What was the problem?
Tuberculosis (TB) is the leading cause of morbidity and mortality among people living with HIV (PLHIV). Early antiretroviral therapy (ART) is recommended for all persons with TB/HIV co-infection, with multiple trials demonstrating that it reduces mortality and loss-to-follow-up, particularly in persons with advanced HIV disease. Despite this evidence, only 84 percent of HIV-positive TB patients received ART worldwide in 2017 leaving important gaps in ensuring that 90 percent of PLHIV are initiated on ART (World Health Organization [WHO], Global Tuberculosis Report 2017). One limiting factor may be that TB and HIV clinics are often physically separate, and thus are run by different programs. Separate and uncoordinated clinical care imposes heavy burdens on co-infected patients, potentially compromising adherence, retention, and treatment outcomes.
What is the solution?
This activity involves implementing and measuring performance of high impact TB/HIV collaborative activities, as recommended by the WHO and supported by epidemiologic, clinical trial, and programmatic evidence. Specifically, activities included in this solution derive from successful examples of TB/HIV integration in Eswatini, where core elements of success included:
1) Political commitment:
Political commitment to improve TB/HIV collaborative activities began as far back as 2007, when the National TB/HIV Coordinating Committee (NCC) was formed, with representation from the Eswatini National AIDS Program, the National Tuberculosis Control Program, implementing partners, civil society, and community partners. Over several years, they agreed to implement WHO-recommended collaborative TB/HIV activities, to train public and private sector healthcare workers, and to roll out aggressive social mobilization and communication strategies. The NCC has since met quarterly to deliberate on progress and to discuss the continued way forward.
2) Decentralization of TB and HIV treatment services:
Beginning in 2008, the Eswatini HIV program rapidly decentralized HIV services to primary health care clinics and the TB program increased the number of Basic Management Units (BMUs). In addition to clinical services, laboratory services such as testing for viral load and TB diagnostic testing (the latter using the GeneXpert platform) were expanded and moved closer to patient care facilities. This ensured that facilities do not refer patients for lab testing, but rather collect samples and use the national sample transportation system to send samples and receive results. This facilitated diagnostic evaluation of TB disease and TB case-finding among PLHIV and safe initiation of isoniazid preventive therapy (IPT).
3) Task shifting:
As part of the service decentralization effort, in 2008 the Ministry of Health (MOH) created a new policy to allow nurse-led ART initiation and provision in Eswatini (NARTIS). This greatly expanded the capacity to treat PLHIV and permitted TB BMUs and clinics to provide ART to PLHIV.
The above core activities allowed for the integration and co-location of TB and HIV services, which was achieved in 2009 in all regions and all TB treatment sites under a “one stop shop” model.
What was the impact?
Along with the above policy changes, integrated service delivery, training, and social mobilization campaigns have yielded high impact results. These successes are demonstrated here through three main data sources: PEPFAR and Eswatini MOH program data, Eswatini’s Annual TB Program Report in 2017, and an evaluation project.
In 2018, PEPFAR program data showed that 98 percent of TB patients had a known HIV status, of whom 68 percent were HIV-positive and 97 percent were receiving ART (Figure 1).
Overall, through TB/HIV collaborative activities, ART uptake among HIV-positive TB patients has increased from 66 percent in 2012 to 94 percent in 2017.
A retrospective cohort evaluation of the integrated TB/HIV program (conducted between July and November 2014) found that 99 percent of HIV-infected TB patients initiated ART within six months of TB treatment initiation (Pathmanathan, 2018). This is much higher than published results from other integrated and non-integrated settings in sub-Saharan Africa. Among PLHIV not already on ART at TB treatment initiation, almost 90 percent initiated ART within eight weeks per national guidelines.
Among the subset of PLHIV who were part of the study, 97.3 percent had TB screening documented at their last HIV care or treatment visit within the study period (Pasipamire, USAID ASSIST Project, p. 5). Although only half of those with a positive TB screen had a documented diagnostic evaluation (including sputum smear microscopy, culture, Gene X-pert, or chest X-ray; still a weakness within the program), all patients with a TB diagnosis received TB treatment, with a treatment success rate of 85 percent (ibid, p.5 – 11).
How does it work?
Integrated TB/HIV activities are relevant for all persons with TB or undergoing evaluation for TB, (i.e., those with “presumptive TB”), and all PLHIV. The WHO has long recommended the integration of HIV services with other relevant clinical services (such as those for TB) to improve program quality and efficiency. This also aligns with the principle of patient-centered care, and the foundational intention of integrating services was to improve care by reducing individual-level barriers. For example, integrating and/or co-locating HIV and TB treatment services may significantly reduce patient attrition between program sites (during treatment initiation or follow up visits/refills) due to time constraints, transportation costs, doubts and/or hesitation, lack of support or treatment navigation, etc.
Health Systems Level
In 2012, Eswatini adopted the revised WHO TB/HIV policy recommendations. This was done after over five years of collaborative TB/HIV programs and implementation research to inform country-specific policy and guidelines, including ART provision for TB patients using a “one stop shop” approach where people can be screened for TB and HIV, and can pick up treatment for both diseases at one site.
As described above, success of this model was driven by several health-system level factors, including creation of national and regional TB/HIV coordinating committees and champions; close collaboration between Swaziland National AIDS Programme (SNAP), the National TB Control Programme (NTCP) and community partners; declaration of TB as an emergency for PLHIV; decentralization of treatment services to primary health clinics; task-shifting of ART initiation to TB clinic nurses; and social mobilization and educational campaigns to garner community and healthcare worker support. The NCC is co-chaired by program managers from SNAP and NTCP, with TB/HIV focal points from both agencies sharing secretariat roles.
The success of this model relied on several shifts in the national environment, including declaration of TB as an emergency, creation of national TB/HIV guidelines in alignment with WHO recommendations and formation of the TB coordinating committees as previously described. Major policy shifts were those allowing nurse-led ART initiation and management (including TB nurses) and decentralization of TB and HIV treatment to primary health centers. All policy shifts first required the development and ratification of policy, and then trainings for relevant providers and stakeholders.
Evaluation of TB/HIV Collaborative Activities in Swaziland (USAID ASSIST Project)