Integrated tuberculosis and HIV care in a resource-limited setting: Experience from the Martin Preuss centre, Malawi

Lighthouse Trust, Lilongwe, Malawi.
Tropical Medicine & International Health (Impact Factor: 2.33). 08/2011; 16(11):1397-403. DOI: 10.1111/j.1365-3156.2011.02848.x
Source: PubMed


To describe the development and operation of integrated tuberculosis (TB) and HIV care at the Martin Preuss Centre, a multipartner organization bringing together governmental and non-governmental providers of HIV and TB services in Lilongwe, Malawi.
We used a case study approach to describe the integrated TB/HIV service and to illustrate successes and challenges faced by service providers. We quantified effective TB and HIV integration using indicators defined by the World Health Organization.
The custom-designed building facilitates patient flow and infection control, and other important elements include coordinated leadership; joint staff training and meetings; and data systems prompting coordinated care. Some integrated services have worked well from the outset, such as promoting HIV testing among patients with TB (96% of patients with TB had documented HIV status in 2009). Other aspects of integrated care have been more challenging, for example achieving high uptake of antiretroviral therapy among HIV-positive TB patients and combining data from paper and electronic systems. Good TB treatment outcomes (>85% cure or completion) have been achieved among both HIV-positive and HIV-negative individuals.
High-quality integrated services for TB and HIV care can be provided in a resource-limited setting. Lessons learned may be valuable for service providers in other settings of high HIV and TB prevalence.

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Available from: Ralf Weigel, Nov 26, 2014
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    • "MPC is an integrated TB/HIV clinic located in Malawi’s capital city, Lilongwe. The clinic, described in detail previously [15], functions in partnership with the Lilongwe District Hospital and has three units: HIV testing and counselling, ART, and TB; the latter unit includes sputum submission. Almost 66% of the TB patients in Lilongwe are registered at MPC. "
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    ABSTRACT: In July 2011, the Malawi national HIV program implemented the integrated antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) guidelines. Among the principle goals of the guidelines were increasing ART uptake among TB/HIV co-infected patients and treating TB/HIV patients with a different drug regimen. We, therefore, assessed the effects of the new guidelines on ART uptake, the factors associated with ART uptake and the frequency of ARV-related adverse events in TB/HIV co-infected patients. This was an observational cohort study using routine program data. All ART-naive adult TB/HIV co-infected patients starting TB treatment over the six months preceding and following implementation of 2011 integrated ART/PMTCT guidelines were included. A total of 685 adult TB/HIV co-infected patients were registered in the study; 377 (55%) before and 308 (45%) after the implementation of the new guidelines. ART uptake increased from 70% (240/308) before implementation of the new guidelines to 78% (262/377) after the inception of the new guidelines (P=0.013). The proportion of TB patients initiating ART within two weeks of starting TB treatment increased from 30% before implementation of the new guidelines to 46% after implementation of the new guidelines (p <0.001). The median time from the start of TB treatment to ART initiation dropped from 16 days (IQR 14-31) before the new guidelines to 14 days (IQR 9-20; p <0.004) after implementing the new guidelines. Factors associated with ART uptake were enrolment in HIV care before starting TB treatment and being a retreatment TB patient. The overall frequency of ARV-related adverse events was higher in patients on d4T/3TC/NVP (35%) than those on TDF/3TC/EFV (25%) but not significantly different (P=0.052). Implementation of the 2011 Malawi Integrated ART/PMTCT guidelines was associated with an overall increase in ART uptake among TB/HIV patients and with an increase in the number of patients initiating ART within two weeks of starting their TB treatment. However, the reduction in time between initiating TB treatment and starting ART was small suggesting that further measures must be implemented to facilitate ART uptake. Early enrolment in HIV care provides opportunities for timely ART initiation among TB patients.
    BMC Public Health 02/2014; 14(1):183. DOI:10.1186/1471-2458-14-183 · 2.26 Impact Factor
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    • "The newest ART initiation guidelines in TB patients now recommend starting ART after 2 to a maximum of 8 weeks of TB treatment in all TB patients living with HIV with CD4 T-cell counts of 350/mm3 or less. Despite those recent and significant changes in policy, barriers in ART initiation in TB patients living with HIV remain including concerns of immune reconstitution syndrome and drug-drug interactions [35], and could in part account for the low proportion (19%) of eligible co-infected patients in surveyed sites initiated on ART. The delay in ART initiation is worrisome, particularly in view of the findings of a recent trial in South Africa, which found that mortality was reduced by 56% among patients started on ART during TB treatment as compared to those initiated after the end of TB treatment, with no significant risk of increased adverse events [36]. "
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    ABSTRACT: Public Health Facilities in South Africa. To assess the current integration of TB and HIV services in South Africa, 2011. Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type. Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001). As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.
    PLoS ONE 03/2013; 8(3):e57791. DOI:10.1371/journal.pone.0057791 · 3.23 Impact Factor
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    • "This discrepancy may influence the quality of reporting on ART-use. Electronic data systems could facilitate data collection but also provide prompts to remind health care providers to take certain action, for example to collect a blood sample for a CD4+ cell count or to start ART [12]. In our study 12% of the co-infected patients did not have a single CD4+ cell count available during TB treatment. "
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    ABSTRACT: Background Antiretroviral therapy (ART) is lifesaving for HIV-infected tuberculosis (TB) patients. ART-use by these patients lag behind compared to HIV-testing and co-trimoxazole preventive therapy. TB programmes provide the data on ART-use by HIV-infected TB patients, however often the HIV services provide the ART. We evaluated whether the data on ART-use in the TB register were complete and correct. The timing of ART initiation was evaluated to assess whether reporting on ART-use could have happened with the TB case finding reporting. We collected data on TB treatment, HIV testing and ART for adult TB cases in 2007 from three TB clinics in Manica Province, Mozambique. These data on use of ART from TB registers were compared with those from the HIV services. Findings Of 628 patients included, 504 (81%) were tested and of these 356 (71%) were HIV-infected. Of the co-infected patients, 81% registered with the HIV services in the same facility. The TB register was correct on ART-use in 73% of co-infected cases and complete in 74%. Information on ART-use could have been reported with the TB case finding reports in 56% of co-infected patients. Conclusion The TB register is reasonably correct and complete on ART-use. However, the HIV patient record seems a much better source to provide this information. Reporting on ART-use at the end of the quarter in which TB treatment starts provides the programme with timely but incomplete information. A more complete but less timely picture is available after a year.
    BMC Research Notes 01/2013; 6(1):23. DOI:10.1186/1756-0500-6-23
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