1. Challenge 4: Linking TB & HIV/AIDS Programs Kayt Erdahl, Project HOPE Rodrick Nalikungwi, Project HOPE Malawi December 18, 2008

2. Topics Introduction Why is it important to link TB & HIV Programs? TB/HIV Interactions TB/HIV Strategies Project HOPE TB/HIV Program in Malawi Challenges Program activities & progress Lessons learned/recommendations

3. Why is it important to link TB & HIV programs? “Tuberculosis (TB) is a leading cause of HIV- related deaths worldwide. In countries with high HIV prevalence, up to 80% of people with TB test positive for HIV. Globally there were 700,000 TB cases among people living with HIV in 2006, and an estimated 230,000 people living with HIV will die as a result of TB in 2008 despite the fact that TB is curable.” http://www.who.int/hiv/topics/tb/en/index.html

4. TB/HIV Interactions HIV promotes progression from TB infection to TB disease. People with HIV are up to 50% more likely to develop TB in a given year than HIV- people. High rates of mortality among TB/HIV co-infected patients TB is more difficult to diagnose in people with HIV Infection control issues Treatment coordination for both diseases: drug interactions, IRIS, system policies

5. The Three Is Three key public health strategies focused on decreasing the impact of TB on people living with HIV: Isoniazid Preventive Therapy (IPT) Intensified Case Finding (ICF) for active TB TB Infection Control (IC)

6. Examples of areas that NGOs/CBOs can get involved Coalition development, coordination between TB and HIV services, PHC and communities Incorporate screening and testing for TB within HIV services and for HIV in TB services Capacity building, TB/HIV education Mobilize communities to demand coordinated services, and to seek diagnosis, treatment and care Decrease burden of HIV in TB patients: CPT, ART, HIV prevention, care and support

7. Mulanje pop. 548,250 Phalombe pop. 296,960 Project HOPE TB/HIV Project in Malawi Tuberculosis Control in Southern Malawi Child Survival TB & TB/HIV Grant funded by USAID Dates: Oct 2006-2011 Location: 2 Districts in Southeastern Malawi

8. Malawi & Program area Malawi Country in Southern Africa, 13 million population Health services provided mainly by Government, also Mission Hospitals and private sector Mulanje and Phalombe districts Shared border with Mozambique Population over 845,000 Largely rural, with inconsistent distribution of health facilities Communicable diseases are common –TB, HIV and Malaria

9. Malawi TB Goal & Objectives Sub-objectives: 1.Improve treatment outcomes of TB cases and TB cases with HIV co-infection in Mulanje and Phalombe 2.Increase case detection of TB, including among people with HIV co-infection in Mulanje and Phalombe Goal: to reduce morbidity and mortality due to TB and TB cases with HIV co-infection in the Mulanje and Phalombe Districts

10. Baseline, 2006Year 2, 2008 IndicatorMalawi 1 2 Districts 2 Malawi 3 Phalombe 4 Mulanje 4 Case detection rate, new SS+ 39%29%42%34%41% Treatment success rate, new SS+ 71%77%73% 76% Died, new SS+ 16%19%15%24%19% HIV Prevalence 14.1%18.6%14% 5 20-22% 5 HIV prevalence est. in incident TB Cases 50%70% TB & HIV Epidemiologic data 1 WHO 2007 Global TB Control Report (2004 cohort) 2 Mulanje & Phalombe District Health Office (TB 08 Q3 2005-Q2 2006) 3 WHO 2007 Global TB Control Report (2005 cohort) 4 Mulanje & Phalombe District Health Office (CD 2007, Treatment outcomes, 2006) 5 2007 AIDS Epidemic Update, Africa (2005 data)

11. Challenges ART accessibility limited for TB/HIV co- infected due to the MOH quota system for ART Service Providers and the community are at risk of TB infection due to inadequate infection control Not all health facilities have access to microscopy for TB diagnosis Existing laboratories need strengthening to improve quality of diagnosis Accessibility to HIV testing still limited in remote areas

12. Challenges Link between TB and HIV programs still weak Clinical issues –Initiation of ART in TB/HIV co-infected only starts after two months on TB treatment, by policy –Patients will not come for ART when they start feeling well –less recruitment on ART and increased risk of dying from AIDS –ART and TB drug interaction poses risks to patients

13. Program Activities - Community ASCM - Community education campaign –Increase recognition of TB symptoms, importance of HIV testing, early TB diagnosis, knowledge of TB/HIV interaction, behaviors related to HIV prevention –Volunteers, community leaders, shop owners, traditional healers, drama groups, families Improve TB symptom screening/referral by –Traditional healers & shop-keepers –HIV patients (self-referral) –Household contacts of SS+ TB cases –VCT/HIV Clinical care providers

14. Program Activities – Health Workers Train/mentor health workers (40) and health surveillance assistants (61) –DOTS, strengthen recording & reporting system –Recognition of TB symptoms & referral for testing, repeat testing for people with HIV –supervision of guardians, advocacy for TB & ARV treatment adherence Advocate for client-friendly services: hours, confidentiality Update/improve training manuals & curricula in collaboration with NTP for HCW, HAS, community groups Collaboration with national, local and international organizations and programs

15. Program activities - System Technical assistance for integration of HIV testing into TB system, and strengthening referral system between diagnostic and treatment services for TB and HIV Establish Coordinating Committees for case management Enhance quality assurance and standard operating procedures in collaboration with local health care authorities –Supportive supervision training –Monitoring visits with district or zonal TB officers Work with NTP to correctly implement WHO TB guidelines and reporting/recording system

16. Program Activities -Laboratories Laboratory assessment done - determined microscopy system needed strengthening Train/retrain laboratory staff in microscopy and recording system Enhance external quality assurance for microscopy - Development of QA monitoring tools Equip new laboratories for sputum microscopy – 3 new peripheral sites established in last year

17. Program activities – new developments New NTP policy of Universal Access to TB Diagnosis – Project HOPE is assisting in implementation of Community Sputum Collection Points in Mulanje and Phalombe High mortality rates among TB and TB/HIV patients - Death audits

18. Program progress IndicatorBaseline, 2006Year 2, 2008 % of TB suspects reporting to health facility within 8 weeks of cough 0%71% % registered TB patients who are tested for HIV 15%96% % TB/HIV Patients referred for HIV support services during TB treatment 15%97% Proportion of registered TB patients with HIV given ART during TB treatment 13%15%

19. Lessons learned/recommendations TB/HIV management capacity building for health workers is particularly important: Health Surveillance Assistants are often allocated to work on TB/HIV with minimal knowledge HIV Counseling and testing done during the TB admission period has increased awareness and access to testing NTP and National AIDS Program should standardize approaches to TB and TB/HIV

20. Lessons learned/recommendations It is important for Programs to make strong links with other groups implementing activities in the community, e.g. nutrition-providing partners, Village health banks, etc. Programs/activities that put focus on community TB interventions are the most effective strategies in controlling TB, e.g. Decentralized microscopy, sputum points and transmission of results Proper data collection and documentation of activities important for sharing information at different levels.

21. Lessons learned/recommendations While clinical interventions are important, community health education is equally important Programs doing community interventions in TB/HIV co-infection should not be short term since they target behavior change that needs adequate time to have impact.

22. Thank you! Any questions?