Trends in TB and HIV care and treatment cascade, Kenya, 2008-2018.

BACKGROUND: HIV infection is associated with high mortality among people with TB. Antiretroviral therapy (ART) reduces TB incidence and mortality among people living with HIV (PLHIV). Since 2005, Kenya has scaled up TB and HIV prevention, diagnosis and treatment. We evaluated the impact of these services on trends and TB treatment outcomes.METHODS: Using Microsoft Excel (2016) and Epi-Info 7, we analysed Kenya Ministry of Health TB surveillance data from 2008 to 2018 to determine trends in TB notifications, TB classification, HIV and ART status, and TB treatment outcomes.RESULTS: Among the 1,047,406 people reported with TB, 93% knew their HIV status, and 37% of these were HIV-positive. Among persons with TB and HIV, 69% received ART. Between 2008 and 2018, annual TB notifications declined from 110,252 to 96,562, and HIV-coinfection declined from 45% to 27%. HIV testing and ART uptake increased from 83% to 98% and from 30% to 97%, respectively. TB case fatality rose from 3.5% to 3.9% (P <0.018) among HIV-negative people and from 5.1% to 11.2% (P <0.001) among PLHIV on ART.CONCLUSION: TB notifications decreased in settings with suboptimal case detection. Although HIV-TB services were scaled-up, HIV-TB case fatality rose significantly. Concerted efforts are needed to address case detection and gaps in quality of TB care.

Can isoniazid preventive therapy be scaled up rapidly? Lessons learned in Kenya, 2014-2018.

BACKGROUND: TB is the leading cause of mortality among people living with HIV (PLHIV), for whom isoniazid preventive therapy (IPT) has a proven mortality benefit. Despite WHO recommendations, countries have been slow in scaling up IPT. This study describes processes, challenges, solutions, outcomes and lessons learned during IPT scale-up in Kenya.METHODS: We conducted a desk review and analyzed aggregated Ministry of Health (MOH) IPT enrollment data from 2014 to 2018 to determine trends and impact of program activities. We further analyzed IPT completion reports for patients initiated from 2015 to 2017 in 745 MOH sites in Nairobi, Central, Eastern and Western Kenya.RESULTS: IPT was scaled up 75-fold from 2014 to 2018: the number of PLHIV covered increased from 9,981 to 749,890. The highest percentage increases in the cumulative number of PLHIV on IPT were seen in the quarters following IPT pilot projects in 2014 (49%), national launch in 2015 (54%), and HIV treatment acceleration in 2016 (158%). Among 250,069 patients initiating IPT from 2015 to 2017, 97.5% completed treatment, 0.2% died, 0.8% were lost to follow-up, 1.0% were not evaluated, and 0.6% discontinued treatment.CONCLUSIONS: IPT can be scaled up rapidly and effectively among PLHIV. Deliberate MOH efforts, strong leadership, service delivery integration, continuous mentorship, stakeholder involvement, and accountability are critical to program success.

Implementing TB preventive treatment within differentiated HIV service delivery models in global programs.

Global HIV program stakeholders, including the US President's Emergency Plan for AIDS Relief (PEPFAR), are undertaking efforts to ensure that eligible people living with HIV (PLHIV) receiving antiretroviral treatment (ART) receive a course of TB preventive treatment (TPT). In PEPFAR programming, this effort may require providing TPT not only to newly diagnosed PLHIV as part of HIV care initiation, but also to treatment-experienced PLHIV stable on ART who may not have been previously offered TPT. TPT scale-up is occurring at the same time as a trend to provide more person-centered HIV care through differentiated service delivery (DSD). In DSD, PLHIV stable on ART may receive less frequent clinical follow-up or receive care outside the traditional clinic-based model. The misalignment between traditional delivery of TPT and care delivery in innovative DSD may require adaptations to TPT delivery practices for PLHIV. Adaptations include components of planning and operationalization of TPT in DSD, such as determination of TPT eligibility and TPT initiation, and clinical management of PLHIV while on TPT. A key adaptation is alignment of timing and location for TPT and ART prescribing, monitoring, and dispensing. Conceptual examples of TPT delivery in DSD may help program managers operationalize TPT in HIV care.

Les parties prenantes du programme mondial VIH, notamment le plan américain PEPFAR (US President's Emergency Plan for AIDS Relief), entreprennent des efforts afin de s'assurer que les personnes vivant avec le VIH (PLVIH), éligibles, recevant un traitement antirétroviral (TAR), reçoivent également un traitement préventif TB (TPT). Dans la programmation PEPFAR, cet effort pourrait nécessiter de fournir le TPT non seulement aux PLVIH nouvellement diagnostiquées dans le cadre de l'initiation de la prise en charge du VIH, mais également aux PLVIH stables déjà traités par TAR à qui on n'aurait pas encore offert le TPT. L'expansion du TPT survient au même moment comme une tendance à offrir une prise en charge du VIH davantage centrée sur la personne à travers une prestation de services différenciée (DSD). Dans la DSD, les PLVIH stables sous TAR bénéficient d'un suivi clinique moins fréquent ou sont soignés hors du modèle traditionnel en structures de santé. Le décalage entre la prestation traditionnelle du TPT et la prestation de soins dans des DSD innovantes peut nécessiter des adaptations aux pratiques de prestation du TPT pour les PLVIH. Ces adaptations incluent des éléments de planification et d'opérationnalisation du TPT dans la DSD, comme la détermination de l'éligibilité au TPT et sa mise en route et la prise en charge clinique des PLVIH sous TPT. Une adaptation majeure est l'alignement en termes de temps et de lieu pour la prescription, le suivi et la délivrance du TPT et du TAR. Des exemples conceptuels de délivrance du TPT dans la DSD aideraient les gestionnaires de programme à rendre opérationnel le TPT au sein de la prise en charge du VIH.

Los interesados directos del Programa Mundial del VIH, incluido el Plan de Emergencia del Presidente (de los Estados Unidos) para el Alivio del Sida (PEPFAR), emprenden ahora esfuerzos encaminados a garantizar que las personas con infección por el VIH (PLVIH), que siguen un tratamiento antirretrovírico (TAR) y que reúnen las condiciones, reciban un ciclo de tratamiento preventivo de la TB (TPT). En la programación del PEPFAR esta iniciativa puede necesitar la provisión de TPT no solo a las personas con un diagnóstico reciente de infección por el VIH, como parte del inicio de la atención del VIH, sino también a las PLVIH, con experiencia de tratamiento y que se encuentran estables recibiendo el TAR, a quienes tal vez no se haya propuesto antes el TPT. La ampliación del TPT ocurre de manera simultánea con la tendencia a ofrecer una atención del VIH más centrada en la persona mediante la prestación diferenciada de servicios (DSD). En la DSD, las PLVIH, estables con el TAR, pueden tener encuentros de seguimiento clínico menos frecuentes o recibir atención por fuera del modelo tradicional en los consultorios. La discordancia entre la provisión tradicional del TPT y la prestación de atención en el marco innovador de la DSD exige adaptaciones de las prácticas de prestación del TPT a las PLVIH. Las adaptaciones incluyen componentes de planeación y puesta en práctica del TPT en la DSD, como la determinación de los criterios para recibir el TPT, el inicio del mismo y el manejo clínico de las PLVIH mientras reciben el TPT. Una adaptación primordial es la coordinación del ritmo y el lugar de prescripción, supervisión y suministro del TPT y el TAR. La presentación de ejemplos teóricos de provisión del TPT en el marco de la DSD puede ayudar a los gerentes de programas a poner en práctica el TPT en la atención del VIH.

Policies, practices and barriers to implementing tuberculosis preventive treatment-35 countries, 2017.

BACKGROUND: Tuberculosis preventive treatment (TPT) reduces the development of tuberculosis (TB) disease and mortality in people living with human immunodeficiency virus (HIV) infection. Despite this known effectiveness, global uptake of TPT has been slow. We aimed to assess current status of TPT implementation in countries supported by the US President's Emergency Plan for AIDS Relief (PEPFAR).METHODS: We surveyed TB-HIV program staff at US Centers for Disease Control and Prevention (CDC) country offices in 42 PEPFAR-supported countries about current TPT policies, practices, and barriers to implementation. Surveys completed from July to December 2017 were analyzed.RESULTS: Of 42 eligible PEPFAR-supported countries, staff from 35 (83%) CDC country offices completed the survey. TPT was included in national guidelines in 33 (94%) countries, but only 21 (60%) reported nationwide programmatic TPT implementation. HIV programs led TPT implementation in 20/32 (63%) countries, but TB programs led drug procurement in 18/32 (56%) countries. Stock outs were frequent, as 21/28 (75%) countries reported at least one isoniazid stock out in the previous year.CONCLUSION: Despite widespread inclusion of TPT in guidelines, programmatic TPT implementation lags. Successful scale-up of TPT requires uninterrupted drug supply chains facilitated by improved leadership and coordination between HIV and TB programs.

TB preventive therapy for people living with HIV: key considerations for scale-up in resource-limited settings.

Tuberculosis (TB) is the leading cause of death for persons living with the human immunodeficiency virus (PLHIV). TB preventive therapy (TPT) works synergistically with, and independently of, antiretroviral therapy to reduce TB morbidity, mortality and incidence among PLHIV. However, although TPT is a crucial and cost-effective component of HIV care for adults and children and has been recommended as an international standard of care for over a decade, it remains highly underutilized. If we are to end the global TB epidemic, we must address the significant reservoir of tuberculous infection, especially in those, such as PLHIV, who are most likely to progress to TB disease. To do so, we must confront the pervasive perception that barriers to TPT scale-up are insurmountable in resource-limited settings. Here we review available evidence to address several commonly stated obstacles to TPT scale-up, including the need for the tuberculin skin test, limited diagnostic capacity to reliably exclude TB disease, concerns about creating drug resistance, suboptimal patient adherence to therapy, inability to monitor for and prevent adverse events, a 'one size fits all' option for TPT regimen and duration, and uncertainty about TPT use in children, adolescents, and pregnant women. We also discuss TPT delivery in the era of differentiated care for PLHIV, how best to tackle advanced planning for drug procurement and supply chain management, and how to create an enabling environment for TPT scale-up success.

Delay in the Provision of Antiretroviral Therapy to HIV-infected TB Patients in Nigeria.

BACKGROUND: Nigeria has a high burden of HIV and tuberculosis (TB). To reduce TB-associated morbidity and mortality, the World Health Organization recommends that HIV-positive TB patients receive antiretroviral therapy (ART) within eight weeks of TB treatment initiation, or within two weeks if profoundly immunosuppressed (CD4<50 cell/µL). METHODS: TB and HIV clinical records from facilities in two Nigerian states between October 1st, 2012 and September 30th, 2013 were retrospectively reviewed to assess uptake and timing of ART initiation among HIV-positive TB patients. Healthcare workers were qualitatively interviewed to assess TB/HIV knowledge and barriers to timely ART. RESULTS: Data were abstracted from 4,810 TB patient records, of which 1,249 (26.0%) had HIV-positive or unknown HIV status documented, and the 574 (45.9%) HIV-positive TB patients were evaluated for timing of ART uptake relative to TB treatment. Among 484 (84.3%) HIV-positive TB patients not already on ART, 256 (52.9%, 95% CI: 45.0-60.8) were not initiated on ART during six months of TB treatment. 30.0% of 273 patients with a known CD4≥50cells/µL started ART within eight weeks, and 14.8% of 54 patients with a known CD4<50cells/µL started within the recommended two weeks. Only 42% of health workers interviewed reported knowing to interpret guidelines on when to initiate ART in HIV-positive TB patients based on CD4 cell count results. CD4 cell count significantly predicted timely ART uptake. CONCLUSION: A large proportion of HIV-positive TB patients were not initiated on ART early or even at all during TB treatment. Retraining of staff, and interventions to strengthen referral systems should be implemented to ensure timely provision of ART among HIV-positive TB patients in Nigeria.

Reducing child mortality in India in the new millennium.

Globally, child mortality rates have been halved over the last few decades, a developmental success story. Nevertheless, progress has been uneven and in recent years mortality rates have increased in some countries. The present study documents the slowing decline in infant mortality rates in india; a departure from the longer-term trends. The major causes of childhood mortality are also reviewed and strategic options for the different states of India are proposed that take into account current mortality rates and the level of progress in individual states. The slowing decline in childhood mortality rates in India calls for new approaches that go beyond disease-, programme- and sector-specific approaches.

Breast feeding--a study of 8750 Malaysian infants.

PIP: Infant feeding patterns in Malaysia were assessed using data obtained by interviewing 5160 women who gave birth to 8755 babies in 3 urban areas and 6 rural areas from 1970-1974. The study was undertaken in an effort to determine appropriate strategies for promoting breast-feeding. 64.2% of the 8755 were breast-fed. Considerable variation in breast-feeding patterns was observed when the data was analyzed in reference to ethnic affiliation, residence, family income, and mother's educational level. While 88.9% of the Malay infants were breast-fed, only 69.7% of the Indian infants and 42.3% of the Chinese infants were breast-fed. 47.0% of the infants in urban areas were breast-fed compared to 77.5% in the rural areas. Women in higher income and educational groupings were less likely to breast-feed their children than women in lower income and educational groupings. In the urban areas, approximately 1/2 of the Malay women, 1/2 of the Indian women, and 2/3 of the Chinese women discontinued breast-feeding before their children were 3 months old. Chinese women who delivered in private hospitals were less likely to breast-feed their infants than those who delivered in government hospitals. Among rural Malay women, those who delivered in hospitals were less likely to breast-feed than those who delivered at home. The findings suggested that 1) hospital personnel, especially those who work in private hospitals, should take a more active role in promoting lactation; 2) health personnel and mothers need to be more adequately informed about the advantages of breast-feeding; 3) women in higher income and educational groups should be encouraged to breast-feed since they serve as role models for women in the lower income and educational groups; and 4) additional studies should be undertaken in order to identify those cultural attitudes which inhibit lactation among Chinese women. Tables showed 1) the number and % distribution of breast-feeding and 2) the % of infants breast-fed by ethnic and residential status according to family income, age of mother, education of mother, occupation of mother, and place of birth.^ieng

A study of current infant feeding practices in rural North Malaysia as a basis for determining needs in nutrition education.

In a study of infant feeding practices in 95 infants aged three months and six months in the rural, predominantly Malay district of Kubang Pasu, which is recently undergoing rapid economic development consequent on the introduction of improved agricultural techniques in rice farming, it was found that approximately 75% of infants in both age groups were wholly or partially breast fed, modified powered milk being the milk food of most of the others. Semisolids were introduced early in the form of commercial prepacked cereals. It is suggested that medical officers of health recognising local socioeconomic and cultural changes that might affect health behavior can initiate simple studies of this type to identify local needs in health education. In circumstances such as this where a still popular beneficial traditional practice like breast feeding might be at risk of losing popularity in the face of socioeconomic development in the community it is suggested that the most useful educational effort regarding infant nutrition would be to preserve breast feeding.