Integration of TB and HIV Screening, Care and Treatment in Mulago Hospital, Uganda

1. Integration of TB and HIV Screening, Care and Treatment in Mulago Hospital, Uganda Rhoda Wanyenze, Doris Mwesigire, Henry Luzze, Violet Gwokyalya, Julius Sempiira, Alphonse Okwera, Alice Namale, Edwin Charlebois, Moses Kamya Mulago-Mbarara Teaching Hospitals’ Joint AIDS Program (MJAP) PEPFAR Meeting, Kigali - Rwanda June 16, 2007

2. Background • Overlapping TB and HIV epidemics • HIV increases susceptibility to TB infection/ disease • TB/HIV co-infection is common • TB/HIV co-infection increases morbidity & mortality especially with late initiation of care • Early & concurrent treatment for both infections desirable to improve outcomes • Programs for TB & HIV often parallel • Delayed diagnosis & linkage to care is common

3. Context of MJAP TB/HIV Services • International TB/HIV guidelines • Uganda TB/HIV Collaborative Policy - 2005 • MJAP initiated integration of TB & HIV services in 2005 • Other MJAP services - 10 sites • HIV testing and counseling • Routine HIV testing and counseling (RTC) • Home based HIV counseling and testing • Care and treatment

4. Integrated TB/HIV Services • Hospital-based screening for both TB & HIV • Enhanced TB screening in the HIV clinic • Routine HIV testing for TB inpatients & outpatients • Concurrent TB and HIV screening of medical inpatients • Integrated TB and HIV care and treatment

5. TB Screening • Criteria for TB screening • Patients with cough >2 weeks • Other clinical evaluation: fever, weight loss, … • Diagnosis • Laboratory • Sputum smears: patients with productive cough • Biopsy/aspiration: Extra-pulmonary TB • Microscopy (ZN or auramine) • Recently started doing culture • X rays

6. Linkage to Care CD4 testing & prep for ART starts in ward for very ill patients

7. Mulago TB/HIV Clinic • Clinic runs one day a week • Within the TB unit (in Mulago hospital) • Patients referred to HIV clinic after completion of TB treatment • Patients receive TB and HIV care • Basic care package and other non-ART care • Anti-TB: 2HERZ/6EH • ART: Combivir + Efavirenz • A few patients on triomune

8. TB/HIV Clinic Procedures • Seen monthly or more frequently when needed • Laboratory tests • CBC: Baseline & every 3 months • CD4: Baseline & every 6 months • Sputum smears: Baseline, 2, 5 & 8 months • SOPs and data collection tools cover TB and HIV care and treatment aspects

9. Results (1) • August 2005-April 2007 • TB patients received RTC: 2,651 • HIV prevalence among tested patients: 33% • 96% accept testing • TB sputum smears in medical wards: 1,869 • 587 (32%) sputum positive • 379 (65%) of sputum Pos co-infected with HIV

10. Results (2) • Screened for TB in the HIV clinic: 4,835 • Number with TB disease: 807 • 724 (15%) - sputum positive • 83 - X ray & other clinical criteria • 706 received care in the TB-HIV clinic • 92 transferred out after completion of Tb treatment • 327 initiated ART within the TB-HIV clinic

11. Challenges/Gaps • Increased resources for treatment • Diagnosis of extra-pulmonary & smear –ve TB • Counseling & support for both TB treatment and ART more complex • Incorporate TB contact tracing • Transfer out after completing TB treatment – some patients are uncomfortable with this

12. Conclusions • Integration of TB/HIV services feasible • Detects a significant number of TB/HIV co-infected patients • Need to strengthen • Diagnosis for smear –ve and extra-pulmonary TB • Adherence counseling, support & monitoring for concurrent TB treatment and ART

13. Acknowledgements • PEPFAR/CDC • National TB and Leprosy program • Mulago Hospital and Complex • TB unit • MJAP Staff