An oral abstract symposium featured a number of presentations on this broad topic at the Union World Conference on Lung Health Friday. What follows is a snapshot of several of them:
Successfully tested but not enrolled in HIV care, missed opportunities for TB patients in rural Zambia
S. Muvuma reported on a study that followed 297 TB patients who were newly diagnosed with HIV infection to evaluate the referral and linkage practices between TB services and HIV care. Only 59 percent of these patients were actually referred for HIV care services and only 28 percent of these patients were actually enrolled in HIV care. Males and those who had previously been treated for tuberculosis were less likely to be linked to HIV care as were younger patients. The recommendations that are generated from these findings include a need to strengthen the referral system between HIV and TB services.
Retention in care in a TB/HIV treatment program in Kinshasa, DRC
Frieda Behets from the University of North Carolina reported on a study to determine the incidence and risk factors for loss to follow up and treatment withdrawal of HIV-infected TB patients receiving antiretroviral therapy (ART) at five primary care centers in Kinshasa, Democratic Republic of Congo (DRC). Loss to follow up was defined as failure to return to care after three contact attempts and 412 patients who had initiated ART were studied. The mean duration of treatment was 10 months.
Seventy-nine percent of patients were retained and 21.6 percent of the patients were lost to follow up or withdrew from treatment. Travel issues related to work or family were the most frequent reason identified for dropping out. Eleven percent of the TB patients prescribed ART refused to take the drugs for a variety of reasons. Other risk factors for loss to follow up or voluntary dropping out of care were young age, high numbers of children in the home and weekly alcohol use.
An official from South African health ministry responded to the presentation by noting that they had found transportation and food insecurity to be key factors in loss to follow up.
Quality of TB-HIV care as perceived by patients in municipal clinics in Bulawayo, Zimbabwe
Sithokozile Hovf, a nurse and Bulawayo city health official, reported on an evaluation conducted of the quality of services being delivered to HIV-positive TB patients receiving ART at three clinics. A total of 197 patients were surveyed about their views about the quality of services they were receiving.
Seventy-nine percent of the patients viewed the quality of the services they received as good and appreciated the reliability of drug access. There were a number of key problems identified by the majority of the patients including high travel costs to get to the clinic, inconvenient hours and long waiting times — often more than four hours.
Recommendations to respond to these issues were decentralization of ART initiation to more clinics, identification of strategies to reduce waiting times, and consider holding clinic hours on Saturday.
The health department took action on these concerns by accrediting four additional ART clinics, piloting an appointment system beginning in late 2010, and beginning Saturday clinic services.
Scale up of intensified TB-HIV package in India
Dr. Ajay Kumar from the Ministry of Health presented on the state of India’s intensified TB/HIV package. While the overall prevalence of HIV is low in India, the overall number of cases is high—some 2.4 million people are living with HIV infection. HIV infection rates vary widely across the nation in contrast to TB, which is everywhere.
India established a package of TB/HIV interventions and the health ministry conducted a review of the program and surveillance data from the 20 states with 75 percent of the country’s TB/HIV burden to see how they were doing. The package includes HIV testing for all TB patients, decentralized access to co-trimoxazole, and referral of TB patients with HIV infection to ART centers for initiation of ART.
They found that 70 percent of TB patients knew their HIV status, double the number among those who were HIV tested in 2008. There is huge variation in the percentage of TB patients who test positive for HIV infection across the region from less than one percent to more than 20 percent. More than 90 percent of co-infected patients had access to co-trimoxazole. The percentage of patients with access to ART was much lower- 57 percent.
Probably as a result of poor linkage with ART and late HIV testing, the health ministry found a 15 percent mortality rate among co-infected patients. There are also concerns about late TB diagnosis contributing to high mortality because of the poor sensitivity of sputum microscopy, especially in the more common smear negative disease in HIV-infected individuals. India will move to increase the use of rapid TB diagnostics in HIV care settings and to expand access to ART to all persons with HIV infection with a CD4 count less than 350.
There are real challenges. Fewer than half of the 30,000 TB testing centers have access to HIV testing on-site.
There are only 300 ART centers across the country compared to 400,000 Directly Observed Treatment TB centers. There is a need to scale up ART services to ensure that there is at least one center per district. For many HIV patients, there are long distances to travel and most patients have few resources.