated No. of baby born per year = 540,000) IMR in 2005 = 66 per 1,000 LB and U5MR = 83 per 1,000LB** MMR in 2005 is 472 deaths per 100,000 LB** Sources: * 2008 census (MOP) ** CDHS, 2005 ** CDHS, 2005

3. HIV/AIDS Situation in Cambodia First HIV detected in 1991 and first AIDS case diagnosed in 1993 Main route of HIV transmission: heterosexual intercourse (95%) MARP Group: EW, MSM, DU including IDU, Mobile people In 2006: HSS’06, SSS’05 and BSS’05 - Estimated HIV prevalence among adult pop. age 15-49 is 0.9% and among pregnant women at ANC is 1% - Estimated number of PLHAs among adult population: 67,100 (women 57,500) and AIDS patients: ~ 30,000 - No official data on HIV infected children (estimated number was 9,000 HIV infected children including 3,000 AIDS patients)

4. Situation of TB in Cambodia Cambodia is one of the 22 high-burden countries of TB in the world 64% of the total population has been infected with TB Incidence Rate of TB all forms: 495/100,000 Incidence Rate of TB SS +: 219/100,000 Prevalence of TB all forms: 664/100,000 Mortality due to TB: 89/100,000

5. 5 HIV Prevalence Among Adult pop. 15-49, between 1995 and 2006

6. AEM-projected prevalence of HIV among the general population aged 15 – 49 years from 2006 – 2012 (with ART available)

7. HIV incidence* among ANC by survey year HIV incidence* among ANC by survey year

8. Actual number of AIDS Patients Receiving ART as of September 2009 (81%) (95%) (97%) 2009 Target: Adult: 33,500 Children: 4,300 Total: 37,800 OI&ART: 52 sites PAC: 29 sites

9. 9 HIV sero-prevalence trend among TB cases

10. 10 TB/HIV Collaborative Activities (1)  1999 : TB/HIV Sub-Committee was set up  2001 : First TB/HIV Clinic (CENAT/JICA) at Capital City  2002 : TB/HIV Framework has been endorsed by MoH  2003 : TB/HIV Pilot Projects at 4 sites: TB screening at OI and ART service  2003: CoC including TB screening and TB diagnosed for suspected case among PLHA before to start ART  2005: Joint statement between TB and HIV Program: - Clearly defined role and responsibility of each Program: LSM - Clearly defined role and responsibility of each Program: LSM - Joint training activities - Joint training activities  2005: SOP for HIV testing among TB patients (HPITC) - Option 1: Refer TB –DOT to the nearest VCCT - Option 1: Refer TB –DOT to the nearest VCCT - Option 2 : Transport blood sample of TB to the nearest VCCT by HC - Option 2 : Transport blood sample of TB to the nearest VCCT by HC - Option 3 : Taken blood sample of TB by HC staff through outreach - Option 3 : Taken blood sample of TB by HC staff through outreach and send it to the nearest VCCT and send it to the nearest VCCT

11. 11 TB/HIV Collaborative Activities (2)  2008 : Standardized TB/HIV Monitoring tools (TB Register, Reporting,...)  2008 : TB/HIV training curriculum and Clinical manual have been developed and endorsed by MoH  2009 : Revised TB/HIV Framework has been submitted to MoH  2009 : Reviewed TB/HIV Monitoring and Reporting System assisted by WHO  2009 : 3 Is Concept have been translated into action - TB screening among all PLHA newly diagnosed (interviewed by HIV Counselors and OI and ART team) - TB screening among all PLHA newly diagnosed (interviewed by HIV Counselors and OI and ART team) - TB Infection Control at CoC services - TB Infection Control at CoC services - IPT (3 sites have been piloted since 2004), but No Expansion - IPT (3 sites have been piloted since 2004), but No Expansion

12. As a Result of the Combined Efforts For Over the Last 10 Year, 1999-2009

13. 13 Result of TB/HIV Training Activities  By 2008 : Health workers in 68 of 77 ODs trained on TB/HIV collaborative activities  By April 2009 : 6 batches of 5 days training program on clinical management were completed: - Trainees: Clinicians working at TB Ward of National Hospital, - Trainees: Clinicians working at TB Ward of National Hospital, RH at Provincial and OD level, NGOs,... RH at Provincial and OD level, NGOs,... - Training Site: 11 provinces, 1 NGO, 3 National hospitals - Training Site: 11 provinces, 1 NGO, 3 National hospitals

14. 14 HIV testing and ART in TB 2007 (all ODs) 2008 Total TB cases registered 36,42139,820 Unknown HIV status after TB registered 31,13636,942 Referred to VCCT 13,535(43%)19,963(54%) HIV tested 11,82018,645 HIV positive 497 (4.2%) 431(2.3%) TB/HIV under CPT 1,1011,279 TB/HIV under ART 610733

15. 15 Intensified TB case finding and IPT 20072008 HIV+ Registered at VCCT 11,6419,511 HIV+ clients screened for TB 5,318 (46%) 5,980 (63%) TB diagnosed 1,9742,159 Sputum smear+ 501 (25%) 522 (24%) Sputum smear- 787 (40%) 826 (38%) EPTB 686 (35%) 811 (38%) IPT (3 sites only) 7766

16. Main Challenge: Human Resource VCCT ANC FP/BS MNCH PMTCT STI Health Staff EPI OI and ART PAC TB CPA and MPA

17. Challenges  Work load of existing health staff at NCHADS, CENAT and PHD/OD  Creating conflict of interest and benefit (competition for resources)  Limited capacity for program management including finance and budgeting, reporting at peripheral level  Limited Capacity to own the TB/HIV collaborative activities at OD level  Limited Understanding of the issues at all levels  Unclear about Vertical and Integrated Programming ?  Limited Capacity in strategic thinking for having new approaches or models and Acceptance of Change.  Harmonization among partners – needs strengthening

18. 18 Increase access to IPT through Linked Response package activity at OD level (Linked response between HIV/AIDS /STI/RH/TB): Increase access to IPT through Linked Response package activity at OD level (Linked response between HIV/AIDS /STI/RH/TB): - 2010: If enabling environment will be good and supportive, - 2010: If enabling environment will be good and supportive, in 15 OD providing one stop service (increasing access to IPT from 66 to 1320 PLHA) in 15 OD providing one stop service (increasing access to IPT from 66 to 1320 PLHA) - Develop SOP for implementing IPT at OD level - Develop SOP for implementing IPT at OD level - Standardize monitoring tools for IPT including community base support activity - Standardize monitoring tools for IPT including community base support activity - Strengthen the referral and follow up TB/HIV co-infection who are receiving IPT through LR network (HIV services and TB service and linking them with community base support activity) - Strengthen the referral and follow up TB/HIV co-infection who are receiving IPT through LR network (HIV services and TB service and linking them with community base support activity) - Build ownership of the OD/HC Management Team to incorporate IPT into LR package - Build ownership of the OD/HC Management Team to incorporate IPT into LR package Next steps

19. NCHADS HIV/AIDS/STI Prev., Care and treat NCMCH (RH, FP, MNH) MOH Package of Services: - Policy, strategy... - Planning and monitoring - Capacity building - Technical support - Logistic management - Data management PAO HIV/AIDS/STI Coordinator HIV/AIDS/STI PMCH (RH, FP, MNH) Coordinator MCH HIV/AIDS/STI and RH: Program Management After 2002 Good collaboration

20. TB +TB +IPT +TB screening

21. Thank you