Programmes gradually adopting TB/HIV activities, as funding and technical partners harmonise monitoring and evaluation

Bit by bit, measures to provide improved care for people with or at risk for TB/HIV are being introduced into countries with high burdens of coinfection — though most countries have yet to deliver the full package of recommended essential services, according to reports at the 2008 HIV Implementer’s Meeting held in Kampala, Uganda in June.

The number of successful model projects is growing — providing useful programmatic experience into what works and what doesn’t when trying to introduce activities to reduce the burden of TB/HIV — but examples of nationwide scale-up remain few. Leadership at the national level is often lacking, and even when TB and HIV programmes talk about coordinating their efforts at the national level — it is often not translated into action at the district level where services are delivered.

However, there is a global push from WHO’s HIV/AIDS and Stop TB Departments to get HIV programmes to take ownership of their role in TB control in people with HIV (see HIV & AIDS Treatment in Practice June 26 2008 edition). Furthermore, a plan from key funding and technical partners including PEPFAR, WHO UNAIDS, the Global Fund to harmonise monitoring and evaluation of TB/HIV activities could help simplify recording and reporting practices — which could both reduce the burden on health staff (and, thereby, increase the likelihood of implementation) as well as provide essential data to guide programme development. And finally, there are a growing number of successful examples where the community and been engaged and educated about TB/HIV — creating advocacy and demand for TB/HIV services.

TB is the leading cause of illness and death in people with HIV, and HIV is the primary reason why countries with a high burden of HIV have been unable to control the TB epidemic. However, TB is both preventable and curable — even in people with HIV (particularly if they are on treatment and care) — while the success of ART programmes in countries with the least resources demonstrates that there is a good chance for managing both conditions.

People with or at risk of TB or HIV may present themselves for care to either a TB or HIV care setting (or the general health services). Whether it is TB or HIV that prompts someone to seek out care, or wherever he or she comes into care, there is an opportunity to check to see whether the person has the other illness, and to provide prevention or treatment and care in a way that is convenient for the patient and more likely to keep the person in care.

To help programmes make the most of these opportunities to reduce the burden of TB/HIV, in 2004, WHO released a Policy on Collaborative TB/HIV Activities.

There are essentially three types of activities: 1) those that foster improved collaboration between National AIDS Programmes and National TB Programmes, 2) activities that TB programmes should do to reduce the burden of HIV in TB patients (such as HIV testing, prevention, care and treatment including ART, and 3) activities that HIV programmes should do to reduce the burden of TB (intensified TB case finding, infection control and Isoniazid preventive therapy, collectively known as the Three I’s (see HIV & AIDS Treatment in Practice June 26 2008 edition).

A year ago, HIV and AIDS Treatment in Practice #88 reported on the successful national implementation of several of these key activities by Kenya and Rwanda. This happened partly as a result of meetings between PEPFAR and some of its focus countries to jump start collaborative activities at the national level.

More fruit from those efforts could be seen in some presentations at this year’s Implementers’ Meeting. Yet, for the most part, much of the progress reported came from either projects at the regional or district level often led by just one implementing partner (such as the International Center for AIDS Care and Treatment Programs (ICAP), University Research Co (URC), TB-CAP, etc). However, equitable delivery on the full package of collaborative activities throughout countries is lagging.

For example, PEPFAR has many partners in Uganda, many of whom are doing ground-breaking work. But despite being a leader in the care of people with HIV, a recent analysis shows that Uganda still has a long way to go in terms of the delivery of collaborative TB/HIV activities at the national level.

Anna Nakanwagi-Mukwaya, of the International Union against Tuberculosis and Lung Disease (the Union) in Uganda and TB-CAP presented the results of a cross-sectional study by the Union and the Ministry of Health into the capacity and delivery of TB/HIV services in 26 Ugandan districts, including a total of 154 health facilities (six randomly selected from each district). The survey, performed in September 2007, included all the regional and district hospitals in those districts, but over three quarters of the sites were smaller, ‘level III’ and ‘level IV’ health facilities.

Although not perfect, TB and HIV diagnostic capacity was described as being ‘satisfactory.’ About 88% of the facilities could do sputum microscopy while 98% offered HIV testing and counselling services. TB treatment services were generally available (at 87% of the facilities), while 77% of the facilities offered community-based DOTS (primarily at the lower level III and IV clinics).

HIV treatment and care services were also reported to be widely available: 93% offered cotrimoxazole, 94% treatment for opportunistic infections, and 87%, PMTCT services. ART on the other hand was not as widely accessible, only being prescribed at 47% of the facilities (54% of the level III clinics offered ART, while 15% of the level IV clinics did). Though there is room for improvement here, this is pretty much the norm in many resource-limited settings, since ART tends first to be rolled-out at larger facilities first — with the lack of trained staff to prescribe treatment at the smaller facilities being the common reason. “HC IVs and HC IIIS had the most significant gaps in human resources,” said Nakanwagi-Mukwaya. For instance, the government requires that healthcare level IV facilities have a medical officer — and 40% of them did not.

Nevertheless, the survey found that the facilities do have the capacity to deliver most collaborative TB/HIV activities — but they just haven’t been doing so. The problem could be that no one has told them exactly what they should be doing. Training was found to be generally poor (20% for medical officers, 27% of clinical officers and 47% of nurses reported having been trained on TB/HIV collaborative activities) while the actual MoH policies (established in 2006) do not seem to have been distributed to the facilities. “Only 17% and 10% of the facilities studied had a copy of the TB/HIV policy guidelines and communications response strategy, respectively,” said Nakanwagi-Mukwaya. “And coordination of TB/HIV activities, which at the national level has been improving steadily, at the district level was almost non-existent.”

Despite on-site HIV testing, uptake among TB patients was very low — only 39% percent of the TB patients seen in the quarter preceding the study period had been tested for HIV. Given the fact that 51% of those had tested HIV-positive, this is a major problem. And what’s worse, of those who were HIV-positive, only 21% actually received cotrimoxazole, and only 7% received ART.

Of the Three I’s, the survey only investigated whether intensified TB case finding is being performed — and only 27% of level IV’s and 37% of level III facilities reporting that they screened for TB in their patients with HIV. However, an examination of the HIV registers could find no data to confirm that TB screening was indeed being performed. However, one possible explanation could be that PEPFAR partners might have different recording and reporting systems — which have not been coordinated with the national system.

While the results sound quite poor, it is important to note that the Ministry of Health, including the National TB and national AIDS programmes, have now taken stock of what the current capacity and level of performance was in the country, which can serve as a baseline to measure future country-wide improvements.

“In terms of actions taken so far, the tuberculosis control programme has used this survey to be able to target what actions we need to put in place in order to fix these gaps. However, this information has also been disseminated to a number of partners within Uganda, especially PEPFAR partners in the districts just to show them what is happening and what needs to be done,” said Nakanwagi-Mukwaya “The partners really need to help the Ministry of Health scale up and increase capacity for TB/HIV collaboration in the districts.”

With the exception of an update on Rwanda’s national scale-up of collaborative activities, other presentations at the Implementer’s Meeting focused either on regional projects or the scale-up of individual TB/HIV services.

In most settings, the lowest-hanging fruit of collaborative activities appears to be the introduction of provider-initiated HIV testing and counselling services (PITC) for TB patients — but different groups have taken different approaches to implementation (see related article). Even though the provision of cotrimoxazole also seems to have a high success rate in most settings, TB programmes are struggling to get TB patients onto other HIV-related services, especially ART — sometimes even when the service is available on-site for TB patients (see related article in HIV & AIDS Treatment in Practice).

Most of the presentations continued to come from the TB programmatic side — but there were indications that HIV programmes are starting to put more effort into activities like the Three I’s to reduce the burden of TB in people with HIV, developing tools and systems to make these activities happen (see related article).

Another way to encourage implementation is to document it, since it’s widely recognised in the world of management that “what gets measured gets done” There were several presentations describing how this may be easier said than done — however, a new effort to harmonise the way TB/HIV collaborative activities are documented and recorded could lead to both improved implementation and monitoring and evaluation (see related article on harmonising monitoring and evaluation).

But ultimately, the best way to make certain that TB/HIV activities get done is to make certain that the community demands them. Efforts to improve treatment literacy on TB and the links between TB/HIV are growing, and there were several presentation demonstrating that a grass roots advocacy for TB/HIV integration can indeed emerge — though it may first need to be nurtured (see related article).