Effect of TB/HIV Integration on TB and HIV Indicators in Rural Ugandan Health Facilities

Opportunities and challenges for the integration of managing non-communicable diseases within HIV care and treatment services in Tanzania

BACKGROUND

People living with HIV and non-communicable diseases (NCDs) are reported to experience challenges in accessing affordable and high-quality NCD care services. Consequently, the World Health Organization (WHO) recommends care integration of NCDs within the HIV services in resource-limited regions. The available opportunities and challenges need to be understood and addressed for an effective integration process. This study explored opportunities and challenges for integrating NCDs within HIV care and treatment services in Tanzania.

METHODS

An exploratory qualitative case study was conducted in Tanzania between April and July 2022. A total of 22 key informants working at the ministerial level, supervising the provision of healthcare services in Tanzania, were recruited purposefully for in-depth interviews. Thematic analysis was employed during the study.

RESULTS

Several opportunities were identified in the study for HIV/NCD services integration including the existence of an integration policy, the availability of regulations and guidelines, the existence of donor support, the presence of physical space and reliable information and communication systems, human resources adequacy, and political will to support the process. However, participants voiced concerns over the costs related to service integration, difficulties in reallocating donor funds, and hesitance of the healthcare providers as likely challenges to effective integration.

CONCLUSION

The findings of this study underscore that the effective and sustainable care integration of NCDs within HIV services relies on the availability of policy, funds, infrastructures, human resources, and stakeholders' willingness to support the process.

Predictors of tuberculosis treatment outcomes among people living with HIV in some States in Nigeria

Introduction

tuberculosis (TB) and Human Immunodeficiency Virus (HIV) remain major public health threats globally and worse when they co-exist in susceptible individuals. The study examined TB treatment outcomes and their predictive factors among people living with HIV (PLHIVs).

Methods

a review of TB/HIV co-infected patients who had TB treatments across comprehensive antiretroviral therapy (ART) sites with ≥500 patients was conducted in seven United States of America President's Emergency Plan for AIDS Relief (PEPFAR)-supported States in Nigeria. Data on patient background, HIV and TB care, and TB treatment outcomes were collected using an Excel abstraction template. The data was analyzed using SPSS and an association was examined using a chi-square test while binary logistic regression was used to determine predictors of TB treatment outcomes (P< 0.05).

Results

two thousand six hundred and fifty-two co-infected patients participated in the study. The mean age of participants was 37 ± 14 years. A majority had TB treatment success (cured = 1059 (39.9%), completed = 1186 (44.7%)). Participants who had pulmonary TB, virally suppressed and commenced isoniazid (INH) before TB diagnosis were more likely to have a favorable TB treatment outcome compared to those who had extrapulmonary TB (AOR = 7.110, 95% CI = 1.506 - 33.565), virally unsuppressed (AOR = 1.677, 95% CI = 1.036 - 2.716) or did not commence INH before TB diagnosis (AOR = 1.486, 95% CI = 1.047 - 2.109).

Conclusion

site of infection, immune status, exposure to ART, and INH prophylaxis were found to predict TB treatment outcomes among PLHIVs. Stakeholders should ensure early commencement of ART and INH prophylaxis for PLHIVs.

Factors associated with tuberculosis treatment outcomes among TB patients aged 15 years and older at chawama level one hospital in Lusaka, Zambia

Tuberculosis is a global health concern n impacting communities, health systems, and economies This study assessed the TB treatment outcomes among individuals aged 15+ at Chawama first level hospital in Lusaka, Zambia, using a retrospective design focussing on individuals notified in 2020. The sample was described using descriptive statistics. The Pearson Chi-square test and logistics regression were used to analyse the characteristics of the patients influencing the treatment outcomes at 5% significant level. Out of 404 participants, 83.4% of them had successful treatment outcomes. Varied outcomes were noted in sex, patient type, TB type, HIV status, and DOT plan, but lacked significance. Odds of success were lower by 72.4% for those aged 65+ compared to those aged 15-24 years (OR (95% CI): 0.276 (0.086-0.881), p = .030). Similarly, after adjusting for other variables, the odds of success were lower by 72.9% (AOR (95% CI): 0.271 (0.083-0.882), p = .030). This study yielded an encouraging 83.4% TB success rate highlighting the potential for improvement to meet WHO targets. Notably, individuals aged 65+ showed a distinct pattern with lower treatment success odds, suggesting a need for focussed interventions. Special attention to elderly patients and targeted TB program interventions are recommended.

Developing a Model for Integrating of Tuberculosis, Human Immunodeficiency Virus and Primary Healthcare Services in Oliver Reginald (O.R) Tambo District, Eastern Cape, South Africa

Despite the policy, frameworks for integration exist; integration of TB and HIV services is far from ideal in many resource-limited countries, including South Africa. Few studies have examined the advantages and disadvantages of integrated TB and HIV care in public health facilities, and even fewer have proposed conceptual models for proven integration. This study aims to fill this vacuum by describing the development of a paradigm for integrating TB, HIV, and patient services in a single facility and highlights the importance of TB-HIV services for greater accessibility under one roof. Development of the proposed model occurred in several phases that included assessment of the existing integration model for TB-HIV and synthesis of quantitative and qualitative data from the study sites, which were selected public health facilities in rural and peri-urban areas in the Oliver Reginald (O.R.) Tambo District Municipality in the Eastern Cape, South Africa. Secondary data on clinical outcomes from 2009-2013 TB-HIV were obtained from various sources for the quantitative analysis of Part 1. Qualitative data included focus group discussions with patients and healthcare workers, which were analyzed thematically in Parts 2 and 3. The development of a potentially better model and the validation of this model shows that the district health system was strengthened by the guiding principles of the model, which placed a strong emphasis on inputs, processes, outcomes, and integration effects. The model is adaptable to different healthcare delivery systems but requires the support of patients, providers (professionals and institutions), payers, and policymakers to be successful.

Adequate funding of comprehensive community-based programs for key populations needed now more than ever to reach and sustain HIV targets

Introduction

Globally, over half of the estimated new HIV infections now occur among key populations, including men who have sex with men, sex workers, people who inject drugs, transgender individuals, and people in prisons and other closed settings, and their sexual partners. Reaching epidemic control will, for many countries, increasingly require intensified programming and targeted resource allocation to meet the needs of key populations and their sexual partners. However, insufficient funding, both in terms of overall amounts and the way the funding is spent, contributes to the systematic marginalization of key populations from needed HIV services.

Discussion

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently highlighted the urgent need to take action to end inequalities, including those faced by key populations, which have only been exacerbated by the COVID‐19 pandemic. To address these inequalities and improve health outcomes, key population programs must expand the use of a trusted access platform, scale up differentiated service delivery models tailored to the needs of key populations, rollout structural interventions and ensure service integration. These critical program elements are often considered “extras,” not necessities, and consequently costing studies of key population programs systematically underestimate the total and unitary costs of services for key populations. Findings from a recent costing study from the LINKAGES project suggest that adequate funding for these four program elements can yield benefits in program performance. Despite this and other evidence, the lack of data on the true costs of these elements and the costs of failing to provide them prevents sufficient investment in these critical elements.

Conclusions

As nations strive to reach the 2030 UNAIDS goals, donors, governments and implementers should reconsider the true, but often hidden costs in future healthcare dollars and in lives if they fail to invest in the community‐based and community‐driven key population programs that address structural inequities. Supporting these efforts contributes to closing the remaining gaps in the 95‐95‐95 goals. The financial and opportunity cost of perpetuating inequities and missing those who must be reached in the last mile of HIV epidemic control must be considered.

A Systematic Review of Linkage-to-Care and Antiretroviral Initiation Implementation Strategies in Low- and Middle-Income Countries Across Sub-Saharan Africa

Linkage to care (LTC) and initiation of antiretroviral therapy (ART) are key components in the longitudinal care cascade for people living with HIV. Many strategies to optimize these stages of HIV care have been implemented, though there is a paucity of analyses comparing the outcomes of these efforts in low- and middle-income countries. We conducted a systematic review of studies assessing interventions along all stages of the HIV care continuum published between 2008 and 2020. A comprehensive search strategy reviewed five electronic databases to capture studies assessing HIV testing, LTC, ART initiation, ART adherence, and viral suppression. Of the 388 articles that met the inclusion criteria, 78 described interventions for improving LTC/ART initiation. Efforts focused on empowering patients through integrative approaches generally yielded more substantive results compared to provider-initiated non-adaptive LTC interventions or cash incentives. Specifically, tailoring care and incorporating ART initiation into existing infrastructures, such as maternal clinics, had a high impact across settings. Moreover, strategies such as home-based HIV counseling and testing (HBHCT) appear to be most effective when implemented in tandem with other approaches including motivational counseling and point-of-care CD4 testing.

Integrating services for HIV and multidrug-resistant tuberculosis: A global cross-sectional survey among ART clinics in low- and middle-income countries

Tuberculosis (TB) is the leading cause of death among PLHIV and multidrug-resistant-TB (MDR-TB) is associated with high mortality. We examined the management for adult PLHIV coinfected with MDR-TB at ART clinics in lower income countries. Between 2019 and 2020, we conducted a cross-sectional survey at 29 ART clinics in high TB burden countries within the global IeDEA network. We used structured questionnaires to collect clinic-level data on the TB and HIV services and the availability of diagnostic tools and treatment for MDR-TB. Of 29 ART clinics, 25 (86%) were in urban areas and 19 (66%) were tertiary care clinics. Integrated HIV-TB services were reported at 25 (86%) ART clinics for pan-susceptible TB, and 14 (48%) clinics reported full MDR-TB services on-site, i.e. drug susceptibility testing [DST] and MDR-TB treatment. Some form of DST was available on-site at 22 (76%) clinics, while the remainder referred testing off-site. On-site DST for second-line drugs was available at 9 (31%) clinics. MDR-TB treatment was delivered on-site at 15 (52%) clinics, with 10 individualizing treatment based on DST results and five using standardized regimens alone. Bedaquiline was routinely available at 5 (17%) clinics and delamanid at 3 (10%) clinics. Although most ART clinics reported having integrated HIV and TB services, few had fully integrated MDR-TB services. There is a continued need for increased access to diagnostic and treatment options for MDR-TB patients and better integration of MDR-TB services into the HIV care continuum.

Mortality in HIV and tuberculosis patients following implementation of integrated HIV-TB treatment: Results from an open-label cluster-randomized trial

BACKGROUND

HIV-TB treatment integration reduces mortality. Operational implementation of integrated services is challenging. This study assessed the impact of quality improvement (QI) for HIV-TB integration on mortality within primary healthcare (PHC) clinics in South Africa.

METHODS

An open-label cluster randomized controlled study was conducted between 2016 and 2018 in 40 rural clinics in South Africa. The study statistician randomized PHC nurse-supervisors 1:1 into 16 clusters (eight nurse-supervisors supporting 20 clinics per arm) to receive QI, supported HIV-TB integration intervention or standard of care (control). Nurse supervisors and clinics under their supervision, based in the study health districts were eligible for inclusion in this study. Nurse supervisors were excluded if their clinics were managed by municipal health (different resource allocation), did not offer co-located antiretroviral therapy (ART) and TB services, services were performed by a single nurse, did not receive non-governmental organisation (NGO) support, patient data was not available for > 50% of attendees. The analysis population consists of all patients newly diagnosed with (i) both TB and HIV (ii) HIV only (among patients previously treated for TB or those who never had TB before) and (iii) TB only (among patients already diagnosed with HIV or those who were never diagnosed with HIV) after QI implementation in the intervention arm, or enrolment in the control arm. Mortality rates was assessed 12 months post enrolment, using unpaired t-tests and cox-proportional hazards model. (Clinicaltrials.gov, NCT02654613, registered 01 June 2015, trial closed).

FINDINGS

Overall, 21 379 participants were enrolled between December 2016 and December 2018 in intervention and control arm clinics: 1329 and 841 HIV-TB co-infected (10·2%); 10 799 and 6 611 people living with Human Immunodeficiency Virus (HIV)/ acquired immunodeficiency syndrome (AIDS) (PLWHA) only (81·4%); 1 131 and 668 patients with TB only (8·4%), respectively. Average cluster sizes were 1657 (range 170-5782) and 1015 (range 33-2027) in intervention and control arms. By 12 months, 6529 (68·7%) and 4074 (70·4%) were alive and in care, 568 (6·0%) and 321 (5·6%) had completed TB treatment, 1078 (11·3%) and 694 (12·0%) were lost to follow-up, with 245 and 156 deaths occurring in intervention and control arms, respectively. Mortality rates overall [95% confidence interval (CI)] was 4·5 (3·4-5·9) in intervention arm, and 3·8 (2·6-5·4) per 100 person-years in control arm clusters [mortality rate ratio (MRR): 1·19 (95% CI 0·79-1·80)]. Mortality rates among HIV-TB co-infected patients was 10·1 (6·7-15·3) and 9·8 (5·0-18·9) per 100 person-years, [MRR: 1·04 (95% CI 0·51-2·10)], in intervention and control arm clusters, respectively.

INTERPRETATION

HIV-TB integration supported by a QI intervention did not reduce mortality in HIV-TB co-infected patients. Demonstrating mortality benefit from health systems process improvements in real-world operational settings remains challenging. Despite the study being potentially underpowered to demonstrate the effect size, integration interventions were implemented using existing facility staff and infrastructure reflecting the real-world context where most patients in similar settings access care, thereby improving generalizability and scalability of study findings.

FUNDING

Research reported in this publication was supported by South African Medical Research Council (SAMRC), and UK Government's Newton Fund through United Kingdom Medical Research Council (UKMRC).

Retention in Care among Patients Attending a Large HIV Clinic in Nigeria Who Were Treated for Tuberculosis

A retrospective study of 2764 patients was conducted at an HIV clinic in Nigeria to evaluate retention in care in patients treated for TB. At 6 and 12 months after commencement of TB treatment, 1842(66.6%) and 1624(58.8%) participants remained in care. Of the 922 and 1140 not in care at 6 and 12 months, 814(88.3%) and 1006(88.2%) respectively were lost to follow-up (LTFU). VL < 1000copies/ml was associated with higher odds of retention in care at 6 and 12 months (OR  =  2.351 and 2.393) than VL > 1000 copies/ml. HAART use was associated with high likelihood of being in care at 12 months (OR  =  3.980). CD4 counts of 200–350 and >350 cells/mm³ were associated with increased odds of remaining in care at 12 months compared with CD4 < 200 cells/mm³ (p  =  0.005 and p  =  0.001). Targeted interventions such as early HAART and close follow-up for high risk groups are likely to improve retention in care.

Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique

INTRODUCTION

AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population.

METHODS

All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months.

RESULTS

A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts.

CONCLUSIONS

A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.

Evolution of Tuberculosis/Human Immunodeficiency Virus Services among Different Integrated Models in Myanmar: A Health Services Review

Myanmar is one of the highly affected countries by tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection. We aimed to review the coverage of TB/HIV integrated services as well as to document the performance of this integrated services. A retrospective program review was conducted using the aggregated data of the National TB Programme (NTP) from 2005 to 2016. In Myanmar, TB/HIV services were initiated in seven townships in 2005. Townships were slowly expanded until 2013. After that, the momentum was increased by increasing the government budget allocation for NTP. In 2016, the whole country was eventually covered by TB/HIV services in different types of integration. Antiretroviral therapy (ART) coverage among HIV-positive TB patients remained low and it was the only significant difference among the three types of integration. Barriers of low ART coverage need to be investigated to reduce the burden of TB/HIV.