TB/HIV Integrationat ICAP-Supported Health Facilities

ICAP Data Dissemination MeetingMarch 4 2008

Andrea Howard and Suzue Saito

Outline• Background and rationale for TB/HIV integration• Review of TB screening questionnaire• Quarterly reported data on TB screening in HIV

care settings• Quarterly reported data on HIV testing in TB

clinics• Challenges of collecting and analyzing

aggregate data• Analysis on site/program level factors

associated with greater TB screening• Q&A

Background

• Up to 80% of TB patients are HIV positive in high TB/HIV prevalence countries

• People with HIV are 50x more likely to develop TB in their lifetime than HIV-negative people

• 1/5-1/3 of all AIDS deaths worldwide are due to TB

Integration of TB/HIV Services

A Common TB and HIV Paradigm

TB Services•Sputum collection•DOT•Contact tracing• IPT•HIV C&T•CPT•ART

HIV Services•C&T•CPT•ART•OI Dx & Tx•Adherence support•PWP•TB screening•TB diagnosis• IPT

HIV Services• C&T• CPT• ART• OI Dx & Tx• Adherence support

• PWP

TB Services

• Sputum collection• DOT• Contact tracing• IPT

National TB Program

National HIV Program

National TB Program

National HIV Program

An Alternative TB/HIV Paradigm

Integration of Services

Communication

Which model for collaboration?

TB HIV

TB HIV

TB HIV

Referral

Referral‘One stop service’ for TB patients with HIV

Partial integration TB/HIV

Rationale for TB/HIV Integration

•TB clinics are an entry point at which HIV-infected persons can be identified and engaged in HIV care

• ART increases survival in HIV-infected persons with TB

• Routine screening for TB in persons enrolling in HIV care is essential to early diagnosis, improved outcomes, and preventing its spread to others in the community and health care settings

TB Screening in HIV Care Settings

Items in TB Screening Questionnaire for Select ICAP Country Programs

Cough Fever Weight loss

Night sweats

Contact with TB

Other

Cote d’Ivoire

√ √ √ √ √

Ethiopia √ √ √ √ √

Kenya √ √ √ √ √Mozambique √ √ √ √ √ hemoptysis

Nigeria √ √ √ √ √ Prior TB

Rwanda √ √ √ √ √

South Africa

√ √ √ √ Chest pain,Swollen nodes

Tanzania √ √ √ √ hemoptysis

Cough Fever Weight loss Night sweats

Contact with TB

Other

Cote d’Ivoire >3 w >3 w >3kg in 1m yes Yes

Ethiopia >2 w >2 w >3kg in 1m >2 w Yes

Kenya >2 w >3 w >3kg in 4w >3 w Yes

Mozambique >3 w >3 w >3kg in 1m >3 w Yes (home treated for TB)

hemoptysis

Nigeria >2 w >2 w Observed >3kg in 4w

>2 w Yes (or long standing cough)

Prior TB

Rwanda >3 w >3 w >3 kg in 4w >3 w yes

South Africa >2 w >2 w Yes >2 w NO Chest pain, swollen nodes

Tanzania >2 w >2 w >3 kg in 1m >2 w NO hemoptysis

Items in TB Screening Questionnaire for Select ICAP Country Programs

TB Screening Questionnaire

TB Suspect

Sputum smear microscopy

Sputum smear positive

Treat for TB

Sputum smear negative

Sputum smear microscopyChest x-ray

Clinical assessmentTB is likely

Not a TB Suspect

TB is unlikely

Treat for bacterial infection or PCP

ResponseNo response

Reassess for TB

+ -TB Screening

TBDiagnosis

The Data: TB Screening in HIV Care Settings

Country Sites supported Sites reportingCote d’Ivoire 23 21

Ethiopia 51 *

Kenya 73 73

Mozambique 35 32

Nigeria 57 57

Rwanda 44 44

South Africa 37 24

Tanzania 77 74

397 325 (82%)

As of December 2008…

Quarterly Indicators• Proportion of new patients screened for active TB at enrollment into HIV

care• Proportion of new patients who were screened for active TB at

enrollment into HIV care who screened positive• Proportion of new patients who screened positive for active TB, were

subsequently diagnosed with active TB and started treatment for active TB disease

• Proportion of new patients who were diagnosed with active TB and started treatment for active TB disease

• Proportion of patients diagnosed with active TB who started cotrimoxazole prophylaxis

• Number of patients eligible for IPT who started it in accordance with national guidelines

Standards of Care (SOC) for TB screening

• All patients enrolled in HIV care and treatment should be screened for TB at their first visit.

– Target: >90%

Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programs,

October-December 2008%

pat

ient

s

• Tanzania close to SOC target of > 90%• In other countries, many patients are not screened at enrollment

n=29,081 n=3,538 n=2,235 n=770 n=7,197n=5,187 n=8,023New HIV patients n=2,131

Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programs

over time

n=8,685 n=14,824 n=18,886 n=19,104New HIV patients n=23,991 n=24,705 n=32,760 n=29,081

% p

atie

nts

Proportion screened for TB has increased over time,but still falls short of SOC target of > 90%

Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment

programs over time, by country

% p

atie

nts

Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment

programs over time, by country

% p

atie

nts

Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment

programs over time, by country

% p

atie

nts

Proportion of HIV patients screened for TB who screened positive at ICAP-supported care and treatment programs, October-December 2008

% p

atie

nts

n=19,610 n=4,614 n=528 n=1,458 n=3,855 n=3,619 n=3,441Screened patients

n=2,095

• Proportion screened positive varies substantially across countries• Results from Moz, CDI, SA may be inflated due to selection bias

Proportion of new HIV patients with a positive TB screen who initiated TB treatment at ICAP-supported

care and treatment programs, October-December 2008

% p

atie

nts

n=4,596 n=510 n=596 n=637 n=2,371 n=259Screened positive patients

• Proportion diagnosed/treated (among those with positive screen)varies substantially across countries

• This may be due to biased screening

na

Proportion of new HIV patients who initiated TB treatment at ICAP-supported care and treatment

programs, October-December 2008

% p

atie

nts

Proportion diagnosed/treated (among all new patients) is relatively lowin all countries

n=29,081 n=3,538 n=2,235 n=770 n=7,197n=5,187 n=8,023New HIV patients n=2,131

HIV Testing in TB Clinics

HIV C&TOnsite Off-

site

HIV +

• Enroll in HIV care & treatment• Provide Cotrimoxazole preventive therapy

Onsite Offsite

HIV -

Unknown HIV status

The Data: HIV testing in TB clinics

• As of December 2008…Country Sites supported Sites reportingCote d’Ivoire 7 7

Ethiopia 51 49

Kenya 73 72

Mozambique 32 32

Nigeria 71 57

Rwanda 29 28

South Africa 2 2

Tanzania NA NA

265 247 (93%)

Indicators

• Proportion of new patients with unknown HIV status at enrollment into TB care who were tested for HIV while in care at the TB clinic

• Proportion of new patients with unknown HIV status at enrollment who test positive for HIV while in care at the TB clinic

• Proportion of new patients diagnosed with HIV while in care at the TB clinic who were subsequently enrolled in HIV care and treatment

• Proportion of HIV positive patients who were started on cotrimoxazole prophylaxis while in care at the TB clinic

SOC for HIV Testing of TB patients

• TB patients with an unknown HIV status or an HIV negative status that is >6 months old should be counseled and tested for HIV during the first 2 months of TB treatment.

– Target: >90%

Proportion of new patients with an unknown HIV status at ICAP-supported TB clinics who were HIV tested, Oct-December 2008

% p

atie

nts

New TB patients n=11,295 n=296n=952 N=6,054 n=1,231n=240n=551 n=1,971

Proportion of new TB patients who are HIV tested is relatively high

Tested at TB clinic Tested at any clinic

Proportion of new patients with unknown HIV status at ICAP-supported TB clinics tested for HIV over time

n=7,441 n=6,955 n=7,481 n=7,271New HIV patients n=10,027 n=8,700 n=10,781 n=11,295

% p

atie

nts

• Proportion new TB patients HIV tested has increased over time• For the past three quarters, we have reached the SOC target >90%.

Proportion of HIV tested TB patients at ICAP-supported TB treatment programs who tested positive, October-

December 2008

% p

atie

nts

HIV tested TB patients N=10,185 N=245 n=937 n=882 n=292 n=189n=1,752n=5,888

Proportion new TB patients tested HIV positive is relatively similar across countries except in Cote d’Ivoire and Ethiopia.

HIV tested at TB clinic HIV tested at any clinic

Proportion of HIV(+) TB patients enrolling in HIV care at ICAP-supported TB treatment programs, October-

December 2008

% p

atie

nts

HIV positive patients n=2,027 n=660n=112 n=360 n=384n=403 n=31

In sites with HIV care and treatment on-site (SA, Rwanda),enrollment in HIV care is universal.

Challenges of Collecting and Analyzing Aggregate Data

• Difficult to pull together data from multiple points of care

• Difficult to establish trend as continuously adding new sites

• Difficult to distinguish whether not recorded = not done or problem with recording

• Standardizing interpretation of indicators across countries

• Incomplete reporting

On-Site Location of TB Services is Associated with TB Screening of

HIV-Infected Patients at Enrollmentin HIV Care Programs

in 6 Sub-Saharan African Countries

AA Howard, S Saito, D Nash, R Flam,B Elul, A Scardigli, B Oyeledun,

A Cunningham, D Hoos, W El-Sadr

Abstract 590, CROI 2009

Study Aims

• To examine trends in the proportion of newly enrolled HIV care patients screened for TB and started on TB treatment between 1/07 & 6/08

• To identify program-level factors associated with greater TB screening at HIV care clinics

Data Sources• Aggregate quarterly data

– Between 1/07-3/07 (Q1) and 4/08-6/08 (Q6)– 238 HIV care clinics (93,935 patients)– 6 countries (Cote d’Ivoire, Kenya, Mozambique, Nigeria, Rwanda,

Tanzania)– 718 observations– TB screening performed using standardized symptom

questionnaire– TB treatment initiation based on national algorithms

• PFaCTS– Cross-sectional structured survey of program and facility

characteristics in 6/08– Site visits and staff queries at 181/327 facilities

Analyses

• Trends over time in mean proportion of newly enrolled HIV care patients– screened for TB using a symptom questionnaire– started on TB treatment– weighted for program size (# patients currently in

care)• Multivariate linear regression to determine

associations of program and facility characteristics with proportion of newly enrolled HIV care patients screened for TB in Q6

Q1 Q2 Q3 Q4 Q5 Q60

50

100

44 44

55 5763

76

Mean Proportion of New HIV Patients Screened for TB, restricted to 58 sites that have 6 quarters of data

(January 2007 - June 2008)

Perc

ent

p=0.016

03/07 06/07 09/07 12/07 03/08 06/080

10

20

43

45 5

6

Mean Proportion of New HIV patients Started on TB Treatment, restricted to 58 sites that have 6

quarters of data (January 2007-June 2008)

Perc

ent

p=0.016

Conclusions• Routine TB screening using a simple symptom questionnaire results in

a substantial number of HIV+ persons being diagnosed and treated for TB at enrollment in HIV care

• Sizable improvement in screening coverage was achieved over time

• Co-locating TB treatment services with HIV care and treatment services could result in increased TB screening and case finding among patients enrolling in care

• Further efforts are needed to– Define individual risk factors for TB in those enrolling in HIV care– Elucidate which characteristics and combination of symptoms are associated

with diagnosis of TB– Rigorously validate the screening questionnaire

Acknowledgements

Y Wu, G Vandebriel, C Casalini,H Yahaya, Z Samoei, D N’Dabian,H Broul, M Sheriff, F Alvim, F Oronsaye,V Mugisha, H Nuwagaba-Biribonwoha, ICAP Country Directors, ICAP Program Directors, site staff, Ministries of Health and partner organizations in Cote d’Ivoire, Kenya, Mozambique, Nigeria, Rwanda and Tanzania.