Intensified TB Case Finding using a TB screening tool integrated into an HIV clinical record: Experiences from the Eastern Cape Province

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1 Intensified TB Case Finding using a TB screening tool integrated into an HIV clinical record: Experiences from the Eastern Cape Province Dr. Sabine Verkuijl Technical Advisor: TB/HIV Integration, ICAP-SA ASSAf-IOM MDR TB workshop Pretoria, 4 March 2010

2 Overview TB/HIV collaborative activities background ECDOH Adult Clinical Record (ACR) TB symptom screening Integrated TB screening questionnaire TB screening M&E Lessons learnt Conclusions and recommendations

3 Estimated HIV prevalence in new TB cases, 2007

4 Drug Resistant TB and HIV Increase in DR TB cases in Africa confirms convergence of both epidemics High (and rapid) mortality among DRTB/HIV co-infected patients Majority of deaths occur before treatment with 2 nd line drugs can be initiated Potentially explosive spread of DR TB in communities with high HIV prevalence Implications for prevention, diagnosis and treatment

5 Paradigm shifts in TB/HIV Advocacy and policies " We can t fight AIDS unless we do much more to fight TB as well " Former President Nelson Mandela, Bangkok, July 2004 " All patients with both TB and HIV will get treatment with anti-retrovirals if their CD4 count is 350 or less. TB and HIV/AIDS will now be treated under one roof. " President Jacob Zuma, World AIDS Day, 1 December 2009

6 Collaborative TB/HIV activities A. Establish the mechanism for collaboration A.1. TB/HIV coordinating bodies A.2. HIV surveillance among TB patient A.3. TB/HIV planning A.4. TB/HIV monitoring and evaluation B. To decrease the burden of TB in PLWHA B.1. Intensified TB case finding B.2. Isoniazid preventive therapy B.3. TB infection control in health care and congregate settings C. To decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients Source: NTCP, 2009

7 Adult Clinical Record background ECDOH Adult Clinical Record (ACR) Developed in partnership between ECDOH, ICAP, RTC, MSF and other NGO s Responding to need to change from an acute model of care approach to a continuity care model Piloted in ICAP-SA supported facilities Revised 8-page record now implemented ongoing mentoring Complementing existing M&E systems Electronic data base (exact copy of ACR) being piloted in East London link with District Health Information System 6 question TB symptom screening questionnaire integrated ECDOH ACR Revision underway to accommodate new ART guidelines

8

9 Symptom screening of patients enrolled into HIV/ART care Symptom screening positive Investigations done to confirm active TB TB diagnosed Intensified TB Case Finding: Steps from TB symptom screening to TB treatment and CPT TB treatment started Co-trimoxazole started

10 TB history section on the front page of the ACR: TB diagnosis and treatment dates can be summarized here

11 * Page 2 of ACR: clinical visits TB Treatment columns TB Screening questions: patients with symptoms will get a tick in any of these columns Patients without TB symptoms will get a tick here * If any of these TB symptoms present, do sputum x3 (2xAFB + TB culture) and/or other investigations to rule out active (P)TB

12 Investigations for and diagnosis of TB Spaces for sputum results (2 AFB s and 1 TB culture) Spaces for other investigations: CXR, FNAB, U/S, DST, etc. Page 3 of ACR: clinical visits The diagnosis of TB will be written here

13 Advantages of integrated TB screening tool in clinical record (1) Quality and continuity of care TB screening at every visit For every patient enrolled in HIV care (irrespective of ART status) Encourages clinician to think TB at all times Prevention of unmasking TB IRIS in patients starting ART Early diagnosis and treatment of TB Allows clinician to monitor TB investigations results, TB treatment progress and outcome Improves practical integration between programs Identification of eligible patients for IPT

14 Advantages of integrated TB screening tool in clinical record (2) Benefits for prevention/early diagnosis of DR TB Monitoring of clinical progress of patients on first line TB treatment Assist with identification of TB patients with suspected drug resistance Monitoring of breakthrough TB disease in patients on IPT Monitoring & Evaluation M&E of the entire TB screening process Using standard pre-art and ART registers

15 Symptom screening of patients enrolled into HIV/ART care Screening positive Investigations done to confirm active TB TB diagnosed TB treatment started Co-trimoxazole started No (%) of patients who were screened at enrolment (or last visit) who screened positive No (%) of patients who screened positive who were investigated for TB No (%) of patients who screened positive and were subsequently diagnosed with active TB No (%) of patients newly diagnosed with active TB who were started on TB Rx No (%) of patients diagnosed with active TB started on CTX

16 Monitoring of TB screening HIV care register ART register Update after every visit Update after every visit Enrolment (into HIV care) Enrolment (start of ART) Ongoing for 1 year after enrolment Ongoing for all patients on ART

17 User feedback ACR easy to use Quality of care Ease of use Reminding to screen for TB TB screening format easy to use Understanding how to use questionnaire Know if patient is on TB Rx Important to screen prior to ART Known when to do TB investigations ACR helps care better for pts Score (scale from 1: strongly disagree to 5: strongly agree)

18 Routine TB screening M&E Example from Qaukeni LSA New HIV care pts New HIV care pts not on TBRx Pts screened for TB Pts screened positive Pts investigated Pts diagnosed with active TB Pts started TBRx Pts started CPT Pts on TBRx at enrolment Oct-Dec09

19 Example: Qaukeni Sub-LSA (13 facilities): TB screening of patients enrolling into HIV care % screened % new TB cases diagnosed % HIV pts with active TB Jul-Sep08 Oct-Dec08 Jan-Mar09 Apr-Jun09 Jul-Sep09 Oct-Dec09

20 Lessons learnt (1) A TB screening questionnaire integrated in a comprehensive HIV clinical record reminds clinicians to think TB at all times The ACR facilitates effective monitoring of TB screening among HIV patients at enrolment and subsequent visits Initially TB screening tends to be a passive process, guided by symptoms reported by patients rather than by clinicians actively asking about symptoms TB case finding increases with improved TB screening

21 Lessons learnt (2) The TB screening questionnaire can be used to monitor clinical progress of TB patients on first line regimens and identify patients with suspected DR TB Routine TB screening is critical in identifying breakthrough TB disease in patients on IPT who need DST Availability of TB-related clinical information to the HIV clinician is critical in ensuring quality of care The ACR can be linked with the District Health Information System (DHIS) through an MS Accessbased electronic database

22 Conclusions and recommendations A comprehensive HIV clinical record, integrating a simple TB screening questionnaire with routine HIV care elements, can provide benefits for quality and continuity of patient care as well as facilitate monitoring and evaluation of the TB screening process The same TB screening questionnaire can be used to monitor clinical progress of patients on 1 st line TB regimens Management of TB and HIV by a comprehensively trained healthcare provider ( under one ceiling ) TB and HIV clinical records to be kept together Finalization of electronic ACR database based on pilot results

23 Acknowledgements Eastern Cape Department of Health Mrs. Coceka Nogoduka Mrs. Sheila Hokwana Regional Training Centre (RTC) Médecines sans Frontières (MSF) Kheth Impilo (former ARK) CDC, PEPFAR ICAP-SA and NY

24 Thank you!

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