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!