Group 5 Provision and Improvement of Clinical Care

Group 5 Provision and Improvement of Clinical Care for Joint TB/HIV Activities

1. What steps are required for strengthening of diagnostic processes for TB and HIV/AIDS? – General health services – TB treatment sites – HIV/AIDS treatment sites

General Features • Strengthening Health System • Community level • Remove barriers to access to health care facilities • Improve human resources at health care facilities • Specific tools/commodities

Strengthening Health System • Collaboration between medical and multisectoral sectors • Increase involvement of district health management authorities • Strengthen interaction between laboratory and health system and other social services (if not the same)

Community Level • Increase community awareness of signs/symptoms of HIV/TB to improve seeking of health services • Include traditional healers, shops • In doing this, liason between medical and multisectoral sectors • Work to reduce stigma related to both diseases

Remove Barriers to Access to TB/HIV Diagnostic Services • Identified barriers – Cost – Distance – Perception that no treatment is available (esp. for HIV)

Strengthen Human Resources at Health Care Facilities • Increase the numbers of health care workers (paid—not volunteer) – Determine numbers of staff needed to provide services – Address IMF recommendation to reduce numbers of government workers • Improve training regarding recognition of sx/suspecting TB/HIV – Update clinicians trained previously – Incorporate TB/HIV information into current curriculae at medical/nursing schools etc.

Improve Human Resources at Health Care Facilities (cont. ) • Provide counseling training for all involved health care workers • Train lab technicians regarding the importance of the results to patients • Cross training – Train laboratory workers currently performing AFB smears to do rapid tests for HIV – Consider training lower level health care workers or counsellors to perform rapid tests for HIV – Consider having staff from TB clinic seconded to HIV clinics

Improve Human Resources at Health Care Facilities (cont. ) • Consider prioritizing treatment of HCWs (losing valuable trained staff to HIV/TB) – Incentive to work as a health care worker

Specific practices/ commodities • Develop joint guidelines that address both HIV and TB (and other needs) – Simple – Wall charts • Increase access to privacy (esp. HIV) • Consider adjustment of diagnostic criteria – Consider more empiric therapy – Consider “diagnostic” trials of anti-TB rx (without rifamycins) – ? Expand access to TB culture facilities – Reduce turn around time for results of diagnostic tests (esp. TB)

Specific practices/ commodities (cont. ) • Reduce turnaround time for results of TB diagnostic tests – Facilitate transport of specimens to laboratories – Facilitate transmission of results to clinicians (phone) • Strengthen procurement of HIV test kits (ensure quality)

Entry Point-Specific Interventions • To improve diagnosis in general medical settings – Develop training materials that address altered presentation of TB in the context of HIV • At TB treatment sites – Incorporate VCT services on site at TB treatment sites • At VCT sites – Conduct active case finding at VCT sites

2. How Can Referral Between TB and HIV Services be Strengthened ? • Ensure information about where to refer is available at relevant sites • Clarify specific roles of referring sites, sites being referred to • Consider provide services for both at the same location • Use of referral forms • Build network referral system in community (with community ownership)

How Can Referral Between TB and HIV Services be Strengthened (cont) • Involve district health managers at initial stage (build into system)

3. What Elements of TB/HIV Programs Need to be in Place Prior to ARVs? • • Need to have infrastructure Need functional health delivery system Boost laboratory services Have drugs and supplies in place for management of TB, HIV (other than ARVs) • Ability to conduct ongoing counselling for TB and HIV • Clear idea of eligibility criteria, ethical considerations

Necessary Elements (cont. ) • Consider implementation of ARV services in areas with strong TB programs…because of experience with: – Long term follow-up of patients/support of medication adherence – Supply chain for drugs – Training • But…. consider implementing HIV programs in areas with weak health systems and using treatment programs for HIV to strengthen the health system.

4. When/How Should ARVs be Implemented to Patients on TB therapy • Begin ARV treatment after completion of initiation phase (include in guidelines) • Consider implementing ARVs after completion of TB therapy (perhaps by the same HCWs, in the same setting) – Continuing adherence support from accompanateur – May improve management of interactions/co-toxicities

When/How Should ARVs be Implemented to Patients on TB therapy • But caution because: – Some infection control issues related to offering both services in the same site – May overburden already stressed TB programs

When/How to Give ARVs to TB Patients Cont. • Also consider closely related program and have patients move from TB to ARV program an included program that is a distinct component