Expanding TBHIV joint activities: the role of PITC for access to HIV care and treatment

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Expanding TB/HIV joint activities the role of
PITC for access to HIV care and treatment

• Dr Somsak Akksilp
• ODPC 7th, Ubon ratchatani
• Department of Disease Control
• Ministry of Public Health

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TB/HIV Collaborative Activities

• Establish mechanisms for collaboration
• Set up a coordinating body for TB/HIV activities
• Conduct surveillance of HIV prevalence among TB
  patients
• Carry out joint TB/HIV planning
• Conduct monitoring and evaluation
• Decrease the burden of TB in PLWHA
• Establish intensified tuberculosis case-finding
• Introduce isoniazid preventive therapy (IPT)
• Ensure tuberculosis infection control
• Decrease the burden of HIV in TB patients
• Provider initiated HIV testing and counselling
  (PITC)
• Introduce HIV prevention methods
• Introduce co-trimoxazole preventive therapy (CPT)
• Ensure HIV/AIDS care and support
• Introduce antiretroviral therapy

WHO Interim Policy on Collaborative TB/HIV
Activities
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TB/HIV situations in THAILAND

• 17th on WHOs list of 22 TB high-burden countries
• Adult HIV prevalence 1.4 (2005), with
  currently gt 500,000 PLWHA
• 100 coverage (MOPH facility) of DOTS
  implementation since 2003
• To access HIV care HIV testing ? CD4 count to
  assess eligibility for anti-retroviral therapy
  (ART) ? attend HIV clinic to begin ART
• Anti-retroviral therapy (ART) now more widely
  available in Thailand

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Why TB/HIV Activities?

• Success rate had not achieved 85 though full
  scale of DOTS implementation gt 73 success rate
  11 TB deaths (Ubon, 2002)
• Theory HIV has a big impact on TB control
• Finding HIV-related TB deaths is around 48,
  54/113 (Ubon, 2002)

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Seroprevalence of HIV in New TB Patients,
Thailand, 1990-2002
Source Thailand Ministry of Public Health
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Results of DOTS implementation1999-2003, Region 7
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Lao PDR
N
Myanmar
Cambodia
Nakorn-panom
7 Provinces in Responsibility of DPC 7
mukdaharn
Amnat
Roi-et
Yasotorn
Ubon
Sri-saket
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Ubon ratchathani Province

• 1.7 million persons
• TB notification rate
• All cases 140/100,000
• Smear-positive 60/100,000
• HIV prevalence 0.6 in antenatal clinics (2003)

Thailand
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Implementation of TB/HIV activities Ubon, 2003

• Background
• Thai health system integrated health services in
  every hospital health center
• TB/DOTS and AIDS/CCC (Comprehensive and Continuum
  of Care) have been already implemented
• Concept
• Routine existing system, reset management for
  coordination of both clinics referral system,
  screening for co-infection, care for TB/HIV etc.
• Regular M E (routine record report)
• PDCA gt learning by doing

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Findings

• of HIV testing is quite low (33)
• Referral system between TB and HIV clinics was
  not satisfied time, workload, awareness of
  transmission, knowledge for the other disease
• No clear recording/ reporting forms for TB/HIV
  patients VCT testing, CD4, OI/ ART data gt
  difficult for M E
• TB clinic staff could not properly perform VCT
  whereas HIV clinic staff are scared of TB
  transmission in their clinic

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Previous TB Register
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Previous TB Register
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Activities

• Training of TB and HIV for HIV and TB clinic
  staff
• Orientation NGO/ PHA for TB activities
• Adapt TB card/register in order to perform M E
  for TB/HIV
• Start implementing PHA register in order to
  perform M E for HIV care including TB/OI
  treatment
• Regular meeting within the network to improve
  performances

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Details of PITC in TB patient

• A shortlist of pre-test giving information was
  created and used for TB patients.
• Confidentiality issue follows the routine HIV
  system.
• Informed consent form and process are similar to
  other HIV testing and counseling services.

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Standard short-list form
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Flow chart for PITC in TB setting
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TB/HIV joint activities
Training
HIV counseling training course for TB clinic
November 17-19, 2004
DOTS training course for HIV clinic staff
November 17-18, 2004
TB knowledge orientation for 60 people working in
NGOs/PHA groups November,
2004
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Adapted TB Register
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Adapted TB Register
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PHA Register
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TB/HIV Report
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Perform S M E
S M E for all hospitals especially big and
problematic hospitals and home surprise visit.
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Summary of performance of TB/HIV project ODPC
7
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Degree of Immune Deficiency in TB/HIV Patients
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TB/HIV Treatment Outcome
N Ubon 68 7 Provinces 112 8 Provinces 219
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Details of provision for TB and HIV-related
servicesin eight provinces, ODPC 7th, 2007
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Details of provision for TB and HIV-related
servicesin eight provinces, ODPC 7th, 2007
(cont)
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Conclusions

• Expanding HIV counseling and testing, PITC, could
  be done as a public health intervention.
• TB/HIV activities could improve the performance
  of TB control even in middle HIV prevalence areas
• TB/HIV joint activities implemented at the local
  level can be used to develop national policies
  that promote greater collaboration between TB and
  HIV programs
• Particular attention should be focused on the
  learning process of field staff gt PDCA cycle
  (needs close SME)

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National targets for TB/HIV
First year target is 100 of TB patients should
be counseled, no target for HIV testing.
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Challenge
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Elderly
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Hope
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CD4 10, TB
Feb 00
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The journey of thousand miles begins with a
small single step!!!
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Acknowledgement

• Health staff in the field who work very hard with
  inspiration.
• Thailand MOPH US-CDC Collaboration for its
  support to the implementation in
  Ubon-ratchathani.
• GFATM for its support to the expansion phase to
  other six provinces.
• Dr Ying Ru-Lo for her continuous efforts to
  support the implementation of TB/HIV
  interventions in the SEA region

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Thanks for your attentions

• www.dpc7.net
• akksilp_s_at_yahoo.com
• akksilp_at_health2.moph.go.th