Post on 21-Feb-2016
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Washington D.C., USA, 22-27 July 2012www.aids2012.org
A National Program Manager’s Perspective on HIV/TB Integration
Dr Owen MugurungiDirector – AIDS & TB ProgrammeMinistry of Health & Child Welfare
Zimbabwe
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Background
• Zimbabwe is ranked 18/ 22 high burden TB countries
• 70% of deaths in 15-44 years are due to TB-HIV (1990-2008)
• Gradual decline in deaths since ART introduction in from public sector facilities (2004 –2008, Dlodlo et al, 2011)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Achievements
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Achievements (2)• Nationwide access to TB treatment: integration of TB treatment
services with general health services strengthened the DOT system
• Treatment success rate (2009) - smear+ve: 78% - smear-ve: 74% - EPTB: 80%
• New TB screening tool : for improved case detection. First piloted by PSI (2005), then rolled out nationally in 2009.
- PSI centers account for 35% of HCT testing in Zimbabwe
• TB Case management training now includes HIV
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Collaborative Activities •
The Union & Two cities Health Service are piloting in 3 urban clinics:– Feasibility of integrating HIV CT and TB services: HCT, antiretroviral
treatment (ART) and TB services
– Households contact screening for TB and ART enrolments (ART initiations are nurse-centred with support from clinical medical officers)
• Initial results (2008-2011): - ART initiation among HIV-positive TB patients have been higher in study sites vs.
national data: 1,779 ( 80%) vs. 29,361 (38%)
- 111(16%) partners of HIV-positive TB patients were traced and HIV tested; 101 (91%) were HIV-positive and all were initiated on ART
- ART retention is encouraging; at least 70% of patients started on ART in 2008 at all 3 clinics were still alive and on ART after 30 months
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Collaborative Activities (2)• PSI leveraged funding for active TB case finding through TB REACH Wave 2 - Improved early TB case detection by integrating LED microscopy and
GeneXpert within PSI’s network of 17 HCT clinics - Intensified active case finding at the community level through mobile,
and mhealth referrals follow up
• Initial results (2010-2011) - 123,109 screened for TB, 5,634 suspected cases identified and 443 new
cases of TB (395 smear+ve TB cases & 48 Gene Xpert +ve cases) - Active referral tracing of identified TB cases at HCT centres using SMS
messaging to ensure follow up and treatment initiation
• Ongoing Operations Research:Assess impact on patient access to care usingXpert MTB/RIF assay technology
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Challenges• Low ART coverage among HIV+/TB patients (only 44% of HIV+/ TB
patients were initiated on ART)• Lack of decentralization of ART initiation to lower level primary clinics as
they are not accredited i.e. currently there 606/1560 (39%) health facilities offering ART countrywide of which 144 are ART initiating sites
• ART initiations are mostly doctor driven
• Reluctance to IPT for HIV +• Health workers and policy makers are reluctant to introduce Isoniazid
Preventive Therapy (IPT) for HIV+ patients due to fears of Isoniazid mono-resistance/ anticipated poor capacity to exclude TB
• Inadequate funding for coordination meeting at district level • Despite WHO recommendations for TB/HIV coordination meetings at all
health levels these are only functional at national level
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Recommendations
• Integrate ART initiation with TB treatment services in order to scale up ART uptake among HIV-positive TB patients
• Advocate for nurse-led ART initiation especially in remote settings where there are shortage of doctors
• Accreditate primary level health facilities as ART initiating sites to accompany increase in ART uptake.
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Recommendations (2)• Strengthen TB diagnosis among patients in HIV clinics
with tools such as Gene Xpert and pave way for introduction of IPT
• Improve funding mechanism efficiency to facilitate TB/HIV coordination meetings at lower levels of the health care system
• Continue close collaboration with implementing partners in TB/HIV and leverage funding through TB REACH and other mechanisms to increase TB case detection rate
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Thank you