Background and Magnitude of the problem:
National Tuberculosis Center (NTC) has been implementing all 6 components of WHO Stop TB Strategy since 2006. The NTP also adopted TB/HIV strategy and policy in 2009. One of the most important and challenging component is TB/HIV as it is needed to coordinate between two programs for effective implementation of the activities. Moreover, it is also helpful to finding out more TB/HIV co-infected cases which increases TB case detection rate and prevent the case fatality rate form TB.So, by considering the objectives of the National Strategy, NTC has been implementing its program activities through the Nepal Government networks and partners organizations which are extremely fundamental to scale up the program in the target areas.
The TB-HIV co-infection rate (the prevalence of HIV infection among TB patients) in Nepal is 2.4%. Overall HIV prevalence in Nepal is estimated at 0.30% in the adult population and it is categorised as a concentrated epidemic. Thus HIV prevention and care must be a priority concern for TB Prevention and Control Programmers and TB care and prevention should be a priority concern for HIV/AIDS Prevention and Control programmers.
Rational for TB/HIV collaboration:
Collaborative TB/HIV activities aim to decrease the burden of TB and HIV in a population affected by both diseases through collaboration between programs. This approach aims to provide integrated and comprehensive tuberculosis and HIV prevention, treatment and care service as close to the client as possible, maintaining existing tuberculosis and HIV program 25 districts through NTC and 5 districts through NCASC rather than combining them or creating a third TB/HIV program center. The other rational for TB/HIV collaboration is, more than any time before there is increased opportunity for joint working with clearer policy guidance and availability of more resource. In addition there is a big need to promote efficient utilization of resource allocated by both programmers. Lastly there is a common need to increase access to comprehensive services to achieve the millennium development goals (MDG) for HIV and tuberculosis.
Objectives of the TB/HIV collaborative activities:
1. Reducing HIV incidence among TB patients.
2. Reducing TB incidence among PLWHAS.
3. Improve care of people for people who are co-infected with TB and HIV.
Major collaborative approaches are as following:
- Establish and Strengthen the TB/HIV Mechanism for Collaboration at all levels.
- Joint TB-HIV planning.
- Develop operational guidelines, training manuals & IEC materials
- Conduct surveillance & operational research (OR) to enhance TB/HIV services.
- Joint supervision, Monitoring and Evaluation of collaborative TB-HIV activities.
- Decrease the Burden of TB in People Living with HIV/AIDS and vice versa.
- Establish and strengthen intensified TB/HIV case-finding and improve access to TB and HIV services.
- Implementation of Isoniazid Preventive Therapy for HIV positive.
- Advocacy Communication and Social Mobilization (ACSM)for TB/HIV
- Provision of cotrimoxazole preventive therapy.
- ARV for HIV-positive and TB patients.
- Provider-initiated and delivered HIV testing and counselling in TB clinical setting.
- Co-morbidity management and monitored.
- Provide care & support to TB/HIV co-infected cases.
- Development & strengthen Human Resources to implement TB/HIV Collaboration.
Challenges and gaps in TB/HIV collaborative activities:
- HIV is often associated with sputum smear-negative and extra-pulmonary forms of TB, which are more difficult to diagnose due to antiquated diagnostic tools and inadequate lab capacity ? better diagnostic methods and tools are urgently needed.
- Scale up and expand implementation of collaborative TB/HIV activities to ensure effective health sector response
- Increase political and resource commitment to collaborative TB/HIV activities
- Contribute to strengthening health systems to deliver TB/HIV activities collaborative TB and HIV programs to ?ensure that all patients with TB are offered VCT [voluntary counseling and testing] and all HIV patients are tested and treated for TB.? but not required or universally available which suggested that opportunities are being missed to reduce mortality of PLWHA due to TB and identify additional HIV-positive individuals.
- Link all HIV-infected TB patients to HIV care and treatment, including ARV and cotrimoxazole therapy
- Link all HIV-infected TB suspects to TB diagnosis and TB treatment using directly observed treatment, short-course (DOTS)
- An important aspect of effective TB-HIV coordination is ensuring that TB-HIV activities link to national TB-HIV strategic plans and TB- and AIDS-specific plans and programs overall.
- Activities in support of national TB-HIV efforts could include training of healthcare workers in diagnosis, treatment, administration and management of TB-HIV cases, strengthening recording and reporting systems in line with national surveillance of TB-HIV co-infection, facilitating discussions between national AIDS and TB program managers and staff, and improving laboratory capacity for diagnosis of TB in HIV-infected patients.
- Indicators and targets that requires to report do not address key areas that effectively measure impact on morbidity and mortality of TB-HIV co-infected patients.
These include the numbers of:
- TB patients tested for HIV and found to be HIV-positive
- HIV-positive TB patients receiving CPT or placed on ART
- PLWHA screened for TB
- HIV-positive TB patients referred to HIV care and support services during TB treatment
- Individuals trained to provide TB diagnostic services for PLWHA
- Evidence of knowledge sharing across key stakeholders on TB-HIV implementation is lacking, and public dissemination of data is limited and the inclusion of TB-HIV indicators within national surveillance systems in order to reflect a more meaningful measure of impact.
- Not all people living with HIV and a far smaller proportion received isoniazid preventive treatment.
- Special groups who are particularly affected by the dual TB/HIV epidemic such as people who use drugs, prisoners, pregnant women and children are not yet benefiting from the progress and need special attention. High level scientific interest and resources need to be solicited for the numerous unmet research needs that are essential for the dual epidemic.
- Staff, infrastructure and quality of services gap between the two National programs.
- On planning and management of TB/HIV collaborative activities with special emphasis to capacity building. The issues to be addressed include:
- Proposal development and soliciting fund for training on TB/HIV collaborative activities.
- Ensuring uninterrupted TB/HIV supplies
- Setting up a coordinating body for TB/HIV collaborative activities at all levels
- Support in the area of TB/HIV operational researches
- Conducting supportive supervision, monitoring and evaluation of TB/HIV collaborative activities
- Establishment of VCT/DOTS in the health care setting needs to deploy extensive effort of both centers.
- Integration of services: RH, TB, Nutrition, IEC, Training
- Involvement of private and business houses
- Involvement of uniform-forces and line agencies