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TB/HIV integration: A field perspective

TB/HIV integration: A field perspective. Gilles Van Cutsem. TB + HIV = double trouble. In HIV+ risk of TB is up to 26 x higher TB is the first cause of death among HIV+ TB deteriorates more rapidly if HIV+ TB is more difficult to diagnose in HIV+

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TB/HIV integration: A field perspective

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  1. TB/HIV integration: A field perspective Gilles Van Cutsem

  2. TB + HIV = double trouble • In HIV+ risk of TB is up to 26 x higher • TB is the first cause of death among HIV+ • TB deteriorates more rapidly if HIV+ • TB is more difficult to diagnose in HIV+ • TB makes HIV evolve more rapidly to AIDS • Treatment challenges of co-infection (pill burden, interactions, toxicity, IRIS, TB deterioration, timing of ART)

  3. Rapid deterioration of TB in HIV+ HIV- Severity HIV+ Hospitalisation Death Months GraemMeintjes, 2008.

  4. Aim of TB/HIV integration • Decrease mortality and morbidity • Improve efficiency of services through: • more rational staff deployment • increased competence in the management of co-infected patients

  5. Objectives of TB/HIV integration • Increase VCT amongst TB clients as an entry point to HIV care • Diagnosing TBdisease earlier in HIV-infected persons • Reduce delay to ART of co-infected patients • Comprehensive care for the co-infected patient: 1 patient – 2 diseases – 1 programme (same clerk/counsellor/nurse/doctor). • Creating a “one stop” service • Improving cure rates for both co-infected and TB patients through a more patient-centred approach to adherence • Benefiting from the experience of the TB programme to standardize the approach and the monitoring of ARV patients

  6. TB/HIV integration in Khayelitsha From complete separation of services to clinical integration.

  7. Collaboration ≠ integration HIV CLINIC TB CLINIC 1 patient 2 folders 2 clinics 2 programs same patients attending 2 different clinics, even if in the same building No integration TB/HIV clinic 1 patient 1 clinic 1 folder 1 program Clinical “full” integration Both diseases treated together

  8. Impact of TB/HIV integration

  9. TB/HIV integration indicators Medecins Sans Frontieres, Lesotho Report 2009-2010.

  10. Nurses with improved clinical skills Medecins Sans Frontieres, Lesotho Report 2009-2010.

  11. Better TB outcomes in patients on ART Medecins Sans Frontieres, Lesotho Report 2009-2010.

  12. Reduced delay to ART Medecins Sans Frontieres, Khayelitsha Report, 2008-2009.

  13. What about nosocomial transmission? • HIV & undiagnosed TB patients sitting together regardless of integration > need for increased infection control in ALL clinic areas. • Multiple contacts in the community in high TB prevalence settings

  14. TB incidence rates in integrated vs non-integrated clinic in Khayelitsha 1.00 RR= 1.02 (0.79-1.32), p= 0.905 0.75 Proportion free of new TB 0.50 0.25 0.00 0 6 12 18 24 30 Follow-up time in months Boulle et al. unpublished. 2006.

  15. High-ventilation design of waiting rooms

  16. Does DR TB change the paradigm? A decentralized, patient centred, model of care for drug-resistant tuberculosis in a high HIV prevalence setting McDermid et al. THAE0101

  17. Integration of monitoring system? • Integrated clinical follow-up sheets • Separate but similar registers • Separate reporting structures • Integrated electronic TB/HIV database • Ideal would be one fully integrated M&E

  18. 1 patient – 2 diseases 2 programmes?

  19. Conclusion • TB/HIV integration NOT just collaboration • Positive impact on HIV and TB indicators • Improves clinical capacity in TB care and public health approach in HIV care • Shorter time to ART saves lives • Infection control is crucial regardless of integration • Lack of integration of administrative structures is barrier to integration at clinic level

  20. Acknowledgments Patients and staff in South Africa and Lesotho

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