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TB and HIV: Coordinating Care

The example of the “Integrated HIV


Care program” in Myanmar
41st Union World Conference on Lung Health, 11-15
November 2010, Berlin, Germany

P Clevenbergh, MD, PhD


Head of The Union’s Office in Myanmar
Myanmar
Myanmar
• TB: incidence 400/100,000 population per year

• HIV: prevalence of 0.7% in adult population


– wide variation among groups (Most at risk groups: up to 30%)
– about 240,000 HIV infected people nationwide

• 70% of HIV-infected patients will develop a TB during their


life-time
– often as the first serious opportunistic infection
– major cause of mortality and morbidity

• 10% of newly diagnosed TB patients are co-infected with


HIV with huge variations across locations (up to 30%)
TB/HIV deadly combination
⇒ HIV epidemics is contributing to an increase in TB cases
further fueling the TB epidemics

⇒ TB disease is the major cause of death of HIV infected


patients

TB

HIV

However, usually two national programs with little


links/interactions
WHO recommended TB/HIV collaborative
activities
3 « Is »
– Intensive case finding (both ways)
• HIV screening in TB patients
• HIV screening among family members of TB/HIV patients
• TB screening for family of TB patients
• TB screening for HIV-infected patients

– Isoniazid Preventive therapy


• To reduce the risk of TB disease in HIV patients

– Infection control procedures


• To stop the spread of TB among HIV patients
• Concerns about MDR/XDR TB
Introduction
 Program started in May 2005 with the agreement of the Ministry of
Health, MoU signed with MoH in September 2007

 Collaboration between MoH, NAP, NTP, WHO and The Union

 Sponsored by 3 Diseases Fund (2011), YADANA consortium


(2014), Global Fund (2015)

 Located in Mandalay, Lashio, Taunggyi, Pakokku (population 2.3


million people)

 Expanded to all HIV-infected patients, suppression of geographic


criteria for enrolment
Objectives of the IHC program

Provide comprehensive and integrated HIV care including
antiretroviral therapy to TB-HIV co-infected patients and their families
(spouses and children)


Strengthen TB-HIV collaborative activities with NAP and NTP
programs by developing and implementing policies regarding the
minimum package of care that should be available to TB, TB-HIV, and
HIV-infected patients


Field test TB-HIV collaborative activities implemented by both
Tuberculosis and HIV/AIDS control programs


Develop the capacity of the public health sector to take care of its
HIV-infected patients


Promote HIV, TB and TB-HIV awareness and prevention in the
community
Activities of stakeholders (1/4)
National Tuberculosis Program (NTP)

Manages TB diagnosis and treatment, including recording and reporting

Entry point for diagnosis of HIV: counselling and testing (PICT) of TB
patients, HIV rapid tests

Coordinates referral to HIV treatment and care services for TB/HIV
patients and family

Assess TB disease in PLWH
National AIDS Program (NAP)

Coordinates the program by providing supervision, monitoring and
evaluation.

Supports HIV VCCT in the NTP (provides HIV tests, training/quality
control)

Provides educational session for the general population

Addresses stigma, increases advocacy

Provides HIV VCCT and STD/STI screening and treatment in STD clinics

Supports People Living With HIV (PLWH) network, advocacy and social
mobilization

Screen PLWH for TB symptoms and refer to TB OPD
Activities of stakeholders (2/4)

Township Health Centres (TSHC)



Delivery of TB diagnostic and treatment services,

HIV counselling and testing for TB patients and spouses/children of
HIV/TB patients

Provision of CPT before IHC enrolment

Provision of IPT

Provision of information and educational material on HIV, and condoms to
patients attending their centres

Follow-up of “chronic care” for HIV-infected patients

Recording and reporting of TB/HIV activities

Tertiary Care District Hospital, Medical Units



Provision of specialized HIV care (ARVs, OIs prevention and treatment,
…) for inpatients and outpatients

Recording and reporting

Linkage with township health centres for defaulters’ retrieval
Activities of stakeholders (3/4)

Laboratories MGH/MTH/PHL/TBH/PGH

Support biological follow-up of HIV-infected patients including CD4
count

Quality control of HIV test and CD4 count

Culture of Mycobacterium tuberculosis of Smear negative TB/HIV and
screening PLWH

Drug store/pharmacy

Management of central and sub-stocks

Recording and reporting

Social Workers

Adherence counselling sessions

Home visit for defaulter retrieval

Help for social problems
Activities of stakeholders (4/4)

People living with HIV (PLWH) self-help groups



Advocacy and educational campaigns

Support of other PLWH for adherence counselling, education, …

Helping in HIV OPDs

TB symptoms screening using WHO questionnaire, IPT screening

Distribution of facial masks

Link with social workers and township health centres for defaulters’
retrieval.
Circui
Description of the services
• Dark blue arrows and blue boxes: places where the patients can seek tuberculosis
diagnosis (NTP)
• Light blue boxes: place where the patients receive TB treatment (NTP)
• Red arrows and red boxes: places where the patients access HIV counselling and testing
with same day test and result (NTP)
• Yellow box: place where the patients receive comprehensive HIV care and treatment
including OI prevention and treatment, antiretroviral drugs, biological follow-up and CD4
• Brown arrows and boxes: places where PLWH are actively screened for TB symptoms
and TB disease using questionnaires, sputum microscopy, chest X ray and culture (NTP)
• Pink boxes and arrows: defaulters'tracing activities by Basic Health Staff, Social
Workers, and Peers
• Light green boxes: places where HIV prevention is available: health education material
and condoms (NTP)
• Orange boxes: places where Cotrimoxazole/Isoniazid Preventive Therapy is distributed
(NTP)
• Dark green box: places where the NAP is taking care of pre-ART HIV infected patients
Patient’s flow Mandalay

STD clinic
Pre-ART pts
MGH OPD UMTBC HIV
OPD
Medical wards
Admitted pts MCH OPD

MTH OPD 7 TSHC HIV


OPD
TB OPD
TSHC (TB/HIV pts)

Care and Decentralization


Entry point
treatment

“in, by, and with the public sector”


Methods: HIV testing register
Recording of TB/HIV activities at township
health centres
Number of adult TB patients
registered

Number of TB patients offered


HIV test

Number of TB patients
HIV tested

Number of HIV co-infected


patients

Number of spouses/children of
TB/HIV patients offered HIV
test

Number of spouses/children of
TB/HIV patients HIV tested

Number of HIV infected


spouses/children
Methods: HIV positive register at township level
Facial mask for patients

Help us to stop transmission of TB from a patient to


another by wearing a facial mask
Summary sheet
LTF/defaulters’ tracing form for TB key person, PLWH
network, Social workers
Care and treatment

• HIV OPDs: capacity approximately 7500 patients in MDY

• GOV clinicians MO, AS, HS: 1 GOV MO responsible for


each OPD, usually + 1-2 AS. OPD starts with the GOV MO

• IHC facilitators: 1-3 facilitators per OPD

• GOV nurses/pharmacists: 2-3 nurses per OPD


(1 pharmacist) for drug delivery

• PLWH network: 1-3 volunteers/ OPD

“in, by, and with the public sector”


Some results....
• > 11,000 TB patients tested for HIV as of October 2010

• > 8000 episodes of TB symptoms screening in HIV OPD

• Referral of TB suspects to TB OPD

• Cotrimoxazole preventive therapy at township level

• Isoniazid preventive therapy at township level

• HIV test at township level

• HIV Chronic care at township level

“in, by, and with the public sector”


TB/HIV activity at Township level
2009 Report for IHC program    

total percentage
Total TB Patients registered
Adult 2991
Children 768
Patient Offered for Testing 2830 95%
Patient tested for HIV 2610 87%
Patient with positive result 803 31%

Relative offered for testing 499 62%


Relative tested For HIV 430 86%
Relative with positive result 263 61%
TOTAL HIV infected 1066
TB/HIV activity at Township level
2009 Report for IHC enrollment
Before Enrollment
Total percentage
Total HIV positive patients 1066
Patients enrolled 832 78%
Patients expired before enrollment 34 4%

patients not enrolled 159 15%


No residential form 10 102 64%
Transferred out 4 3%
Not willing to enroll 18 11%
Other 35 22%
TB/HIV activity at Township level

2009 Report for IHC enrollment

After Enrollment

Patients enrolled 832


Patients received CPT 981
Patients received ART 543 65%
Patient expired after enrollment 47
Patients expired on ART 61
• One third of TB cases are due to HIV co-infection

• TB clinic is an efficient entry point to enter an HIV


care program

• Many HIV-infected patients are diagnosed late,


when symptomatic

• Spouse testing yield many additional HIV-


infected patients, usually asymptomatic
Enrollment of TB/HIV co-infected patients

34%
TB outcomes in relation to HIV sero-status

Higher mortality among TB/HIV co-infected


group (3% vs 15%)
Risk factors of an unfavorable TB outcome for all TB/HIV
co-infected patients

Risk factors Adjusted 95% CI p


OR

Not having access to HIV care 4.26 (3.41 – 5.32) < 0.01
program

Old age (above 44 years) 1.49 (1.07 – 2.08) 0.02

Category II TB treatment 2.43 (1.67 – 3.56) < 0.01


Risk factors of an unfavorable TB outcome for co-infected
patients accessing HIV care program

Risk factors Adjusted 95% CI p


OR
Old age (above 44 years) 2.18 (1.28 – 3.72) < 0.01
Female gender 1.50 (1.00 – 2.23) 0.05
Underweight (BMI ≤ 18) 1.91 (1.28 – 2.86) < 0.01
Not started on ART 2.82 (1.87 – 4.26) < 0.01
Baseline CD4 count ≤ 100 cells/µl 1.89 (1.24 – 2.89) < 0.01
Moderate anemia 1.98 (1.17 – 3.34) 0.01
Severe anemia 3.29 (1.93 – 5.60) < 0.01
A history of prior TB 3.33 (2.03 – 5.47) < 0.01
Total enrollment patients and Total active follow up of
IHC program in Myanmar (MDY +PKK +TG + LS)

Total

Total ever 6448


enrolled patients

Active follow up 4897

Total patients 4650


ever started
ART
Active follow up 3702
on ART
ART outcomes of IHC program in Myanmar
(MDY + PKK+ TG+ LS (Sept 2010)
Conclusions (1/2)
 Recognition: After > 5 years of implementation the IHC
program is a success and is seen by the medical society at
national and international scale and by the United Nations
Agencies as extremely effective. Pioneer program in
Myanmar.
 Sustainability: The IHC program brings together health
authorities at local, national and international level and
ensures the capacity building across the sectors.
 Networking: The IHC program relies on the collaboration
of various participants including township health centres
staff , PLWH self-help groups, and social workers
 Expansion: Thanks to the organisation and the policies put
in place, the IHC program is technically sound to be
scaled up
Acknowledgements
• Myanmar National AIDS Program

• Myanmar National Tuberculosis Program

• Medical and Para-medical teams in Mandalay General


Hospital and Mandalay Teaching Hospital
• Township Medical Officers

• People Living With HIV Network « Spectrum »

• WHO Myanmar, TB and HIV Dpts

• Union's HIV Department


Sponsors:

This program is jointly supported by


Thank you!