Union project shows how low-income countries can deliver integrated TB/HIV care

18 December 2012 - Paris, France - Today partners from the International Union Against Tuberculosis and Lung Disease (The Union)’s Programme of Integrated HIV Care for TB Patients Living with HIV/AIDS (IHC) reported results - some of them quite surprising - of operational research projects in Benin, the Democratic Republic of Congo (DRC) and Zimbabwe. The project, which began nine years ago, in 2004, has engaged 59 primary health care clinics to conduct action research on how to provide joint TB and HIV services in resource-limited settings.

"One of our main objectives has been to test whether lessons from TB care - which is available widely through primary health care facilities - could be translated into HIV services, which at the time were available only in bigger cities and hospitals," explained Dr Paula Fujiwara, Director of the Union’s TB/HIV department.

The programme aimed at bringing quality integrated TB/HIV care to patients while also improving patient education and reducing the stigma associated with both diseases; and to address staff training, providing accurate diagnoses, ensuring the supply of medicines and obtaining financing for free care. Between 2006 and 2012, the projects provided care for a total of 26,372 TB patients, of whom 5,791 were found to be HIV positive, including 14,025 TB patients (1,683 HIV+) in DRC, 8,368 TB patients (1,255 HIV+) in Benin and 3,979 TB patients (2,853 HIV+) in Zimbabwe.

"The outcomes of the IHC Programme offer valuable models for integrated care that we hope to see taken up by other countries", says Dr Nils E Billo, Executive Director of The Union. "IHC has shown that is possible to strengthen the supply of adequate care, even settings facing tremendous economic and political challenges. With more than one million people needing simultaneous treatment for TB and HIV, it is essential that care for these patients be scaled up and coordinated successfully within the general health system."

The meeting at which these results were announced and discussed was attended by IHC partners from the ministries of health in Benin, DRC and Zimbabwe, and the Université de Montpellier’s Institut de Recherche pour le Développement and Alter Santé, as well as the project’s funder, the European Union. It included participants from the French Ministère de la Santé, Ministère des Affaires étrangères, Agence nationale de recherches sur le sida et les hépatitis virales and Agence Française de Développement (France); the World Health Organization, UNAIDS and Stop TB Partnership (Switzerland); the US Agency for International Development (USAID), the US Centers for Disease Control and Prevention (CDC) and Office of the US Global AIDS Coordinator (USA); the KNCV Tuberculosis Foundation (Netherlands) and Action Damien (Belgium).

The main highlights of the results are as follows:

TB clinics are a valuable entry point for HIV diagnosis and care. IHC found that TB services can handle the workload and perform effective provider-initiated testing and counselling for HIV among TB patients. IHC partners saw that TB services offer an excellent opportunity for co-management of both diseases, at least for the duration of TB treatment. In Zimbabwe, IHC pilot clinics now provide patients with comprehensive TB/HIV services that include diagnosis and treatment for TB and HIV, ART initiation and follow up. In both DRC and Zimbabwe, by the end of 2012, IHC pilot clinics had extended their services to all patients with HIV, regardless of their TB status. In DRC, IHC also demonstrated that TB microscopy laboratories can successfully carry out CD4 cell counts for people living with HIV at the point of care. The introduction of blood sampling on filter papers also made it possible to measure patients’ viral load, hence improving patient follow-up. The latter method provided a further quality assurance regarding HIV diagnoses and enabled the clinics to monitor HIV+ patients for resistance to ARV drugs.

Quality microscopy proved to be the cornerstone for TB diagnosis; and the researchers stressed the need to make and keep these services strong. In DRC, new, widely promoted molecular diagnostic tools, such as GeneXpert®, did not significantly increase case detection, but access to X-ray services made it possible to detect active TB - particularly among HIV-infected patients, nearly half of whom may not have a cough.

Nurses and other primary care health workers can provide high-quality care if they receive hands-on training, on-the-job coaching and supervision. In Zimbabwe, between 2007 and 2012, IHC trained close to 600 nurses in TB diagnosis and care, rapid HIV testing, basics of HIV medicine and integrated TB/HIV care. In DRC, this opportunity to expand the pool of resources helped the National AIDS Programme to manage a high turnover of staff related to the poor economic conditions.

Patients stay in HIV treatment following TB care: The completion of TB treatment represents a critical point in the care of people with TB/HIV, and good coordination between services eases this transition. In Zimbabwe, over 70% of the HIV+ patients who began ART as TB patients are still alive and taking their medicines three years later. In DRC, as a result of the severe socio-economic conditions and guerrilla warfare in North Kivu province, 30% of the HIV+ patients had to be transferred to other centres, but 50% were still receiving their medications from the same health centre three years after treatment onset.

Documentation of results is critical for building political and financial support, as well as for monitoring and evaluation of the quality of care and performance of services. In Zimbabwe, local use of available data has improved quality of care and strengthened ownership of TB/HIV collaboration. In DRC, IHC developed an information system for HIV, based on the one used for TB, which has allowed the National AIDS Programme to better document the outcome of HIV care and better describe access to HIV care and the efficiency of case detection interventions.

In closing, participants looked ahead to the future of the fight against TB in the post-2015 era. USAID’s Dr Amy Bloom, Chair of the Stop TB Partnership Coordinating Board, stressed the need for intense advocacy to keep TB on the agenda. TB is the number one killer of people living with HIV, yet only a small percentage of available funding is devoted to it, she said. "We need to do something big to have an impact on TB/HIV."

Dr Billo lamented the lack of "noise" around TB. "People don’t talk about TB enough, and so far we have not done a good enough job keeping it on the agenda. We need to rethink how we approach TB. Otherwise the poorest of the poor will suffer," he said, adding that initiatives like the Stop TB Partnership’s plans to "rebrand" TB could be key.

Click here to link to the Union publication, Implementing Collaborative TB-HIV Activities: A Programmatic Guide