Putting HIV, TB under one roof

James Makiyoni from Thyolo claims to have suffered ill health from the moment he was diagnosed with tuberculosis (TB). Despite taking TB drugs, his continued poor health forced medical personnel at Thyolo District Hospital to advise him to undergo HIV testing and counselling (HTC).

After the HCT, Makiyoni was found HIV-positive. His immunity was low and he was put on antiretroviral therapy (ART).  Besides having to take drugs for HIV and tuberculosis, doctors advised him to be making follow up visits at the facility to check whether he was responsive to drugs or not.

However, the numerous trips took a toll on Makiyoni. Not only did he have to spend more money on transport to get TB and HIV treatment on separate trips each time his appointments were due, but it was also tiresome for him.

Surprisingly, health workers too, had their own stories to tell.

One such worker is Stella Ndunya, an HIV and TB health surveillance assistant at the district hospital. “I would attend to over 50 patients at a time. Our job was to provide counselling and medical drugs. It was tiresome. You would close the TB department to assist those seeking ART in another clinic,” she says, adding that other patients would miss their appointments.

The World Health Organisation (WHO) says the Sadc Region, which has the greatest number of HIV-infected individuals, has one of the highest TB incidence rates worldwide.

“Co-infection with tuberculosis and HIV is reported to be 38 percent in the WHO Africa region, and as high as 80 percent in some parts of Sadc. The risk of active TB disease doubles in the first-year after HIV infection and is one of the leading causes of morbidity and mortality among HIV-infected patients,” said the WHO in 2004, before recommending the co-infection treatment.

To address the dual burden of TB and HIV, in 2004, the WHO developed a framework of strategic collaborative activities aiming to promote the collaboration of the two programmes to achieve holistic care for co-infected patients. The framework, which is now being used by organisations such as Medecins Sans Frontieres (MSF), doctors without borders, was updated in 2012 by WHO.

MSF-Belgium says most national health policies acknowledge that prevention and effective treatment of HIV are crucial to managing the TB epidemic, and the revised WHO guidelines for ART initiation recommend early initiation of ART in all TB and HIV co-infected people, regardless of their CD4 count.

However, while the importance of integrating HIV and TB services is now widely acknowledged, service models that consider the practical realities on the ground have not been outlined and national and provincial programmes still function vertically with little or no cooperation.

But such challenges are now being reduced following the integration of HIV and Aids services in Nsanje and Thyolo districts. MSF is part of government’s national technical working group on addressing problems of TB and Aids.

With government’s support, MSF is implementing a one-stop centre at Thyolo District Hospital and surrounding health centres.

“Health services should always be adapted to the needs of the patient. Offering integrated HIV and TB services under one roof allows one patient with two diseases to get the care he needs to improve or even save his live,” says Kelvin Phiri, medical activity manager for MSF in Thyolo.

Through this project, not only do co-infected patients receive all services under one roof, but patients can take care of their treatment with less visits to health facilities since TB and HIV are considered co-infections meaning, the most common two diseases found in the same patient.

In Thyolo alone, the co-infection rates are estimated to be around 60 percent and an estimated 75 percent of people diagnosed with TB are also HIV positive.

“With the programme, we now provide help to both TB and HIV patients in one clinic following synchronisation of operations unlike in the past. We register close to 500 cases of TB and more HIV cases per month which are handled under one roof,” says TB district officer, Benson Isake.

Isake says co-infected patients are at a much greater risk of poor outcomes and death since in high HIV prevalence settings such as Malawi, HIV is driving the TB epidemic and TB remains the main cause of death for those living with the virus.

MSF-Belgium advocacy and communications consultant Yasmin Rabiyan says to provide quality care for HIV and TB patients, MSF trained health staff in managing both diseases.

“The training was piloted in Thyolo in October 2013 and resulted in 22 out of 27 health facilities moving from vertical or collaborative to integrated HIV and TB services,” Rabiyan says.

She says Thyolo has now a coordinated provision of healthcare services, ranging from two separate services under the same roof, to a one-stop-shop model that provides a complete package of services delivered by one health care team.

Currently, government is advocating an expanded rapid testing and decentralised care service to health centre levels wherever possible. Ministry of Health spokesperson Henry Chimbali says government is aware of the programme, which if replicated in other health facilities can cut costs on workforce.

“Service integration has the potential to create synergies between existing TB and HIV control programmes, to maximise their strengths and minimise redundancies. Joint efforts are necessary to win against the dual epidemic in the long run,” says Chimbali.

According to the current National TB Programme (NTP) Strategic Plan, an estimated K1.5 billion per year is required for a full response to the TB epidemic in Malawi.

Malawi’s upcoming concept note submission to the Global Fund, due in June 2014, is a great possibility for Malawi to solicit funds for the twin-epidemic. In fact, it is a requirement of the GF’s new funding model that Malawi submits a joint HIV and TB proposal.

With the World Health Day falling today, Dr Daniela Garone, medical coordinator for MSF in Malawi, and others say joint HIV and TB Global Fund proposal presents an opportunity for Malawi to improve the situation.

“Joint funding means that the country will have to develop a combined programmatic approach. The only way to win the fight against this dual epidemic is through collaborative action,” she says.