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Tuberculosis and HIV Models for TB programmes to contribute to the delivery of ART What are the operational research questions?

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... Control structure to HIV treatment and care is one 'model' ... Reduced queuing time. Improved clinical monitoring. Allow adjustment for treatment interactions ... – PowerPoint PPT presentation

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Title: Tuberculosis and HIV Models for TB programmes to contribute to the delivery of ART What are the operational research questions?


1
Tuberculosis and HIVModels for TB programmes to
contribute to the delivery of ARTWhat are the
operational research questions?
  • Gerald Friedland, MD
  • AIDS Program
  • Yale University School of Medicine

2

Models of TB/HIV Care
  • TB and HIV-two cultures
  • Minimal TB and HIV Program needs
  • Spectrum of collaboration/integration
  • Case studies
  • Operational research issues

3
HIV/TB-Two Cultures
  • TB culture
  • public health approach, with firmly established
    algorithms, fixed and standardized measures and
    outcomes
  • TB services
  • geared for chronic care-but relatively short
    term, standardization, simplified regimen ,
    epidemic control, difficulty with individual
    nuance and new TB diagnostic dilemmas with HIV
    disease
  • HIV as an intruder
  • disrupting TB strategies and
  • programs
  • HIV culture
  • individual patient and human rights approach,
    guidelines but no standardization, familiar with
    rapid treatment paradigm changes
  • HIV services
  • clinically and patient oriented with only recent
    emerging public health practices lifelong
    treatment, limited experience with TB treatment
    and public health approach
  • TB as a challenge
  • discomfort with treatment in HIV setting

4

The Minimum for effective TB-HIV collaboration
  • Comprehensiveness
  • Continuity
  • Competence
  • Compassion
  • Cost effectiveness

5
The Minimum for effective TB-HIV collaboration
the TB side
  • Counseling and Testing for to identify HIV
    infected
  • HIV/AIDS staff training/awareness
  • Co-trimoxazole prophylaxis for TB patients who
    are HIV infected
  • Mechanism for referral for antiretroviral therapy
    for TB-HIV co-infected patients who need it (?)
  • Primary and secondary HIV prevention education
    for TB patients
  • Patient confidentiality

6
The Minimum for effective TB-HIV collaboration
the HIV side
  • Active TB case finding for all HIV infected
    patients
  • TB staff training/awareness
  • Mechanism for referral for Dx and TB treatment(?)
  • Mechanism for continuation of HIV treatment
  • Tuberculin skin testing (TST) for HIV infected?
  • INH preventive therapy (IPT) for TST
  • TB transmission prevention
  • Patient confidentiality

7

Models of TB/HIV Care OUTCOMES
  • Although delivery models differ, outcomes should
    be identical
  • TB treatment success- cure/completion of therapy
  • Reduction in HIV disease progression and
    mortality
  • Decrease in transmission of both diseases

8

Models of TB/HIV Care
  • Need for many models
  • One model may not fit all countries
  • Differences in HIV and TB prevalence
  • Differences in history, resources, culture,
    expertise
  • Differences in feasibility
  • One model may not fit one country
  • Urban vs. rural
  • TB clinic vs. primary care clinic
  • Logical to maximize/exploit existing site
    infrastructure
  • Hospitals, clinics, existing TB DOTS and HIV VCT
    programs, nascent HIV programs, available
  • human resources

9
Current and Optimal TB and HIV Program Paradigms
Current TB and HIV Programs Paradigm
Optimal TB and HIV Programs Paradigm
National HIV Program
National TB Program
National HIV Program
National TB Program
Communication Collaboration
HIV Services VCT OI Px Antiretrovirals Adherenc
e Support
Communication Collaboration
TB Services Sputum collection DOT Treatment
Support Contact Tracing LTBI Treatment
TB Services Sputum collection DOT Treatment
Support Contact Tracing LTBI Treatment
HIV Services VCT OI Px Antiretrovirals Adherence
Support
10
Which model of collaboration ?
TB
HIV/AIDS
TB
AIDS
TB/AIDS
TB
AIDS
Separate TB/ HIV patients referral
Full One stop service for TB-HIV
co-infected
Partial Some mixing
11
Models of TB/HIV Care and Treatment
  • HIV programs learn lessons from TB program with
    little to no integration of services
  • Malawi
  • TB programs serve as site for some integration
    and collaboration of services
  • START- Durban, Sizonqoba-Tugela Ferry
  • HIV and TB programs organized with full
    integration of services
  • Khayelitsha

12
Malawi model Anthony D Harries, HIV/AIDS Unit,
Ministry of Health, Malawi
  • HIV program learns from and uses DOTS model
  • No true integration of TB and HIV care
  • Appropriate in Malawi
  • Poor infrastructure with very few physicians
  • Large population with immediate need to start a
    significant number of patients on ART
  • 1 million people infected with HIV
  • 170,000 people needing HAART

13
Apply Tuberculosis Control structure to HIV
treatment and care is one model
  • Standardised diagnosis and case finding
  • (smear microscopy and well defined types of
    TB)
  • Standardised treatment
  • (three treatment categories to cover all
    types of TB)
  • Standardised recording and reporting system
  • (treatment cards, registers, cohort
    analysis, monitoring)
  • Standardised system of drug procurement
  • Management by paramedical officers
  • Free drugs for patients

14
Standardised Treatment Outcomes
  • TB Programme
  • Cured
  • Treatment completed
  • Dead
  • Defaulted
  • Failed
  • Transferred out
  • ART delivery
  • Alive and on ART
  • Dead
  • Defaulted
  • Stopped treatment
  • Transferred out

15
TB programs serve as site for some integration
and collaboration of services The START study
  • Demonstrate effectiveness and safety of HIV/TB
    integrated treatment strategy in an urban,
    resourced setting- Prince Zulu Communicable
    disease clinic, Durban, KwaZuluNatal, South
    Africa
  • Partnership of
  • I kithweni Muncipality Department of Health
  • CAPRISA- US NIH
  • Nelson R Mandela School of Medicine
  • Yale University, Columbia University
  • Irene Diamond Fund, Doris Duke Charitable
    Foundation

16
START-Pilot
  • TB program staff strengthened
  • Patients with active TB offered HIV counseling
    testing
  • ONCE-DAILY ART (DDI, 3TC, EFAVIRENZ)
    given concomitantly with standard TB DOT
    regimen (INH, RIF, ETH, PZA) 5 d/wk with weekend
    ART self administration
  • Adherence training and social support emphasized
  • Transition to ART self-administration at TB Rx
    completion- Referral to HIV Clinic
  • Assessment of viral load, CD4, mortality, side
    effects and toxicities
  • Assessment of acceptability and cost


17
(No Transcript)
18
Pilot START Results Mean Viral load and CD4
change over 21 months
Self administration
19
TB programs serve as site for some integration
and collaboration of services Sizonqoba study
  • Demonstrate effectiveness and safety of HIV/TB
    integrated treatment strategy in a rural,
    resource-poor setting, Tugela Ferry,
    KwaZuluNatal, South Africa

20
The Sizonqoba rural study
  • Project outline
  • Strengthening of TB DOT program
  • Merging TB DOT and Home Based Care Program
  • Training of physicians, nurses, community health
    workers-TB and HIV
  • TB pts identified in hospital, receive VCT
  • Once-daily DOT ART added to Home-based /TB DOT
    program and given with TB meds in community
  • Community and family social and adherence support
  • Community and clinical monitoring for benefit and
    risk.
  • Transition to self-administration at completion
    of TB therapy
  • Cost effectiveness study
  • Sexual risk study
  • Separate records, mostly separate staff, program
    monitoring, reporting, funding

21
adherence support group
22
Integrating 2 vertical services HIV/AIDS and
TB services , Khayelitsha, South AfricaDavid
Coetzee, Eric Goemere
  • 2000 opening HIV/AIDS clinics in public
    services, next to the TB clinic
  • 2001 first HAART patient gt 1400 patients 9-05
  • 2002 VCT re-enforced in TB service and easier
    access to HAART
  • 2003 merging both buildings and stepwise
    integration of HIV and TB services

23
Objectives of TB/HIV integration
  • For TB patients
  • To stimulate VCT among TB clients
  • 47 counselled and 87 accepted testing-(8-40
    Gugulethu) 63 co-infection
  • To accelerate access to HAART for TB/HIV
    co-infected
  • To reduce TB incidence among HIV patients
  • To improve TB diagnostic algorithms
  • To increase adherence and cure rate among TB
    patients by using the HIV adherence tools
  • HIV 95 (36 mos vs TB 75 Rx completion
  • HIV adherence tools and counselors

24
Objectives of TB/HIV integration
  • For HIV patients
  • To have an easier access to TB diagnosis and
    treatment
  • To develop a one stop service
  • To benefit from existing TB network to support
    HIV
  • For the health services
  • To pool TB and HIV staff and integrate training
  • To improve staff morale

25
develop a one stop service
  • Both building have been merged
  • 2 different patient flows
  • TB non co-infected 2 clinical visit/episode
  • HIV and co-infected monthly clinical visit
  • A positive impact on TB/HIV patients
  • Reduced queuing time
  • Improved clinical monitoring
  • Allow adjustment for treatment interactions
  • A negative impact on non-co-infected TB cases

26
pool TB and HIV staff and integrate training
  • Tb and HIV staff now able to rotate between
    services
  • No recruitment out of existing TB service but
    rather re-enforcement
  • Improved staff morale with improved treatment
    outcomes
  • New clinical career path for TB staff
  • Renewed doctors interest in TB

27
Operational Issues in TB and HIV Care
  • How to improve diagnosis of HIV in TB patients
  • Expand voluntary counseling and testing
  • Provide rapid point of care HIV testing
  • Provide routine counseling and testing in TB
    patients
  • Encourage provider based testing
  • Perform opt out vs. opt in testing
  • How to improve diagnosis of TB and LTBI in HIV
    patients
  • Develop algorithms for clinical assessment of
    TB disease
  • Develop and use of rapid diagnostic tests

28
Operational Issues in TB and HIV Care
  • How to improve treatment of HIV in TB
    patients
  • Determine best setting(s) to initiate and
    continue antiretroviral therapy in
    co-infected patients
  • Degree of integration/collaboration
  • Elucidate mechanisms to support adherence
  • Define the role of DOT in antiretroviral
    therapy
  • Identify most effective DOT dose, intensity and
    duration
  • Determine most appropriate person(s) to provide
    treatment
  • Determine role of non-physician health care
    workers
  • Determine role of community and family
  • Determine training needs
  • Determine how to minimize occupational/nosocom
    ial risk from HIV and TB

29
Operational Issues in TB and HIV Care
  • How to improve treatment of HIV in TB
    patients
  • Determine optimal time to start antiretroviral
    therapy
  • Identify optimal antiretroviral regimens to use
  • Determine how rifampin interactions with
    antiretroviral agent effect clinical outcomes
  • Identify proper dose of antiretrovirals in the
    presence of rifampin
  • Conduct observational and clinical trials to
    assess treatment effectiveness in co-infected
    patients
  • Establish appropriate schedules for toxicity and
    efffectiveness monitoring

30
Operational Issues in TB and HIV Care
  • How to improve the treatment of TB in HIV
    patients
  • Determine ways to strengthen existing TB
    programs
  • Evaluate measures of treatment success
  • Examine role of newer diagnostic tests to
    assess treatment
  • success.
  • Determine optimal duration of therapy
  • How to accommodate differing TB and HIV
    traditions and practices
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