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Challenges of service integration:
the TB model
Linda-Gail Bekker
The Desmond Tutu HIV Centre, Faculty of Health Sciences,
University of Cape Town, South Africa
AIDS Conference
Melbourne
July 2014
Global TB in 2012
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33 million HIV infected
1/3 have TB
8.6 million new cases of TB globally
13% co-infected with HIV.
1.3 million deaths (320 000 deaths in HIV/TB)
SA: >300 cases notified annually (3rd largest number)
933/100 000 Largest number TB/HIV co-infected
(65%)
TB incidence rates : 2012
HIV prevalence/ new TB cases : 2012
Number of HIV-infected persons receiving antiretroviral
treatment (ART) and percentage of persons receiving
concomitant tuberculosis treatment in Africa 2002-2007
HIV in a sea of TB/TB in a sea of HIV
• In our TB clinics: reason for HIV testing and
diagnosis of HIV
– Similar symptoms
– Now an indication for referral for ART
• In our HIV Clinics: TB not always symptomatic
but must be actively investigated for.
– Indication to start ART regardless of CD4.
• In our primary health clinics : both conditions
often present simultaneously
35000
Annual TB notifications
30000
25000
20000
15000
10000
5000
0
Cape Town
United
Kingdom
Switzerland
The numbers of tuberculosis notifications,
stratified by 5-year age groups and HIV-status
4000
3000
2000
1000
75
+
9
10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
5-
4
0
0-
TB notifications
5000
Age strata
HIV negative
HIV unknown
HIV positive
TB Burden Prior to Initiation of HAART
Percentage of patients starting HAART
100
90
80
70
60
50
40
67%
30
47%
20
22%
10
8%
0
Total TB
burden
PH TB
On TB Rx
TB @ Screen
A:TB Incidence by CD4 without HAART
B: TB Incidence by CD4 with HAART
30
R2 = 0.9702
25
20
15
10
5
0
0
100
200
300
CD4 cell count
400
B: Cape Town ART Cohort
TB incidence rate (cases/100pys)
TB incidence rate (cases/100pys)
A: Cape Town AIDS Cohort
500
30
R2 = 0.9643
25
20
15
10
5
0
0
100
200
300
400
500
CD4 cell count
A: Holmes, Wood, Badri, et al JAIDS 2006
B: Lawn, Myers, Edwards Bekker, Wood. AIDS 2009
90 100
1000
cells/ul
50
60
70
80
TB rate = 1.5
500
cells/ul
10 20
30
40
TB rate >4.2-5.5
TB rate 9.3-16.8
200
cells/ul
0
Percentage of patients with CD4 below contour
Good to get TB/HIV positive people onto
ART
0
4
8
12
16
20
24
28
32
Duration of ART (months)
36
40
44
48
Presentation of TB and HIV co-infection:
1. TB diagnosed before starting ART
2. A patient develops TB while on ART
3. A patient who has defaulted ART develops TB
Reason for urgency
• Patients known to be HIV positive who
develop TB and are not diagnosed or not
treated – morbidity and mortality
• In addition they are a TB risk to others
• Patients known to have TB who are diagnosed
HIV+ need ART (recommend: <8weeks)
• Delays result in morbidity and mortality
– Number of RCTs – lower CD4 groups
HIV prevalence in the PHC TB service-CT 2009-2011
2009
2010
2011
Total
25,841
26,104
25,554
77,499
HIV Positive (%)
49.7
50.4
50.9
50.3
HIV Negative (%)
44.9
46.8
47.1
46.3
HIV status unknown (%)
5.4
2.9
2.0
3.4
TB cases (n)
1.00
0.751.00
Survival stratified by ART status for patients
with CD4 counts < 350
0.50
0.95
Median Time to Death
Started ART
71days (IQR: 38-119)
0.25
0.90
On ART at TB diagnosis
60 days (IQR: 26-118)
0.00
0.85
No ART
54 days (IQR: 25-104)
00
50
50
100
100 150
150200
Time (days)
Time (Days)
No ART
Started ART during TB treatment
250
200
250
On ART at TB diagnosis
Half of the deaths in patients who do not start ART occur within 8 weeks
Summary: In the PHC TB service in Cape Town
• 50% of adult TB patients are HIV positive
• 82% have CD4 counts below 350
• 91% of deaths in HIV+ve patients occur in patients
with CD4 counts below 350
• 32% of patients with CD4 counts <350 did not start
ART during TB treatment (2009 – 2011)
• Mortality for patients on ART was 50% less than
patients not on ART for CD4 counts <350
• Median time to death for patients not on ART is +/8 weeks
Delays occur moving between the facilities
• A median delay of over 16 weeks between start of TB
•
treatment and start of ART was noted for patients referred
from TB facilities to the Gugulethu ART clinic.
This was reduced to 41 days if TB diagnosis was made at
the ART clinic. 1
• Median delay of 2.66 months (+/- 74 days) between start of
TB Rx and start of ART in clinics in CT (Masiphumulele,
Gugulethu and in Khayelitsha) between 2002 and 20082
1Lawn
et al BMC Infect Dis 2011, 2Lawn et al JAIDS 2011,
Primary Health care setting
TB clinic
HIV/ART clinic
HIV CT
Referral to ART
services
TB
ACTIVE CF
Referral to TB
services
Missed opportunities: HCT, ACF, IPT, CTX
Inherent DELAYS and LOSS TO FOLLOW UP
The primary health care setting
HIV only
HIV/TB
TB treatment for
6-9 months
ART for life
ART for life
TB only
TB treatment for
6-9 months
Overburdened clinics
and overburdened
patients
By “integrating” services (the 4th I)
• Tackle the 3 Is in HIV+:
– Intensified case finding (delay freeTB Rx)
– (INH) Prophylaxis
– Infection control
• But other advantages in TB suspects and
patients:
– Test all for HIV
– Offer ART without delays (5th I !!)- ? All CD4s?
– Streamline services to provide both medications
hassle free- quality of services (?reduce LTFU).
Variety of Models:
• Co-location of services in the same clinic with
referral between services on site.
• Co-location of services with shared
management discussions and shared
adherence support services.
• Integration of services with HIV/ART services
managing TB
• Integration of services with TB services
managing HIV/ART
• HIV/ART/TB clinics de novo.
A model for service integration
DOCTOR
Nurse run ART
Facility based
counsellors
Nurse run HIV
Nurse run TB
Weekly
Interdisciplinary
meeting
VCT
TB
ART
Treatment readiness
Sessions and ad hoc
counselling
FIELD SUPPORTERS
Home Visit
Support
mentorship
DOTS visits: Post integration of
services
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Jan-06
Feb-06 Mar-06 Apr-06 May-06 Jun-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06 Dec-06
Jan-07
Feb-07 Mar-07 Apr-07 May-07 Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07 Dec-07
Jan-08
Feb-08 Mar-08
Systematic review :2010
Grant, et al 2010)
• 136 papers describing models of integration
• None RCTs and very few with TB or HIV
outcomes
• Models based on referral only easiest to
implement
– Referrals may fail, communication key and often
poor.
• More integration needs more staff buy in and
training.
Barriers and enablers to integration:
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Service users unconvinced of need for more testing!
Those referred battling to find referral services
Fragmentation of services
Poor communication between services
Data systems inadequate for coordinated care
Infrastructure poor for privacy
Staff not motivated to take on “more”
Supply of drugs and test kits unreliable
• Joint staff training and support
• Identifying staff “champion”
Simply Integrating TB and ART services doesn’t simply
solve uptake and delays.
• In the Nyanga CHC which has co-located TB and ART clinics1
– 19.7% of ART eligible TB patients did not start ART
– Median delay of 51 days from TB Rx start to ART start
• In an integrated ART/TB clinic in Khayelitsha2
– 34/100 TB patients ART eligible patients did not start ART
– Median delay of 58 days from TB Rx start to ART start
• Town 2 Clinic after ART was introduced into a TB service3
– Median delay of 75 days between TB and ART initiation post
integration (decreased from 147 days)
1Nglazi
et al S Afr Med J 2012, 2Pepper et al PLoS One 2011, 3Kershberger et al PloS One 2012
Pilot analysis in 5 clinics in CT vs Standard TB
program
Caldwell et al, 2010
Qualitative data
• Preferred by field adherence supporters
– Better relationships with patients and better
outcomes
• Preferred by patients
– Less transport and “hassle” factors
– Better understanding of both diseases
• Preferred by nursing staff.
– Less “DOTS” burden and improved outcomes.
TB outcomes in facilities in CT:
A: 13 integrated and B: 4 single service facilities.
N= 13 542 newly registered patients (66% HIV+).
Kaplan, et al 2014
Conclusions
• There is a burden of co-infection especially in areas
where TB and HIV are hyperendemic
• Both diseases require long term adherence to
medications that can interact.
• Outcomes are improved when TB/HIV is managed
actively: 3 Is – ICF, IPT, IC (and now add IS)
• Delays in treatment of both HIV and TB leads to
increased morbidity and mortality.
• Pragmatic to co-locate and move toward integration
paying attention to infection control.
• More research required that measures outcomes
including TB cure, viral control and any risks (IC).
Thanks
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Sten and Paolo
Richard Kaplan (DTHC)
Judy Caldwell and CoCT
Steve Lawn