Integrating TB into the HIV Response TB/HIV Shadow Reports to Review UNGASS Progress for 2009 in Kenya, Uganda, and Zambia
Why Is It Necessary to Monitor TB/HIV Indicators for UNGASS? Despite being curable, Tuberculosis (TB) continues to be the leading cause of death among people with HIV in 2008, accounting for 25% of all HIV-related deaths.1 The World Health Organization (WHO) has developed a 12-point policy package and recommended collaborative activities to address the TB/HIV coepidemic. The WHO recommended activities to address TB/HIV coinfection include establishing mechanisms of collaboration between TB and AIDS programs, activities to reduce the burden of HIV in TB patients, and a set of activities that are to be led by national AIDS programs (NAPs) to reduce the burden of TB among people with HIV. The WHO recommended activities that should be implemented by AIDS programs are comprised of three interventions jointly known as the “Three I’s”: intensified TB case finding (ICF) among people with HIV, TB infection control (IC), and isoniazid preventive therapy (IPT). Despite the strides in the scale-up of antiretroviral therapy (ART) to reach more than four million people at the end of 2008, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that only 42% of people in need are getting access to HIV treatment.2 As the WHO guidelines for ART eligibility were revised upward in 2009 from a CD4 cell count of 200 to 350, the number of people who are eligible for ART but are unable to access it has increased. In light of this fact, there is urgent need to scale up all programs that can keep people with HIV healthy, even as we advocate for the expedited rollout of ART to achieve universal access. Implementing all of the WHO’s recommended TB/HIV collaborative policies can significantly contribute to reducing disease and death among people with HIV. Despite this, the NAPs have not demonstrated leadership in integrating the Three I’s into services that are offered to people with HIV. The 2009 WHO report shows that of all of the recommended TB/HIV collaborative activities, the Three I’s were the least implemented. In 2008 only 1.6 million of the estimated 33 million people with HIV were screened for TB, and less than 1% of the estimated number of people coinfected with TB/HIV were given access to IPT; data on IC was not reported.3 1 2 3 4
In order to assist in advocacy toward the uptake of the Three I’s and to streamline the monitoring of TB/HIV collaborative services, the TB and HIV departments of the WHO, along with UNAIDS; the Global Fund for AIDS, TB, and Malaria (GFATM); and the U.S. President’s Plan for AIDS Relief (PEPFAR) have come together to agree upon 13 monitoring indicators that all of them use to track the Three I’s. As part of this strategy, the UNAIDS United Nations General Assembly Special Session on HIV/AIDS (UNGASS) country reports that track compliance with the Declaration of Commitment to universal access to HIV are also required to report on the 13 TB/HIV indicators.4
Activist TB/HIV Monitoring Efforts Treatment Action Group (TAG) and the International Community of Women Living with HIV–Eastern Africa (ICW) have been encouraging Africa-based HIV activists to become involved in TB/HIV advocacy. As part of this effort, TAG and the ICW have partnered to conduct TB/HIV treatment, science, research, and policy literacy workshops. To support activist-led UNGASS TB/HIV shadow reports, the ICW developed a survey to measure the 13 TB/HIV indicators and trained a core of activists in Kenya, Uganda, and Zambia to implement the survey. The activists chose districts of these countries that have high TB/HIV burdens and collected data through one-on-one interviews with program implementers such as AIDS and TB clinic heads, policy makers such as national TB program staff, and people who were living with TB and HIV and accessing the TB/HIV collaborative services. These report cards are a product of this activist-led TB/HIV monitoring exercise to ensure greater inclusion of TB/HIV indicators in the UNGASS country reports to UNAIDS and to track how well country TB and HIV programs are collaborating to reduce the burden of TB/HIV. The activists conducted their monitoring in September–November 2009. The report card was based on the data gathered for specific indicators pertaining to each of the 12 points of the WHO’s recommended collaborative TB/HIV activities. The full country reports that covers each of the TB/HIV indicators can be downloaded from http://treatmentactiongroup.org/ungassreports.aspx
World Health Organization. Global Tuberculosis Control: A Short Update to the 2009 Report. Geneva, Switzerland: World Health Organization, 2009. UNAIDS. AIDS Epidemic Update .Geneva, Switzerland: UNAIDS, 2009. World Health Organization. Rapid Advice: Antiretroviral Therapy for HIV Infection in Adults and Adolescents. Geneva, Switzerland: World Health Organization, 2009. Stop TB Partnership. Monitoring and Evaluation: Harmonization, 2009. Retrieved 28 July 2009 from http://www.stoptb.org/wg/tb_hiv/issues_monitor.asp
Key Findings Across Kenya, Uganda, and Zambia The monitoring efforts of the TB/HIV activists have shown that although AIDS and TB programs had begun collaborating, there are missed opportunities that could greatly strengthen TB/HIV collaborative activities to reduce TB-related mortality among people with HIV. Key Findings: •
The national TB and AIDS programs in Kenya, Uganda, and Zambia have all set up mechanisms for joint planning and collaboration. However, in many cases the information or implementation guidelines have not been disseminated to district levels to ensure that both health care workers and people with TB/HIV understand the policies and the need for collaborative services.
•
Intensified TB case finding among people with HIV is being implemented in all HIV clinics surveyed in the three countries. However, when and how often people with HIV are being screened is not consistent. In Uganda and Zambia they are often screened only when they present with TB-like symptoms, while in Kenya people are being screened during HIV testing and intake for ART programs. Though TB and HIV facilities are often located in close proximity to each other, the mechanisms to facilitate TB testing for people with HIV with TB-like symptoms are not well established and add further burden on people coinfected with TB/HIV. Establishing routine screening for TB among people with HIV and systems to facilitate easy access to TB testing can lead to improved early diagnoses of TB.
•
Implementation of isoniazid preventive therapy to prevent TB is a disgrace. None of the countries are providing routine IPT, even if they have national policies to do so, as is the case in Kenya and Uganda. There is an urgent need for AIDS programs to implement this vital intervention that can prevent active TB among people with HIV, both in ART and pre-ART programs, and for the WHO to provide guidance that will assist programs to implement ITP while ruling out active TB.
•
Most HIV clinics do not have written TB infection control plans, even when a national policy exists. Though elements of IC are sometimes being practiced, there is a need to standardize and provide clear guidance on IC. Additionally, very little IC education is targeted at people with HIV. Thus, an opportunity that can reduce community transmission of TB and allow for community members to be greater proponents of IC in clinic settings has been lost. The rate of TB incidence among health care workers in HIV clinics—an indicator of TB transmission in HIV clinics—is not consistently known. Clinics, especially in Uganda, sited stigma as a reason why health care workers avoid sharing information about their TB disease.
•
Cotrimoxazole preventive therapy (CPT) is also inconsistently implemented across the three countries. In Kenya, TB clinics consistently provide CPT to persons coinfected with TB/HIV. In Uganda and Zambia, TB/HIV coinfected persons are referred to ART clinics to access CPT, and in Uganda stockouts of cotrimoxazole are an additional barrier to the rollout of this intervention.
•
HIV testing and prevention methods are widely offered, either on-site or more often through referrals to a nearby HIV testing site. However, consistent mechanisms have not been not established to triage people who have referrals to get easy access to HIV testing. This is a barrier for TB patients who could benefit from this intervention.
•
Antiretroviral therapy is most accessible in TB clinics in Kenya. In Uganda and Zambia, the majority of TB clinics surveyed only offer referrals to ART clinics. Additionally, the TB clinics do not have a full picture of all the ARTs that people coinfected with TB/HIV could be taking. This information is important as ARTs can have drug interactions with TB treatment.
2009 Kenyan Civil Society Grades for the Availability of TB/HIV Collaborative Services In Nyanza and Nairobi Provinces ACTIVITIES
GRADE
NOTES
Goal A: Assessing the planning and coordination between TB and HIV programs (establishing the mechanism for collaboration) A.1. TB/HIV coordinating bodies
A.2. HIV surveillance among TB patients A.3. TB/HIV planning
A.4. TB/HIV monitoring and evaluation
B
N/A B
N/A
A TB/HIV collaborative policy is in place; officials agree that a joint coordinating board (JCB) has been established at the national, provincial, and district levels but the officials from the national programs do not understand all the components of the policy. Members of the affected communities have knowledge about the policy and its components, and some know about the JCB at all levels. Not monitored Most policy makers could not confirm that TB and HIV programs work jointly to create resource mobilization, community involvement, operational research, a communication strategy, or a combined approach to monitoring and evaluation. Members of the affected communities report that the policy is being implemented in most of the districts. Not monitored
Goal B: Assessing the availability of services to decrease the burden of TB among people living with HIV (The Three I’s) B.1 Intensified TB case finding (ICF)
B
Service providers acknowledge existence of TB screening policies for persons with HIV in antiretroviral therapy (ART) clinics. Persons with HIV are screened routinely and, if necessary, referred for further diagnosis within the same health facility. Most health service providers work with public institutions and private nongovernmental organizations (NGOs) to carry out ICF in congregate settings. Most members of the affected communities confirm that TB screening is conducted at HIV clinics, but was not done consistently. Some clinics screened for TB when testing people for HIV, others when enrolling for ART, and some when people with HIV presented with TB-like symptoms.
B.2 Isoniazid preventive therapy (IPT)
D
There is no policy to routinely provide IPT for people with latent TB. Two HIV clinics provide IPT to people with HIV with latent TB infection as part of research studies. Some clinics claim to provide information on IPT to people with HIV. All community respondents report that HIV clinics do not provide IPT.
B.3 TB infection control (IC)
D
HIV service providers and members of the affected communities disagree about infection control (IC). HIV service providers report implementing some IC measures. Some HIV clinics partner with other organizations to provide IC education for people with HIV. None of the respondents from the affected communities have knowledge of any IC measures being implemented and could not confirm that IC is being undertaken in the HIV clinics they frequent.
Goal C: Assessing the availability of services to decrease the burden of HIV among people living with TB C.1 HIV testing and counseling
A
Most TB service providers report that voluntary counseling and testing (VCT) is done at the TB clinic or referral is provided to VCT centers. All respondents from affected communities agree that VCT is offered to TB patients in HIV clinics.
C.2 HIV preventive methods
B
Most TB clinics provide HIV prevention methods for those coinfected with HIV and TB. All community respondents concur that clinics provide education materials and talks on HIV prevention.
C.3 Cotrimoxazole preventive therapy (CPT)
A
Most TB service providers report providing CPT to all HIV-positive TB patients, and respondents from the affected communities concur.
C.4 HIV/AIDS care and support
B
Many TB service providers report that they offer a variety of HIV support services. Some respondents agree that their TB clinics provide HIV/AIDS care and support services, but that some services are being provided by affiliated NGOs.
C.5. Antiretroviral therapy (ART) to TB patients
C
Only half of TB service providers indicate that ART is available to HIV-positive TB patients at TB clinics, while most community respondents interviewed mention that ART is available for eligible TB/HIV patients.
Legend: A = Excellent; B = Good; C = Mediocre; D = Bad; F = Very Bad
2009 Ugandan Civil Society Grades for the Availability of TB/HIV Collaborative Services in the Kampala, Mpigi, and Wakiso Districts ACTIVITIES
GRADE
NOTES
Goal A: Assessing the planning and coordination between TB and HIV programs (establishing the mechanism for collaboration) A.1. TB/HIV coordinating bodies
A.2. HIV surveillance among TB patients A.3. TB/HIV planning
A.4. TB/HIV monitoring and evaluation
B
N/A C
N/A
A national TB/HIV collaborative policy is in place, but even some policy makers interviewed at the district level are not aware of it. Similarly, community members vary in their awareness and knowledge of the policy. The national joint coordinating body exists but it has not been established at the district level. Not monitored Joint planning, resource mobilization, and monitoring and evaluation are only functioning at the national level. At the district level the HIV and TB focal persons do not collaborate effectively, if at all. Not monitored
Goal B: Assessing the availability of services to decrease the burden of TB among people living with HIV (The Three I’s) B.1 Intensified TB case finding (ICF)
C
Responses from HIV service providers and persons with HIV differ significantly as to the extent of routine ICF or TB screening. Though HIV providers say they do provide ICF, people with HIV say ICF is only done when they present with TB-like symptoms.
B.2 Isoniazid preventive therapy (IPT)
F
IPT and information about IPT are not available; community members concur that IPT is not available.
B.3 TB infection control (IC)
B
Some infection control measures are in place and observed by community members, however clinic staff are not consistently trained in IC, nor are there clear IC protocols in place.
Goal C: Assessing the availability of services to decrease the burden of HIV among people living with TB C.1 HIV testing and counseling
C
TB clinics report referrals to HIV clinics for free HIV testing and counseling; however, delays in HIV testing are common and patient follow-up measures are not in place.
C.2 HIV preventive methods
C
TB clinics allege providing HIV prevention information to community members, but community members do not concur. Testing referrals are in place.
C.3 Cotrimoxazole preventive therapy (CPT)
C
Clinics reported that clients are referred to HIV clinics for CPT, but stockouts of cotrimoxazole are consistently noted as a barrier to therapy.
C.4 HIV/AIDS care and support
B
A variety of HIV support services are reported at TB clinics, yet some TB/HIV patients are referred for similar services to HIV clinics.
C.5. Antiretroviral therapy (ART) to TB patients
C
TB/HIV coinfected patients are regularly referred to HIV clinics for access to ART.
Legend: A = Excellent; B = Good; C = Mediocre; D = Bad; F = Very Bad
2009 Zambian Civil Society Grades for the Availability of TB/HIV Collaborative Services in Lusaka ACTIVITIES
GRADE
NOTES
Goal A: Assessing the planning and coordination between TB and HIV programs (establishing the mechanism for collaboration) A.1. TB/HIV coordinating bodies
A.2. HIV surveillance among TB patients A.3. TB/HIV planning
A.4. TB/HIV monitoring and evaluation
A
N/A B
N/A
A TB/HIV collaborative policy is in place and information about it has been distributed to all health centers in the district. Most of the affected community members have no knowledge of the content of the TB/HIV collaborative policy. Not monitored A joint coordinating board has been set up by the ministry of health (MOH) in each of the nine provinces, with representation from government and civil society. The board meets at quarterly intervals to share their implementation successes and challenges. Most members of the affected communities have no knowledge about any mechanism put in place to ensure the implementation of the TB/HIV collaborative plan. Not monitored
Goal B: Assessing the availability of services to decrease the burden of TB among people living with HIV (The Three I’s) B.1 Intensified TB case finding (ICF)
C
Four out of the nine clinics assessed report that they are screening for TB, but most of these screen only when a person presents with TB-like symptoms. Patients are then referred to a separate TB clinic. One facility works within prisons as one of the congregate settings in order to address ICF.
B.2 Isoniazid preventive therapy (IPT)
D
IPT is not part of the MOH treatment guidelines, and none of the HIV clinics assessed provide IPT. Members of the affected communities note that IPT is only provided to those in the ZAMSTAR research study.
B.3 TB infection control (IC)
B
All clinics assessed have IC plans, but most do not fully comply with recommended World Health Organization IC guidelines. Members of the affected communities report that they are not educated about the importance of infection control measures.
Goal C: Assessing the availability of services to decrease the burden of HIV among people living with TB C.1 HIV testing and counseling
D
None of the TB clinics provide HIV testing for their patients; such patients are referred for HIV testing to antiretroviral therapy (ART) clinics within the same health care facilities. Members of the affected communities also report that long queues at the HIV testing center are a barrier to access. All clinics capture HIV status and HIV treatment regimen in their TB registers.
C.2 HIV preventive methods
B
TB clinics report providing some HIV preventive services to TB patients.
C.3 Cotrimoxazole preventive therapy (CPT)
D
None of the TB clinics assessed provide CPT for HIV-positive patients. For CPT, HIVpositive patients are referred to the ART clinics.
C.4 HIV/AIDS care and support
B
HIV care and support services are provided at some of the TB clinics assessed, and people from the affected communities concur that these are available.
C.5. Antiretroviral therapy (ART) to TB patients
B
None of the TB clinics provide ART to eligible HIV-positive TB patients; rather, such patients are referred to the ART clinics. All parties view the referral system that is in place as effective.
Legend: A = Excellent; B = Good; C = Mediocre; D = Bad; F = Very Bad
ABOUT TAG The Treatment Action Group is an independent AIDS research and policy think tank fighting for better treatment, a vaccine, and a cure for AIDS. TAG works to ensure that all people with HIV receive lifesaving treatment, care, and information.
Treatment Action Group 611 Broadway, Suite 308 New York, NY 10012 Tel 212.253.7922 Fax 212.253.7923 tag@treatmentactiongroup.org www.treatmentactiongroup.org
ABOUT ICW ICW–Eastern Africa is based in Kampala, Uganda. ICW is the only international network run for and by HIV-positive women. It was founded in response to the desperate lack of support, information, and services available to HIV-positive women worldwide and their need for influence and input on policy development.
International Community of Women Living with HIV/AIDS (ICW) Eastern Africa Plot 16, Tagore Crescent P.O. Box 32252, Kampala, 0414, Uganda Tel +256.414.53.19.13 Fax +256.414.53.33.41 lmworeko@icwea.org www.icwea.org