Policy review of HIV and TB guidelines for high HIV/TB burden African countries

HIV/AIDS Department World Health Organization

WHO 2010 ART guidelines

Target Population HIV+ asymptomatic patients ARV-nave individuals ART guideline CD4 < 350 cells/mm3

HIV+ pregnant women

CD4 < 350 cells/mm3 irrespective of clinical symptoms or WHO clinical stage 3 or 4 irrespective of CD4 cell count
Presence of active TB, irrespective of CD4 count

HIV/TB co-infection ARV- nave individuals

WHO 2004 Interim Policy on Collaborative TB/HIV Activities

A. Establish NTP-NACP collaborative mechanisms Coordinating bodies for effective TB/HIV activities at all levels Conduct surveillance of HIV prevalence among TB cases Carry out joint TB/HIV planning Monitor and evaluate collaborative TB/HIV activities

B. Decrease burden of TB among PLHIV (the "Three I's for HIV/TB") Establish intensified TB case finding Introduce INH preventive therapy Ensure TB infection control in health care and congregate settings
C. Decrease burden of HIV among TB patients Provide HIV testing and counselling Introduce HIV prevention methods Introduce co-trimoxazole preventive therapy Ensure HIV/AIDS care and support Introduce ARVs

WHO 2010 IPT/ICF Recommendations

Use of four-symptoms screening algorithm to rule out active TB and offer IPT Four symptoms include cough, fever, weight loss and night sweats Past history of TB and current pregnancy should not be contraindications for IPT TST or chest radiography are not required

Estimated 2009 HIV/TB and HIV burden

Country People with HIV-Figure in '000 (% of global HIVpositive people) 320 (1.0) N/A 1500 (4.5) 290 (0.9) 920 (2.8) 1400 (4.2) 180 (0.5) 3300 (9.9) 5600 (16.8) 180 (0.5) 1400 (4.2) 1200 (3.6) 980 (2.9) 1200 (3.6) 18470 (55.5) People with HIV and TBFigure in '000 (% of global HIV/TB burden) 6.8 (0.6) 34 (2.8) 53 (4.4) 8.7 (0.7) 27 (2.3) 54 (4.5) 9.2 (0.8) 87 (7.3) 290 (24.2) 10 (0.8) 38 (3.2) 54 (4.5) 23 (1.9) 48 (4.0) 742.7 (61.9) People eligible for ART at CD4 < 350 cells ('000) 170 N/A 710 130 440 570 93 1400 2600 80 660 520 440 640 8453 People on ART ('000) ART coverage (%) People living with HIV screened for TB ('000) 159.1 24.1 14.1 N/A N/A 24.3 87.5 195.1 433.7 8.4 5.5 57.7 N/A N/A 1009.5 ART coverage (%)

Botswana Ethiopia Kenya Lesotho Malawi Mozambique Namibia Nigeria South Africa Swaziland Tanzania Uganda Zambia Zimbabwe Total

145.2 176.6 337 61.7 198.8 170.2 70.5 303 971.6 47.2 199.4 200.4 283.9 218.6 3384.1

83 N/A 48 48 46 30 76 21 37 59 30 39 64 34 38

11700 2403 N/A N/A N/A 2429 17700 1853 23600 2107 153 N/A N/A N/A 61945

Source : 2010 Stop TB global surveillance report, UNAIDS Report on global AIDS Epidemic 2010

Objectives and Methodology

Objectives:
Compare national HIV, TB and HIV/TB guidelines for 14 African countries with recently released WHO ART and HIV/TB guidelines

Methodology:
Main guidelines were collected from the following sources: National HIV Guidelines
National TB Guidelines HIV/TB and TB infection control Guidelines

Standard abstraction form was used to review recommendations on:

ART initiation criteria The Three Is for HIV/TB The Three I's for HIV/TB monitoring and evaluation indicators

Source : National HIV, TB and HIV/TB Guidelines

Country
Botswana
Ethiopia Kenya Lesotho

National ART guidelines

2008
2008 2011 2007

National TB control guidelines

2007
2008 2009 2008

HIV/TB, ICF, IPT, OI guidelines

TB infection control guidelines

2007 2008

Malawi
Mozambique Namibia Nigeria South Africa Swaziland Tanzania Uganda Zambia Zimbabwe

2011
2010 2010 2010 2010 2010 2009 2008 2010 2010

2007
2008 2011 2010 2008 2010 2006 2010 2008 2010 2006 2010 2010 2008 2010 2011

2008
2010 2010 2008 2007 2011

2011

* Published guidelines, Drafts, Preliminary drafts

ART initiation criteria in people with HIV

Country (Year of publication of ART guidelines)
Botswana (2008) Ethiopia (2008) Kenya (2011) Lesotho (2007) Malawi (2011) Mozambique (2010) Namibia (2010) Nigeria (2010) South Africa (2010) Swaziland (2010) Tanzania (2009) Uganda (2008) Zambia (2010) Zimbabwe (2010)

Asymptomatic people
<250 <200 <350 <350 <350 <250 <350 <350 <200 <350 <200 <250 <350 <350

People with HIV and TB

Irrespective of CD4 count <350 Irrespective of CD4 count <350 Irrespective of CD4 count <350 Irrespective of CD4 count Irrespective of CD4 count* <350 Irrespective of CD4 count <350 <350 <350 Irrespective of CD4 count*

Pregnant women
<250 <200 <350 <350 Irrespective of CD4 count <350 <350 <350 <350 <350 <200 <350 <350 <350

All figures in cells/mm3, Guidelines in white are similar to WHO recommendations.

* Nigeria's TB and HIV/TB guidelines and Zimbabwe's HIV/TB guidelines recommend ART for people with HIV and TB at CD4 count < 350 cells/mm3

ART initiation for asymptomatic people

2010 WHO Recommendation : CD4 count < 350 cells/mm3

350

Kenya, Lesotho, Malawi, Namibia, Nigeria, Swaziland, Zambia, Zimbabwe

250 200

Botswana, Mozambique, Uganda Ethiopia, South Africa, Tanzania

CD4 Count

ART initiation for people with HIV and TB

2010 WHO Recommendation : ART irrespective of CD4 count
Irrespective of CD4 count
Botswana Kenya Malawi Namibia Nigeria Swaziland Zimbabwe

CD4<350 cells
Ethiopia Lesotho Mozambique South Africa Tanzania Uganda Zambia

Zambia recommends ART at CD4 count > 350 cells/mm3 if any other stage III or IV illnesses Ethiopia recommends ART for all extrapulmonary and disseminated TB patients

ART initiation for pregnant women with HIV

2010 WHO Recommendation : CD4 count < 350 cells/mm3
Irrespective of CD4 count Malawi CD4<350 cells Kenya Lesotho Mozambique Namibia Nigeria South Africa Swaziland Uganda Zambia Zimbabwe Malawi, under Option B+, recommends lifelong ART for all pregnant women irrespective of CD4 count CD4<250 cells Botswana CD4<200 cells Ethiopia Tanzania

Co-trimoxazole prophylaxis
2006 WHO Recommendation : CD4 count < 350* cells/mm3 or WHO stage 3 or 4

CD4< 200 Cells or WHO Stage 3 or 4

All HIV positives Kenya, Malawi, Swaziland Botswana CD4< 200 Cells or WHO Stage 2, 3 or 4 South Africa

Different guidelines followed by different countries

CD4< 350 Cells or WHO Stage 2, 3 or 4 Mozambique, Tanzania, Zambia, Ethiopia**, Zimbabwe CD4< 350 Cells or WHO Stage 3 or 4 Lesotho, Namibia, Nigeria
*Countries may choose to adopt a CD4 threshold of < 200 cells/mm3 **Source: Ethiopia's Co-trimoxazole prophylaxis guidelines, 2006

CD4< 250 Cells or WHO Stage 2, 3 or 4 Uganda

National policies for HIV, TB and HIV/TB, and the Three I's for HIV/TB
Country Botswana Ethiopia Kenya Lesotho Malawi Mozambique Namibia Nigeria South Africa Swaziland* Tanzania Uganda Zambia Zimbabwe ICF NAP NAP, NTP, HIV/TB NAP, OI, NTP NAP, NTP NAP, NTP NAP, NTP NTP NAP, NTP, HIV/TB NAP, NTP, IPT NAP, IPT NAP, NTP NAP, NTP, HIV/TB NAP, NTP, ICF NTP, HIV/TB IPT NAP, NTP NAP, NTP, HIV/TB NAP, OI, NTP NAP, NTP NAP, NTP** NAP, NTP NAP, NTP NAP, NTP, HIV/TB NAP, NTP, IPT NAP, IPT NAP, NTP NTP, HIV/TB NTP**, ICF NTP**, HIV/TB** TB infection control NAP, NTP NTP, HIV/TB NAP, OI, NTP NAP, NTP IC NAP, NTP, IC NTP, IC NTP, HIV/TB, IC NTP, IC NAP, IC NAP, NTP NTP, HIV/TB, IC NTP NTP, HIV/TB Indicators on the Three I's for HIV/TB NTP HIV/TB x NTP NTP NAP NTP, IC IC IPT NAP, IPT, IC x HIV/TB, IC NTP x

NAP National ART Policy, NTP National TB Policy, ICF National intensified TB case finding guidelines, IPT National IPT guidelines, IC TB infection control guidelines, OI National guidelines on management of HIV-related opportunistic infections Note: * 2011 NTP for Swaziland recommends Three I's for HIV/TB but do not mention any guidelines ** These guidelines do not recommend IPT

Countries recommending the Three Is for HIV/TB

Country
Botswana Ethiopia Kenya Lesotho Malawi Mozambique Namibia Nigeria South Africa Swaziland Tanzania Uganda Zambia Zimbabwe

ICF

IPT
*

TB infection control

* Zambia: Preliminary draft on ICF guidelines recommends IPT

TB screening criteria for IPT

2010 WHO Recommendation : Symptom-based screening

Nigeria

Ethiopia

Uganda Kenya

LEGEND IPT Initiation criteria

Malawi

Tanzania

IPT not recommended Symptom-based

Zambia Zimbabwe Botswana Mozambique

Namibia

Symptom-based + sputum smear microscopy + chest X-ray Symptom-based + sputum smear microscopy + chest X-ray + TST

Swaziland South Africa Lesotho

Note: The map shows IPT initiation criteria recommended by the most recent guidelines for a country

TB exclusion criteria for IPT initiation

2010 WHO Recommendation : Four-symptom screening for cough, fever, weight loss and night sweats
BOTSWANA NAMIBIA* NTP 2007 NAP 2010 Enlarged Diarrhoea glands SOUTH AFRICA Coughing blood NAP 2010
Sputum production

WHO recommendation SOUTH AFRICA IPT 2010 ETHIOPIA HIV/TB 2008

KENYA OI 2008 NIGERIA*** NTP 2009 NAP 2010 Chest Sputum X-ray smear Chest X-ray Chest pain Enlarged lymph nodes Night sweats Fever Cough Enlarged glands

MOZAMBIQUE NAP 2010

Coughing blood Chest pain Loss of appetite

Shortness of breath

ZAMBIA IPT 2010

MALAWI NAP 2011 Night sweats Weight loss Fever Cough UGANDA NTP 2010 TST Sputum smear Chest X-ray Cough LESOTHO NAP 2007 Sputum smear Chest X-ray Night sweats Cough

KENYA TANZANIA** NAP 2011 NAP 2009 SWAZILAND Abnormal Swelling NAP 2010 chest findings Chest Chest Coughing

Chest pain Loss of appetite

Shortness of breath

Loss of appetite
Shortness of breath

pain
Enlarged lymph nodes Weight loss Fever Cough Night sweats Weight loss Fever Cough

blood Night sweats Weight loss Fever Cough

pain
Night sweats Weight loss Fever Cough

Night sweats Weight loss Fever Cough

Night sweats Weight loss Fever Cough

Night sweats Weight loss Fever Cough

* 2011 TB guidelines for Namibia recommend enlarged lymph nodes as an additional symptom ** 2006 TB guidelines for Tanzania recommend chest pain as an additional symptom *** 2008 IPT guidelines for Nigeria recommend weight loss as an additional symptom, 2010 NTP guidelines do not recommend chest X-ray and sputum smear microscopy

Exceptions to WHO recommendations on IPT

2010 WHO Recommendation : IPT to all irrespective of previous history of TB or current pregnancy and IPT with ART also recommended
1. 2. Botswana and Mozambique No IPT initiation in pregnancy Botswana and Tanzania IPT not for children

3.
4. 5. 6. 7.

South Africa IPT with ART is a conditional recommendation

Lesotho IPT offered to TB-exposed HIV infected children and at pilot sites where active TB can be ruled out Malawi Stop IPT when patient is started on ART Kenya and Swaziland IPT provided in clinics with TB screening, adherence counselling and patient follow-up services Uganda IPT provided in institutions with adequate human resources, infrastructure, and equipment and logistics

Indicators for monitoring and evaluating performance on the Three Is for HIV/TB
ICF
Yes Lesotho Ethiopia Malawi Mozambique Namibia Nigeria Swaziland Uganda Zambia Malawi, Namibia, Nigeria, Swaziland and Uganda have indicators for TB infection control No Botswana Kenya South Africa Tanzania Zimbabwe Yes Botswana Ethiopia Lesotho Mozambique Namibia South Africa Swaziland Uganda

IPT
No Kenya Malawi Nigeria Tanzania Zambia

Limitations
Guidelines may be outdated and/or in the process of being updated Written policies may not reflect programme implementation Other guidelines covering ART and the Three Is for HIV/TB may exist

- Infection control guidelines - Monitoring and evaluation guidelines

Conclusion

Many countries follow the recently released WHO guidelines

- Asymptomatic patients 8 countries - HIV/TB co-infected people 7 countries

- Pregnant women 10 countries

Malawi recommends lifelong ART for pregnant women irrespective of CD4 count (Option B+) Almost all countries have recommendations on the Three Is for HIV/TB CPT initiation criteria differs widely across countries ICF and IPT guidelines specified in both NAP and NTP for many countries

Many countries have ICF and IPT indicators

Room for improving monitoring and evaluating progress on TB infection control

Recommendations
ART policy

Revise ART eligibility criteria where necessary

IPT policy

Adapt policies to recommend IPT for all, including pregnant women, previous TB patients and PLHIV on ART Simplify criteria for IPT initiation

Monitoring and evaluating of the Three I's for HIV/TB

Include indicators on ICF and IPT in National ART Guidelines Adapt and implement indicators for TB infection control

Thank you