ICAP News - July 2008

South Africa TB Hospital Provides Antiretroviral Therapy to HIV Co-infected Patients
In September 2006, ICAP-supported Nkqubela Tuberculosis Hospital in East London, South Africa, launched an integrated TB/HIV service program led by a new multidisciplinary team of providers. In addition to strengthened HIV counseling and testing for TB patients, the program provides clinical staging and laboratory assessment of co-infected patients, cotrimoxazole prophylaxis, antiretroviral therapy (ART) initiation, and patient transfer to HIV service sites after discharge, among other components.

In the first 18 months of integrated services, nearly 900 patients of unknown HIV status received HIV counseling and testing and more than 300 people were identified as HIV infected. Nearly all of these patients, as well as 1,264 TB patients with previously diagnosed HIV infection, received cotrimoxazole prophylaxis and 84 percent were assessed based on CD4 cell count or World Health Organization (WHO) staging guidelines for the initiation of ART.

A total of 215 HIV-infected TB patients with CD4 counts less than 50 cells/mm3 or WHO stage 4 began ART during the initial phase of TB treatment at the hospital. After discharge, these patients and those with CD4 counts between 50 and 200 cells/mm3 were referred to HIV care and treatment sites nearest their homes and also received follow-up home visits from peer educators. All co-infected TB patients took part in an ART readiness program at the hospital, which included management of HIV-related clinical problems, adherence counseling, and education about HIV medications.

In total, nearly two-thirds of TB in-patients counseled were co-infected with HIV and nearly three-quarters were severely immuno-compromised with CD4 counts below 200 cells/mm3.

Mortality was high among TB/HIV co-infected patients preparing to initiate ART and those who had already started ART at 16 and 21 percent, respectively. This owed in part to drug-resistant TB, which was identified among 5 percent of co-infected patients who had initiated ART. To reduce HIV/TB-related mortality, ICAP-South Africa staff recommend initiating ART for all co-infected patients with CD4 counts less than 100 cells/mm3 or stage 4 disease while undergoing TB treatment at the hospital.

The poster may be accessed here.

For more about ICAP South Africa, visit here.

TB Screening Questionnaires Dramatically Improve Detection of Active TB Among HIV Patients
Ethiopia hospitals increase TB case detection by fourfold
Routine TB screening of patients receiving HIV care and treatment services is an important strategy for early identification of TB. Beginning in 2006, ICAP Ethiopia piloted the use of a simple TB screening form at five hospitals (Dilchora, Hiwot Fana, Jimma, Nekemt, and Woliso Hospitals) which provide HIV care and treatment services.

Healthcare providers completed screening questionnaires for all HIV-positive patients when they enrolled in care and treatment at the hospitals’ HIV clinics. From 2006 to 2007, the proportion of HIV patients screened for TB at enrollment increased from 55 percent (992 out of 1,794 patients) to 95 percent (1,015 out of 1,065 patients). During the same period, the proportion of active TB cases detected increased fourfold, from 4 percent (67 out of 1,794 patients) to 16 percent (172 of 1,065 patients).

At the clinics, all members of the multidisciplinary teams received orientation in the use of the form and were provided with regular clinical mentoring on TB screening. Based on the success of the pilot initiative, ICAP plans to support the implementation of TB screening at all ICAP-supported sites in Ethiopia.

The poster may be accessed here.

For more about ICAP Ethiopia, visit here.

Tanzania hospital screens all newly diagnosed HIV patients for TB
In late 2006, ICAP Tanzania began supporting trainings and mentorship of staff at Tumbi Regional Hospital in TB screening and management of HIV patients. Trainings initially focused on implementing a revised national data tool for TB screening and later an ICAP-developed TB questionnaire to screen HIV patients upon enrollment into care and treatment and at all subsequent follow-up visits.
By the latter half of 2007, Tumbi providers were screening all newly enrolled HIV patients for TB or a total of 927 patients. Over the course of that year, a total of 63 HIV patients were identified with active TB and referred for treatment at the hospital.

In addition to supporting improved TB screening of HIV patients, ICAP has been working with Tumbi Hospital to ensure TB patients are tested for HIV and, if found infected, referred for treatment at the hospital’s HIV clinic. In 2007, 93 percent of the TB clinic’s 475 patients of unknown HIV status received an HIV test. Nearly one-third of these patients were identified as HIV infected and enrolled into care and treatment at the hospital’s HIV clinics.

ICAP continues to work closely with the hospital to ensure TB screening is incorporated into routine care of HIV patients – not just at enrollment visits.

The poster may be accessed here.

For more about ICAP Tanzania, visit here.

Rural Mozambique Health Center Bridges TB and HIV Services
Nicoadala Health Center, a rural facility in Mozambique’s Zambezia Province, provided both HIV and TB services, but co-infected patients were rarely referred between the services. In July 2007, ICAP began working with the health center to establish systems for screening HIV patients for TB, providing HIV counseling and testing to TB patients, and ensuring those who are found to be co-infected receive coordinated care and treatment for both conditions.

In addition to providing clinical mentoring and other technical support, ICAP worked with the site to designate a TB/HIV focal point nurse to escort co-infected patients between services and reinforce their counseling. Efforts also focused on improving collection of TB/HIV patient data, including the adoption of a standardized TB screening questionnaire.

Between October and December 2007, 88 percent of 353 newly enrolled HIV patients were screened for TB, of whom 7.4 percent were diagnosed with active TB. During the same period, the center’s TB service provided HIV counseling and testing to 45 patients of unknown HIV status, of whom nearly half tested positive.
Patients identified as TB/HIV co-infected had high rates of enrollment in both services at the health center. Eventually, 87 percent of TB patients enrolled in HIV care and treatment, while 84 percent of HIV patients started cotrimoxazole prophylaxis in the HIV service.

ICAP staff credit the successful integration of TB/HIV services at Nicoadala Health Center to the commitment of the staff in both treatment settings to identifying and treating co-infected patients. Having a focal person for TB/HIV integration is also instrumental to successful service integration.

The presentation may be accessed here.

For more about ICAP Mozambique, visit here.

Rwanda’s ‘One-Stop’ Model of TB/HIV Integration Promotes Closer Coordination of Services
In recent years, the Rwandan Ministry of Health has embarked on a national campaign to increase TB/HIV integration, including establishing a national TB/HIV working group and revising program guidelines, tools, and training materials. In support of these activities, ICAP worked with the ministry to design a ‘one-stop’ model for TB/HIV integration, which was originally piloted at two ICAP-supported TB/HIV Model Centers and is now being adopted on a national scale with ICAP technical support.

TB treatment units serve as the sites for the co-located services where TB patients receive treatment and are offered HIV testing. If found to be HIV infected, patients begin HIV care and treatment in the TB units and continue to receive these services until they have completed TB treatment. At that time, they are accompanied and transferred to the facility’s HIV care and treatment program.

Providing TB and HIV services at a single location for patients with both conditions ensures better coordination of care and reduces the number of appointments patients must make with healthcare providers. The integrated system also limits contact between TB patients and larger numbers of HIV-infected individuals during early periods of TB treatment when co-infected patients may be most infectious.

Efforts to integrate TB/HIV services also focus on increasing TB screening at HIV service sites using a standardized, five-question checklist. Patients confirmed to have active TB are accompanied to TB clinics for treatment. Home visits are also conducted to screen family members and identify others who may have had contact with TB patients, and provide HIV testing.

Between 2004 and 2007, integration of TB/HIV services nationwide resulted in significant increases in the percentage of TB patients who received an HIV test (from 45 to 91 percent) and a rise in the percentage of TB patients newly diagnosed with HIV who received cotrimoxazole prophylaxis (from 0 to 61 percent). In 2007, 2.2 percent of the 12,179 patients newly enrolled in HIV care and treatment in Rwanda had active TB. Among patients in HIV care for more than six months, TB prevalence was only 0.6 percent.

The presentation may be accessed here.

Photo caption: ICAP works with its partners to support mentoring and clinical training in TB/HIV integration.

For more about ICAP Rwanda, visit here.

Newly Renovated Pediatric Model Center Provides High-Quality Services for Children with HIV, Training Opportunities for Healthcare Providers in Rwanda
On June 26, Centre Hospitalier Universitaire de Kigali (CHUK) inaugurated the newly renovated Pediatric HIV Care Model Center to provide comprehensive services for children with HIV through a unique family-focused approach, including early infant diagnosis, care and treatment, psychosocial and nutritional support. The center also provides training opportunities for healthcare professionals from around Rwanda focusing on best practices in pediatric HIV care and treatment.

At the center’s inauguration, Elaine Abrams, MD, director of ICAP’s MTCT-Plus Initiative, described the facility as “a center for learning and discovery for health providers as well as children and their families.

“Health providers from all over Rwanda will be able to spend time here learning how to care for children and families with HIV using a multidisciplinary approach and relying upon the most updated, evidence-based practices and research. There will be unique opportunities to document learning, disseminate knowledge, and simply discover the best ways to improve the quality of life for children living with HIV.”

ICAP-Rwanda County Director Ruben Sahabo, MD, credited the development of the model center to the strong partnership between CHUK and ICAP, as well as the leadership of the Rwandan Ministry of Health, the Treatment and Research on AIDS Center (TRAC), and the U.S. President’s Emergency Plan for AIDS Relief, which provided funding for the center’s renovation.

CHUK is one of two national teaching hospitals in Rwanda supported by ICAP with pediatric HIV care model centers. The other is housed at University Hospital Centre of Butare (CHUB).

Since 2002, ICAP has been working with TRAC to scale-up HIV services, including prevention of mother-to-child transmission of HIV and pediatric HIV services in the context of a comprehensive, family-focused approach. Currently, ICAP supports HIV care for more than 34,000 people in Rwanda, including more than 3,700 children. ICAP also has supported Rwanda’s National Reference Laboratory in expanding infant diagnosis services to more than 126 sites throughout the country.

Photo captions: A plaque unveiled at the model center dedication highlights the partnership that made possible the facility's renovation.
From left to right, ICAP-Rwanda Country Director Ruben Sahabo, MD, MTCT-Plus Initiative Director Elaine Abrams, MD, and Pediatric HIV/AIDS Care and Treatment Advisor Gilbert Tene, MD

For more about ICAP Rwanda, visit here.

Motor Park in Nigeria Adds New Service: HIV Counseling and Testing
In Nigeria, motor parks draw together large numbers of people, including drivers, vendors, and artisans. Recognizing the need to make HIV services more accessible, ICAP is supporting the launch of HIV counseling and testing centers at motor parks in Benue State in north central Nigeria.

In June, Benue Links Motor Park partnered with the JIREH Foundation, a community-based organization, and ICAP to establish a freestanding HIV counseling and testing center. At a rally marking the official inauguration of testing services, Victoria Ugor, project manager for the Benue State Action Committee on AIDS, who was joined by representatives from government, community and non-governmental organizations, and road transport unions, praised ICAP for its support and urged audience members to take HIV tests. On opening day, the Benue Links facility tested 202 people and identified 13 potentially HIV-positive individuals, who were referred to nearby ICAP-supported HIV service sites.

ICAP is supporting the opening of an HIV testing center at another Markudi motor park later this year.

“Motor parks are excellent venues for providing HIV testing and connecting those who test positive with HIV services,” said ICAP-Nigeria Country Director Bola Oyeledun, MD. “We look forward to supporting the establishment of many more counseling and testing sites.”

Photo caption: A rally marking the inauguration of counseling and testing services at Benue Links Motor Park highlights the importance of knowing one's HIV status.

For more about ICAP Nigeria, visit here.