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


• 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


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

 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.


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 Medical wards Admitted pts MCH OPD MTH OPD TB OPD TSHC (TB/HIV pts) Entry point
Care and 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 Total TB Patients registered Adult Children Patient Offered for Testing Patient tested for HIV Patient with positive result Relative offered for testing Relative tested For HIV Relative with positive result TOTAL HIV infected 2991 768 2830 2610 803 499 430 263 1066 95% 87%   percentage

62% 86% 61%

TB/HIV activity at Township level
2009 Report for IHC enrollment Before Enrollment Total Total HIV positive patients Patients enrolled Patients expired before enrollment patients not enrolled No residential form 10 Transferred out Not willing to enroll Other 832 34 159 102 4 18 35 percentage 1066 78% 4% 15% 64% 3% 11% 22%

TB/HIV activity at Township level
2009 Report for IHC enrollment After Enrollment Patients enrolled Patients received CPT Patients received ART Patient expired after enrollment Patients expired on ART 832 981 543 47 61 65%

• 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 HIVinfected patients, usually asymptomatic

Enrollment of TB/HIV co-infected patients


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 Not having access to HIV care program Old age (above 44 years) Category II TB treatment Adjusted OR 4.26 1.49 2.43 95% CI (3.41 – 5.32) (1.07 – 2.08) (1.67 – 3.56) p < 0.01 0.02 < 0.01

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

Risk factors Old age (above 44 years) Female gender Underweight (BMI ≤ 18) Not started on ART Baseline CD4 count ≤ 100 cells/µl Moderate anemia Severe anemia A history of prior TB

Adjusted OR 2.18 1.50 1.91 2.82 1.89 1.98 3.29 3.33

95% CI (1.28 – 3.72) (1.00 – 2.23) (1.28 – 2.86) (1.87 – 4.26) (1.24 – 2.89) (1.17 – 3.34) (1.93 – 5.60) (2.03 – 5.47)

p < 0.01 0.05 < 0.01 < 0.01 < 0.01 0.01 < 0.01 < 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 Total patients ever started ART 4897 4650

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

• 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!