Impact of integrated tuberculosis/human immunodeficiency virus (TB/HIV) services in Africa

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1 African Journal for Physical, Health Education, Recreation and Dance (AJPHERD) Volume 21(1:2), March 2015, pp Impact of integrated tuberculosis/human immunodeficiency virus (TB/HIV) services in Africa L. MAKHADO 1, M. SERAPELWANE 1, L. J. HLONGWANE 2, O. M. BODIGELO 2, M. B. DICHATE 2, K. E. SEBOGADI 2 AND C. L. BAYO 2 1 Department of Nursing Science, North West University, Mafikeng Campus, P. Bag X2046, Mmabatho 2735, South Africa @nwu.ac.za 2 Department of Health, North West Province, Mafikeng, South Africa (Received: 14 August 2014; Revision accepted: 21 January 2015) Abstract The human immunodeficiency virus (HIV) pandemic presents a significant challenge to global tuberculosis (TB) control. Worldwide, TB is the most opportunistic infection affecting HIV positive individuals, and it remains the most common cause of death in patients with AIDS. To address the dual burden of TB/HIV, World Health Organization (WHO) developed guidelines promoting the collaboration of the two programmes to achieve holistic patient care. However, in most African countries this policy is often not implemented at the level of patient care contributing to delayed diagnosis and linkage to care. In Africa, the control of TB/HIV a coinfection remains a major challenge despite the availability of international guidelines of TB/HIV services. Hence this study seeks to systematically review the impact of TB/HIV collaborative services in Africa. In order to identify relevant studies, electronic database: Pubmed, Embase, CIHNAL and Sabinet were searched from 2005 to end of august The general search structure for electronic databases was (impact of or synonyms) AND (collaborat* or integrat*) AND (TB/HIV or TB-HIV or TB and HIV) AND (services) AND (Africa). Further studies were identified by citations in retrieved papers and by consultation with experts. The level of integration seems to vary according to country and facility. It was evident that the impact of TB/HIV integration is somewhat difficult to rigorously measure; hence rigorous evaluative studies are needed to measure the impact of TB/HIV integration. This is due to different models of integration employed in different facilities and countries in Africa. Keywords: Impact, collaborative/integration, TB/HIV services, Africa, systematic review. How to cite this article: Makhado, L., Serapelwane, M., Hlongwane, L. J., Bodigelo, O. M., Dichate, M. B., Sebogadi, K. E. & Bayo, C. L. (2015). Impact of integrated tuberculosis/human immunodeficiency virus (TB/HIV) services in Africa. African Journal for Physical, Health Education, Recreation and Dance, 21(1:2), Introduction The human immunodeficiency virus (HIV) pandemic presents a significant challenge to global tuberculosis (TB) control. TB and HIV have been closely linked since the emergence of AIDS. Worldwide, TB is the most opportunistic

2 274 Makhado, Serapelwane, Hlongwane, Bodigelo, Dichate, Sebogadi and Bayo infection affecting HIV positive individuals, and remains the most common cause of death in patients with AIDS, HIV infection has contributed to a significant increase in the worldwide incidence of TB (WHO, 2011). In 2011, 1.1 million (13%) of the 8.7 million people who developed TB worldwide were HIV-positive, 79% of these HIV-positive TB cases were in the African Region. Globally, there was an estimated 0.4 million HIV-associated TB deaths in 2011 (WHO, 2012). By producing a progressive decline in the cell-mediated immunity, HIV alters the pathogenesis of TB, greatly increasing the risk of disease from TB in HIV co-infected individuals (WHO, 2011). Hence TB/HIV co-epidemic requires urgent and effective attention and demands a collaborative effort between TB and HIV programmes employing different but complementary strategies. Both programmes should be able to identify and manage both diseases. To mitigate the dual burden of TB/HIV in populations at risk of or affected by both diseases, the Stop TB Department and the Department of HIV/AIDS of the World Health Organization (WHO) published an Interim policy on collaborative TB/HIV activities in 2004, with three domains: establishing mechanisms for collaboration, reducing the burden of TB in people living with HIV, and reducing the burden of people living with TB (WHO, 2004). Also in this policy they set a target that by 2015, TB mortality rates among people who are HIVpositive should be reduced by 50%, compared with 2004 the year in which TB mortality among HIV-positive people is estimated to have peaked. WHO has provided clear recommendations about the interventions needed to prevent, diagnose and treat TB in people living with HIV since The recommended interventions are collectively known as collaborative TB/HIV activities. They include HIV testing of TB patients, provision of antiretroviral therapy (ART) and co-trimoxazole preventive therapy (CPT) to TB patients living with HIV, HIV prevention services for TB patients, intensified TB case-finding among people living with HIV, isoniazid preventive therapy (IPT) for people living with HIV who do not have active TB, and infection control in health care and congregate settings (WHO, 2011). However, this policy is often not implemented at the level of patient care contributing to delayed diagnosis and linkage to care Integration of TB/HIV services has emerged as an important component for many countries in response to TB/HIV epidemic with the aim being to create coherence between two programmes, not only to address problems with access to TB/HIV services, but also to enhance efficiency, quality of care and patient satisfaction. Hence the purpose of this study is to evaluate the impact of TB/HIV services in Africa.

3 Impact of integrated tuberculosis/human immunodeficiency virus services 275 Review question What is the impact of integrated TB-HIV services in Africa? Methodology A systematic review of literature was conducted to retrieve international and national studies on the impact of integrated Tuberculosis/Human Immunodeficiency Virus (TB/HIV) services in Africa guided by the search criteria which were explicitly developed for the study. Data sources and search strategy In order to identify relevant studies, electronic databases: Pubmed, Embase, CIHNAL and Sabinet were searched. The general search structure for electronic databases was impact (of or synonyms) AND (collaborat* or integrat*) AND (TB/HIV or TB-HIV or TB and HIV) AND (services) AND (Africa). Further studies were identified by citations in retrieved papers and by consultation with experts. Inclusion criteria The studies had to be written in English as the researchers can read and interpret the language. Full journal articles, official reports based on research studies, dissertations and thesis addressing the impact of TB/HIV collaborative services were the sources of data. The articles had to include two or more of the search key words of the study on the title. Only quantitative studies or mixed method studies that reported quantitative findings were considered. All the relevant articles addressing the impact of TB/HIV collaborative services whether negative or positive were included to avoid bias. The articles were published between 2005 and Study selection Titles of all the articles found using the search strategy described above were screened and articles that were clearly not legible were discarded. The abstracts of the remaining screened articles were further assessed and those that clearly did not meet the inclusion criteria were also discarded. Team reviewers accessed full copies of the remaining articles and independently assessed whether the articles meet the inclusion criteria and identified potentially relevant articles. Disagreements between reviewers were resolved by discussion (Figure 1).

4 276 Makhado, Serapelwane, Hlongwane, Bodigelo, Dichate, Sebogadi and Bayo Data abstraction For each article, the following information was abstracted: first author and year of publication, study purpose/objective, study design, target population and sample size, outcome measures, results and study limitations. See Table 1. Strength and limitation of the literature search Strengths include structured and thorough search of electronic databases with the assistance of a librarian, the use of five independent reviewers for study selection and data abstraction to increase the reliability of our findings. Limitations of the study are that the study included only published data and English literature while other sources maybe available in different languages. Record identified through database searching Total number of 83 articles (using keywords) No duplicates were identified= 83 Title and abstract screened = 83 Articles excluded= 65 Year of publication=15 Not in Africa= 18 Language= 03 Not HIV/TB collaborative services=29 Full texts articles assessed for eligibility= 18 Articles excluded= 11 Design= 02 Does not discuss impacts of HIV/TB collaborative services= 09 Studies eligible for inclusion in the review= 07 Figure 1: Flowchart of the search strategy

5 Impact of integrated tuberculosis/human immunodeficiency virus services 277 Results The systematic search results yielded 83 papers. The titles of 83 non duplicated records were screened for inclusion, of which 18 full text records were further assessed for eligibility and only 7 were included in the review. Only studies in English satisfied the inclusion criteria.

6 278 Makhado, Serapelwane, Hlongwane, Bodigelo, Dichate, Sebogadi and Bayo

7 Impact of integrated tuberculosis/human immunodeficiency virus services 279

8 280 Makhado, Serapelwane, Hlongwane, Bodigelo, Dichate, Sebogadi and Bayo Discussion Efficiency of service delivery Integration of TB/HIV services led to improved efficient service delivery in many health care centres. According to Kerschberger, Hilderbrand, Boulleet al. (2012), integration of TB/HIV services overcome challenges such as: losing patients to follow-up during the referral process between TB and HIV services, long waiting times in clinics and burdening patients with increased travel costs. It also increases staff expertise and experience in treating co-infected patient, (Kerschberger et al., 2012). Anti-retroviral therapy (ART) initiation Out of seven (n=7) studies, two (n=2) studies: Phiri, Khan, Grant et al. (2011) and Kerschberger et al. (2012), report that: There was faster ART treatment initiation after integration of TB/HIV services. There was also a decrease in the number of days to start ART treatment after starting TB treatment. Estimated median time from TB treatment start to ART initiation decreased from 147 days to 75 days). This is true given the fact that all TB infected HIV patients are eligible for ART hence the integrated services fast track the process of ART initiation. Co-trimoxazole preventive therapy (CPT) provision The studies have shown a significant high uptake in CPT provision since the implementation of integrated TB/HIV services. Pevzner, Vandebriel, Lowrance, Gasana and Finlay (2011) in their study from Rwanda reported that the provision of co-trimaxole for people with TB/HIV increased from the 2.5% noted during their evaluation to 15% in 2005 and then to 95% in 2009 after rapid scaling up of collaborative TB/HIV activities. Chehab, Vilakazi-Nhlapo, Vranken, Peters and Klausner (2013) indicated an increase with 314 (70%) of 451 having been initiated on CPT. 95% of patients eligible for CPT in 2009 were provided with CPT Phiri et al. (2011) whereas Njozing, Miguel, Tih, Hurtig (2010) revealed that of 1114 patients who were eligible for CPT only 524 (47%) were enrolled on CPT. Which indicates that the provision of CPT differed among countries and regions. These findings may have been impacted by the different types of country, knowledge regarding CPT among health care providers, the health care system approach employed within each country, patients characteristics as well as CPT s availability in the facilites.

9 Impact of integrated tuberculosis/human immunodeficiency virus services 281 HIV testing in TB patients Since the integration of TB/HIV services, HIV testing among TB patients has greatly increased. Pevzner et al. (2011) reported that HIV testing among TB patients increased from 48% to 69% during the first scaling up of TB/HIV integrated services in 2005 then increased to 97% in Increased HIV testing resulted in people being diagnosed and treated for HIV who otherwise would likely have had delayed diagnosis or died of undiagnosed HIV disease. Integrated TB/HIV services fully encourage HCT among TB patients. TB screening in HIV patients It is evident from the two studies (Kerschberger et al., 2012; Chehab et al., 2013) that the collaboration of TB/HIV activities has led to the increase in HIV people being tested or screened for tuberculosis because the integration resulted in a one stop shop TB /HIV model of care where both services are delivered by the same health professional at a single entry point. According to Chehab et al. (2013) 76% of newly diagnosed patients with HIV in South Africa were screened for TB symptoms. It is also reported by Kerschberger et al. (2012) that HIV-infected patients were systematically screened for TB at every consultation using the WHO symptom screen, enquiring on cough for more than 2 weeks, night sweats, loss of weight and fever. TB treatment outcome Complete integration of TB and HIV care has contributed to an increase in the proportion of patients who completed TB treatment alive and decreased default rate in various African countries and these overcomes the challenges of losing patients to follow-up during the referral process between TB and HIV services, and burdening patients with increased travel costs and more time spent in clinic (Kerschberger et al. 2012). In a study conducted in Uganda by Hermans, Castelnuovo, Katabira, Mbidde, et al. (2013) patients who died or defaulted decreased from 33% to 25% and patients who completed treatment increased from 62% in 2007 to 68% in 2009 since the integration of TB/HIV services. Kerschberger et al. (2012) reported that after integration the incidence of pulmonary tuberculosis decreased from 70% to 58% in Khayelitsha South Africa. Conclusion The systematic review reveals that TB/HIV collaborated services have resulted in the immediate benefits for patients such as the TB screening and HCT which

10 282 Makhado, Serapelwane, Hlongwane, Bodigelo, Dichate, Sebogadi and Bayo led to early diagnosis of TB in HIV patients and vice versa; it also led to improved treatment outcomes, early initiation of ART treatment and increased provision of CPT therapy which are of paramount importance in reducing the burden of TB and HIV in Africa. It was also evident that the impact of TB-HIV integration is somewhat difficult to rigorously measure; hence rigorous evaluative studies are needed to measure the impact of TB-HIV integration. This is also due to different models of integration employed in different facilities and countries in Africa. References Chehab, J.C., Vilakazi-Nhlapo, A.K., Vranken, P., Peters, A. & Klausner, J.D. (2013). Current integration of tuberculosis (TB) & HIV services in South Africa, Plos One, 8(3), e Hermans, S.B., Castelnuovo, B., Katabira, C., Mbidde, P., Lange, J.M., Hoepelman, A.I., Coutinho, A. & Manabe, Y.C. (2013). Integration of HIV and TB services results in improved TB treatment outcomes and earlier, prioritized ART initiation in a large urban HIV clinic in Uganda. Journal of Acquired Immune Deficiency Syndrome, 60(2), e29 e35. doi: /qai.0b013e318251aeb4 Kerschberger, B., Hilderbrand, K., Boulle, A.M., Coetzee, D., Goemaere, E., De Azevedo, V. & Van Cutsem, G. (2012). The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study. Plos one, 7(10), e Doi: / journal.pone Njozing, N.B., Miguel, S.S., Tih, P.M. & Hurtig, A. (2010). Assessing the accessibility of HIV care packages among tuberculosis patients in the Northwest region, Cameroon. BMC Public Health, 10(129), doi: / Pevzner, E.S., Vandebriel, G., Lowrance, D.W., Gasana, M. & Finlay, A. (2011). Evaluation of the rapid scale-up of collaborative TB/HIV activities in TB facilities in Rwanda, BMC Public Health, doi: / Phiri, S., Khan, P.Y., Grant, A.D., Gareta, D., Tweya, H., Kalulu, M., Chaweza, T., Mbetewa, L., Khanyerere, H., Weigel, R. & Feldacker, C. (2011). Integrated tuberculosis and HIV care in a resource-limited setting: experience from the Martin Preuss centre, Malawi. Tropical Medicine and International Health, 16 (11), World Health Organization (WHO) (2004). Interim Policy on Collaborative TB-HIV activities. Geneva, Switzerland: WHO

11 Impact of integrated tuberculosis/human immunodeficiency virus services 283 World Health Organization (WHO) (2011). Guidelines for Intensified Tuberculosis Case-Finding and Isoniazid Preventive Therapy for People Living With HIV in Resource-Constrained Settings. Geneva, Switzerland: WHO. Department of HIV/AIDS. Stop TB department World Health Organization (WHO) (2012). Global Tuberculosis Control. Geneva, Switzerland: WHO. Yumo, H.A., Kuaban, C. & Neuhann, F. (2011). WHO recommended collaborative TB/HIV activities: evaluation of implementation and performance in a rural district hospital in Cameroon. Pan African Medical journal, 10(30), PMC

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