Active TB cases Finding in The Integrated HIV Care Programme

Active TB cases Finding in The Integrated HIV Care Program Dr Sai Ko Ko Zaw The Union Office in Myanmar No.36, 27 street between 73 & 72 streets, Chan Aye Thar Zan Township, Mandalay, Myanmar Tel/Fax: +95 2 71082 Email: skkzaw@theunion.org 1

Outlines • Magnitude of TB problem in Myanmar • Active TB case finding at Integrated HIV Care (IHC) clinics • Challenges & Solutions • Ways forwards

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Magnitude of TB problem in Myanmar Estimated TB Burden 2011* Prevalence

506/100,000 population

Incidence

381/100,000 population

Mortality

48/100,000 population

*Data:www.who.int/tb/data

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Active TB case finding (ACF) at Integrated HIV Care (IHC) clinics in Mandalay, Myanmar

The photo was taken with written consent and agreed to use in public

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Active TB case finding at the Integrated HIV Care (IHC) clinics • • • • •

IHC program had started in 2005 “In, By, With” public sectors Screening for HIV in all TB patients Introduced WHO-3Is activities in 2009 ACF using GeneXpert Jan 2012 (Program to increase catchment of TB suspects – PICTS ) • Up to July 2013,  in 20 townships of Myanmar  17,422 HIV patients (Active Follow up)  15,395 HIV patients on ART (Active Follow up) 5

HIV screening among TB diagnosed patients in Mandalay seven townships ( Jan- July 2013) Adult TB patients in Register

1340

Adult TB patients tested for HIV

1251 (93%)

Adult TB patients HIV + among tested

239 (19%)

Adult TB-HIV co-infected put on CPT

239 (100%)

Adult TB-HIV co-infected started ART at clinics in reporting period*

273

*not only from Mandalay Township but also from other hospitals/GP/INGOs such MMA & PSI

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ACF in IHC clinics: Education Posters about TB symptoms at HIV clinics

HE at HIV clinic of THC 7

ACF in IHC clinics :TB screening & IPT initiation protocol for HIV clinics Patients with known HIV infection attending HIV care

Symptom Screen Each Visit (Ask TB screening questions, Record results on Daily OPD register)

≥ 1 symptom

MO Refers for TB evaluation (using cross referral form)

No symptoms Assess IPT Eligibility (using stamp inside patient booklet)

If diagnosed TB – Treat TB If not TB – Return patient to HIV care

IPT Eligible • • •

Initiate IPT Counseling Prescribe IPT Register for IPT 8

TB screening questions Does patient have any: • • • • •

Cough Fever Weight loss Night sweats Enlarge Lymph Node

Photo of five symptoms

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Any symptom, refer for detailed TB & clinical evaluation Daily OPD and TB screening register

Date______________________

S. No

Name

Age

Sex

Township

Q1 Cough (any) (√/X)

Q2 Fever

Q3 Weight loss

11

U Myint

44 M

CATZ

X

X

X

12

Bo Htwe

24 M

MHAM

X

X

√

For asymptomatic patients, Stamp inside ‘Patient OPD booklet’ For “IPT Evaluation” (Recommendation 1)

Q4 Night sweats

Q5 Lymph node enlarged

X X

Current TB Rx / Prior TB Tx / Current IPT / Prior IPT

X X

X X

Referred for Referred for IPT TB eval evaluation (√/X) (√/X)

X

√

√

X

Patients with any symptoms should be referred for TB evaluation (Recommendation 2)

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Refer from HIV clinic

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Feedback From MGH TB OPD

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TB screening activities and Refer for further evaluation at Pre-ART clinics and ART clinics (MU 1 & MU 2) in Jan-July 2013 ART Clinics Pre-ART clinic (MU1 &MU2)

Total visits of the clinics screened for TB Refer For TB diagnosis evaluation Refer for IPT evaluation IPT started

1795

8111

101 (6%)

92 (1%)

917

997

105 (11%)

116 (12%) 13

Patients’ flow For TB evaluation IHC Clinics

Sputum Examination NAP Clinic

Chest X Ray Machine TB OPD MGH

TSHC

GeneXpert Machines Link with Pathological examination Refer for other EPTB investigations

MGH 14

Known HIV (+) Child TB suspects

New TB suspect

Sputum Smear Examination Ss +

Ss -

TB Diagnosis algorithm in PICTS program

Antibiotics trial s/s +

Cat I +

Chest X Ray Abnormal

Normal HIV (-)

EPTB investigations according to need

Gene Xpert

Reconsider TB or EP TB Dx

Negative

Positive MTB+R+

Decision by Clinician

MTB + R-

LPS and DST No TB Tx

Cat I -, GXP + TB Tx

DR TB Treatment15 a/t National Guidelines

Cascades of TB diagnosis for HIV infected patients at MGH TB OPD in Jan 2012 - July 2013

949 1000

Alternative Diagnosis/ Outcomes?

800 600

317 (33%) 400

154 (49%)

200 0 Refer for TB Dx Evaluation

TB diagnosed (All Forms)

Bact/Pathological comfirmed TB cases 16

Proven TB cases in 2012 versus 2013

18 (17%)

94 (44%)

120 (56%)

85 (83%)

Bact/Patho comfirmed TB Cases

Bact/Patho comfirmed TB Cases

Clinically Diagnosed TB Cases

Clinically Diagnosed TB Cases

2012

2013 up to July 17

Routine Contacts tracing and modified activity with PICTS program • Done by BHS and Community TB Care volunteers as soon as patients enrolled in Township TB registers • Two kinds contact tracing in Mandalay - Initial Home Visit ( screening of cough >3wk in Household members) - Extended Contacts Tracing ( screening of 5 TB -/s in household, neighbours, at work places) 18

Routine Contacts tracing and modified activity with PICTS program

Total Number of registered TB patient (Jan-June 2013) Total number of TB patient had home visit

Total number of contact identified

Initial Home Visit

Extended Contact Tracing

1610

1610

1585 (98%) 1528 (95%) 7649

28210

Total number of contact evaluated

6270 (81%) 23989 (85%)

Total number of TB suspects

792 (12%)

1272 (5.3%)

545

1018

13 (1.6%)

84 (7%) 19

Total number of TB Suspects examined for sputum for ATB Total number of contact put on anti-TB treatment

Challenges • Screening Tools and Diagnostic Tools (sensitivity/specificity?)

• Screening Algorithm for public sectors in specific context • Individual Clinical Care and Management • Need to strengthen recording system 20

Solutions • Developing a better Algorithm • Regular Monitoring and Supervision • Training of recording and reporting for staff • Health education to HIV infected patients at clinics 21

Way Forwards IHC Program

TB

HIV

PICTS Program

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Thanks!

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