Integrated TB/HIV Care Programme in Myanmar

Integrated TB/HIV Care Programme in Myanmar

Dr. Ko Ko Naing Assistant Director National AIDS Programme Department of Health

National Strategic Plan for HIV/AIDS (2011-2015) • Is developed based on findings from the review through multi-sectoral coordinated efforts of implementing partners • NSP has a vision of achieving the HIV related MDG targets by 2015

• A common planning and monitoring framework for all stakeholders in the national response to

HIV, 29 August 2013

2

HIV/AIDS/STD Prevention and Control Activities of NAP 1. Advocacy 2. Awareness raising (Health Education) 3. Prevention of sexual transmission of HIV/STD a. 100% TCP b. Early and effective treatment of STIs 4. Prevention of HIV transmission through injecting drug use 5. Prevention of Mother to Child Transmission of HIV(PMCT) 6. Provision of safe blood supply 7. Provision of Care & Support 8. Enhancing the multi-sectoral collaboration & cooperation 9. Special intervention programme 29 10.Supervision, August 2013 monitoring and evaluation

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Integrated TB/HIV Care Programme in Myanmar - A strategic frame work to decrease the burden of TB/HIV in Myanmar Goal and Objectives - To decrease the burden of TB/HIV in dually affected populations Objectives (A)To established mechanism for collaboration between National Tuberculosis Programme (NTP) and National HIV/AIDS Programme (NAP)_ (B)To decrease the burden of TB in PLWHA (C) To decrease the burden of HIV in TB patient

22-Aug-13

4 National AIDS/STD Control Program

Special intervention programme 1. Cross- border activities 2. TB/HIV collaborative activities

Background on the TB/HIV collaborative activities Myanmar  2005 Mandalay 5 townships, Myitkyina, Taunggyi  2007 Lashio, Mandalay 2 tsps & Pakokku  2011 Magway, Pathein, Tachileik,Monywa  

2012 Total

Mawlamyine, Dawei, Pyay 18 Townships

WHO-recommended TB/HIV strategy

Status of activities in Myanmar

Establish mechanisms of coordination

Coordinating body at all levels

TB/HIV coordinating body established in central/State and township levels

Surveillance of HIV among TB patients

TB patients included in the annual HIV surveillance (25 sentinel sites).

HIV sero-prevalence among TB patients 9.7% in 2012.

Joint TB/HIV planning

Joint planning conducted

Monitoring and Evaluation

Joint M&E is conducted Decrease the burden of TB in PLHA

Establish intensified case finding

PLHA suspects for TB are referred to TB clinic for screening

Isoniazid preventative therapy (IPT)

Advocacy and trainings provided and started since 2009

Ensure TB infection control

Airborne infection control guidelines are planned to be developed Decrease the burden of HIV in TB patients

Provide HIV Testing and Counseling

HIV testing infrastructure limited but growing: 470 VCT service in the country; HIV testing available in the TB clinic only in pilot sites. VCT for TB patients now national policy

Introduce HIV prevention methods

Integrated into general health care system as 100% targeted condom promotion programme

Cotrimoxazole preventive therapy (CPT) and Antiretroviral therapy (ART)

CPT included in national guidelines and available in the TB/HIV project sites

Estimated number of people living with HIV/AIDS (Adults + Children) 213,668

Estimated number of AIDS Deaths (Adults + Children) 15,741

20000

16000

12000

8000

4000

0 1985

Estimated number of New HIV Infections

1990

1995

2000

2005

2010

2015

Estimated number of ART Needed 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 2011

2012 15+

2013 <15

2014

needing PMCT

2015

Trends of HIV prevalence among low risk sentinel populations, HSS 1992-2012 3.0%

2.5%

HIV Prevalence

2.0%

1.5%

1.0%

0.5%

0.0%

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Pregnant women

1.8%

1.4%

1.6%

1.3%

1.3%

1.5%

1.9%

2.7%

2.2%

2.2%

2.1%

1.6%

1.8%

1.3%

1.5%

1.4%

1.3%

1.0%

0.9%

0.9%

0.7%

Blood donors

0.3%

0.5%

0.5%

0.5%

0.7%

0.7%

0.6%

0.9%

1.0%

1.1%

1.2%

1.2%

0.8%

0.7%

0.4%

0.4%

0.4%

0.3%

0.3%

0.2%

0.14%

0.4%

0.5%

0.5%

0.4%

0.5%

2.5%

1.8%

1.4%

1.8%

2.0%

2.1%

1.6%

1.3%

1.0%

1.3%

2.5%

1.6%

1.0%

1.5%

1.0%

Military Recruits

Trends of HIV prevalence among most at risk population, HSS 1992-2012 80%

70%

HIV prevalence

60%

50%

40%

30%

20%

10%

0%

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

9%

6.9%

5.7%

7.1%

7.7%

8.9%

7.1%

8.4%

7.1%

8.0%

6.5%

6.0%

3.2%

4.1%

4.9%

5.3%

5.4%

4.9%

5.2%

4.6%

4.1%

Injecting Drug Users

62.8%

74.3%

71.4%

54.5%

66.5%

54.1%

56.2%

50.9%

62.7%

40.9%

24.1%

37.9%

34.4%

43.2%

42.5%

29.2%

37.5%

34.0%

28.1%

21.9%

18.0%

Female Sex Workers

4.3%

9.0%

16.5%

18.0%

21.5%

25.0%

29.0%

26.0%

38.0%

33.5%

32.3%

31.4%

27.5%

32.0%

33.5%

15.6%

18.4%

11.2%

11.4%

9.4%

7.1%

29.3%

28.8%

22.3%

11.0%

7.8%

8.9%

Male STI patients

Men Sex with Men

Trends of HIV prevalence among new TB patients, HSS 2005-2012 12% 11.1% 10.8% 10.4%

10.3%

9.9%

9.8%

10%

9.7%

9.2%

8%

6%

4%

2%

0% 2005

2006

2007

2008

2009

2010

2011

2012

Strategic framework of intervention for the prevention and control of HIV/TB TB Infection HIV/TB Co-infection

Clinical HIV/TB

HIV Infection Strategy 1

Strategy II

Strategy III

Reduce morbidity and mortality of HIV associated active TB and AIDS VCCT

TB Screening

DOTS

Counselling

CPT

STD

ART

Blood Safety

Care and Support

PMCT Harm Reduction 11

ARV Service Delivery Model Follow-up

AIDS/STD

Entry point

T.B VCCT Drug Treatment Centre MCH

c ati m o pt ve ym (+) s A V HI Sy m HI ptom V (+ atic )ve

Counselling

Selection Committee • Physician • TMO • AIDS/STD State/Divisional Officer/Team Leader •Representative from Hospital adm.

• PLWHA

Hospital Hospital Selection Committee

Under Observation (Do not meet the criteria for ART)

Initial Treatment (Meet the criteria for ART) Drug taken under observation of family member, PLWHA peer support Follow-up and maintenance Treatment

12

Collaboration for co-infected patients

TB suspect

HIV suspect

TB Screening

HIV Screening

Active TB DOTS

HIV(+) HIV/AIDS Treatment & Care

TB facilities

Collaboration For Treatment &Care

HIV/AIDS facilities 13

The joint strategy of the two national programmes

1. Intensified case finding of TB among HIVinfected individuals, 2. VCCT services for TB patients, 3. Improved TB/HIV awareness and health education, 4. Cotrimoxazole prophylaxis, and 5. Referral to HIV care and treatment including ART.

Integrated TB and HIV services • Integrated TB and HIV services are implemented in 18 TB/HIV sites at the end of 2012.

• In 2013 17-NAP and 11-IHC sites will implement TB/HIV services (total 28).

• In 2014 8 sites will expand integrated TB/HIV services (total 36) and • 6 sites in 2015 (total 42).

Integrated TB and HIV care activities • Activities will be integrated into national disease programs at the central, region/state, and township level.

• The primary activities that will be conducted at integrated TB/HIV sites include joint training of NTP and NAP staff on – the management of TB/HIV co-infection, – intensified TB case finding among HIV patients through the implementation of enhanced TB screening procedures, – provision of HIV VCCT services to TB patients and – appropriate referrals to HIV care and treatment services as needed, – as well as the establishment of elements of TB infection control in institutional settings

TB/HIV Joint M & E Visit

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Elements of the national TB/HIV strategy • As some elements of the national TB/HIV strategy fall within the responsibility of the NTP while others are under NAP responsibility, • the currently proposed work plan and budget were developed collaboratively by both national programs with inputs of NGO stakeholders.

• The budget has been divided between both proposal components without causing duplications.

• Regarding the HIV component costs for ARV, condoms and cotrimoxazole prophylaxis are included in the NAP budget.

• The testing kits for TB patients have been budgeted under the NTP.

2011 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

AMTZ CATZ CMTZ Mahaaungmyae Amrapura Patheingyi Pyigyitagon Myitkyina Pakkoku Lashio Monywa Pathein Magway Taunggyi Tachileik

2012 AMTZ CATZ CMTZ Mahaaungmyae Amrapura Patheingyi Pyigyitagon Myitkyina Pakkoku Lashio Monywa Pathein Magway Taunggyi Tachileik Dawei Mawlamyine Pyay

Global Fund Round 9 ( TB/HIV townships) 2013 AMTZ CATZ CMTZ Mahaaungmyae Amrapura Patheingyi Pyigyitagon Myitkyina Pakkoku Lashio Monywa Pathein Magway Taunggyi Tachileik Dawei Mawlamyine Pyay Bahmaw Hpaan Myeik Bago Pyinmana Thanlyin N/Okkalapa Kyaington Kalaw Mingaladon

2014

AMTZ CATZ CMTZ Mahaaungmyae Amrapura Patheingyi Pyigyitagon Myitkyina Pakkoku Lashio Monywa Pathein Magway Taunggyi Tachileik Dawei Mawlamyine Pyay Bahmaw Hpaan Myeik Bago Pyinmana Thanlyin N/Okkalapa Kyaington Kalaw Mingaladon Loikaw Taungoo Naung U Kawthaung Sittwe Hinthada Maubin Myaungmya

2015 AMTZ CATZ CMTZ Mahaaungmyae Amrapura Patheingyi Pyigyitagon Myitkyina Pakkoku Lashio Monywa Pathein Magway Taunggyi Tachileik Dawei Mawlamyine Pyay Bahmaw Hpaan Myeik Bago Pyinmana Thanlyin N/Okkalapa Kyaington Kalaw Mingaladon Loikaw Taungoo Naung U Kawthaung Sittwe Hinthada Maubin Myaungmya Myawaddy Shwebo Kalay Pyin Oo Lwin Thakata Muse

Number of TB patients who have started ART treatment & Number of patients on IPT Prophylaxis â&#x20AC;&#x201C; 2012 (NAP/GF)

Number of TB patients who have started ART treatment & Number of patients on IPT Prophylaxis - 2013 (NAP/GF)

Implementing partners involving in TB/HIV activities INGO • MSF - Holland • MSF - Switzerland • AHRN • Malteser • PACT Myanmar • PSI National NGO • MHAA

Organization • The Union

Scale-up plan To decrease the burden of TB in people living with HIV/AIDS Expansion of TB/HIV collaborative townships • 2010 – 11 townships • 2015 – 26 townships (3 townships per year) (Townships with NAP plans to deliver ART) Intensified TB Case Finding • Routine TB screening at TB/HIV townships • By using already developed screening questionnaire • Investigation with sputum examination, CXR and culture if available IPT Following the results of IPT pilot sites, will make consensus and set target for the provision of IPT Training: Cross training to NAP staff In both TB and AIDS/STD teams are existing In addition to TB/HIV townships, TB screening, diagnosis and treatment will be provided to HIV patients

Scale-up plan To decrease the burden of HIV/AIDS in TB patients Expansion of TB/HIV collaborative townships • 2010 – 11 townships • 2015 – 26 townships (3 townships per year) (Townships with NAP plans to deliver ART) HIV testing and counseling for TB patients • 80% of TB patients will receive HIV testing CPT • 95% of HIV-positive TB patients will receive CPT Training: Cross training to NTP staff In both TB and AIDS/STD teams are existing In addition to TB/HIV townships, TB centers will be providing VCCT and CPT

25 National AIDS/STD Control Program