Provider-Initiated HIV Testing and Counseling of TB Patients --- Livingstone District, Zambia, September 2004--December 2006

Tuberculosis (TB) is the second most common cause of death from infectious disease in the world after human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (1). Immunosuppressed HIV-infected persons are highly susceptible to TB disease, and countries in sub-Saharan Africa have the highest TB incidence rates, primarily because of the HIV epidemic (2,3). In Zambia, the TB rate increased during 1984--2005 from approximately 100 cases per 100,000 population to 580 cases per 100,000 population (4). Much of this increase has been attributed to the high rate of coinfection with HIV; currently, an estimated 50%--70% of TB patients are infected with HIV (N. Kapata, Ministry of Health, Zambia, personal communication, 2008). In 2007, the World Health Organization (WHO) recommended that countries with high coinfection rates develop TB/HIV collaborative activities, including routine provider-initiated HIV testing and counseling (PITC) of TB patients in TB clinical settings, using an "opt-out" approach (5). This report summarizes results from a PITC pilot study conducted by the Zambian Ministry of Health, with assistance from the CDC Global AIDS Program Zambia, during September 2004--December 2006 with TB patients at three clinics in the Livingstone District in the Southern Province of Zambia. The results indicated that, among 4,148 persons who had TB diagnosed, 2,072 (50%) were tested for HIV; of these, 1,497 (72%) tested positive. These findings demonstrate the practicality and acceptance of PITC and HIV rapid testing and support the need to expand this program to TB clinical settings in Zambia and other countries with high rates of TB and HIV.

The usual manner in which HIV-testing services are offered in sub-Saharan Africa is through voluntary counseling and testing (VCT), also called client-initiated counseling and testing. VCT uses an "opt-in" approach, in which patients seek HIV testing and must consent to be tested; VCT also requires pretest counseling sessions of up to 45 minutes with a trained counselor. In contrast, PITC is offered by health-care providers as part of routine clinical care with brief pretest counseling of less than 15 minutes. All patients are offered HIV testing and consent to be tested is implied as with any other clinically indicated laboratory test; patients may opt out if they do not want to be tested. In Zambia, management of TB, including diagnosis, notification, and treatment, primarily occurs through primary health centers. Specialized TB clinics are found only in larger district hospitals, provincial hospitals, and tertiary-care hospitals. Treatment for TB is provided on an outpatient basis, with hospital admission limited to patients who are too ill to go home. Zambia has adopted the WHO Stop TB strategy for control of TB using directly observed therapy (6).

In 2004, in response to a recommendation by WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) that diagnostic HIV counseling and testing be part of routine management of TB patients (7), CDC Zambia provided technical assistance to the Ministry of Health in development of a pilot study to test the feasibility of offering these services as part of routine TB care. Livingstone District, the capital of Southern Province, which had an estimated adult HIV prevalence of 28% in 2002 (Zambia Central Statistics Office, unpublished data, 2004) and a TB incidence of 751 cases per 100,000 population in 2003, was chosen as the site for the pilot study. The district has three TB diagnostic clinics: the Livingstone General Hospital chest clinic and urban TB clinics in Dambwa and Maramba.

In September 2004, the pilot study was begun at the three clinics. Counseling and testing data were collected from record books, using an abstraction form; monthly reports of the number of TB patients counseled and tested for HIV and their test results were sent to CDC Zambia. Data also included basic sociodemographic, clinical, and referral information.

The pilot study was implemented in three phases: 1) VCT was provided by referral off-site, 2) VCT was provided on-site; and 3) PITC and rapid testing were provided on-site by TB clinic staff members. During the first phase of the study (September--December 2004), TB patients in the Livingstone General Hospital chest clinic were referred for VCT to the hospital's VCT unit. At Dambwa Clinic and Maramba Clinic, during the first phase (September 2004--June 2005 for the two urban clinics), patients were referred to off-site nurse-counselors for VCT. During the second phase (January--December 2005), at Livingstone General Hospital, a room adjacent to the chest clinic was renovated for counseling, and VCT was provided on-site by part-time counselors. During the second phase at Dambwa and Maramba clinics (July 2005--March 2006), part-time nurse-counselors provided on-site VCT. The nurse-counselors were given transportation allowances that enabled them to travel from their homes to the clinics. Later, full-time counselors were assigned to these clinics. Finally, in the third phase, TB clinic staff members at the hospital and two urban clinics received training on PITC and the use of HIV rapid tests. The staff members provided PITC to TB patients at the chest clinic during January--December 2006 and at the two urban clinics during April--December 2006.

During September 2004--December 2006, a total of 4,148 TB cases were reported by the three clinics (Table). Among the patients, 1,922 (46%) were female. A total of 1,717 (41%) TB cases were diagnosed at Maramba Clinic, 1,637 (40%) at the Livingstone General Hospital chest clinic, and 794 (19%) at Dambwa Clinic.

At Livingstone General Hospital, during September--December 2004 (during the first phase), when patients were referred out of the TB clinic to the VCT unit of the hospital, of 252 patients in whom TB was diagnosed at the chest clinic, 178 (71%) were counseled; of these, 92 (52%) TB patients were tested, and 80 (87%) tested HIV positive. In 2005, during the second phase, after VCT services were made available on-site in the room adjacent to the chest clinic, of 624 TB patients, 366 (59%) were counseled, and 291 (80%) were tested, of whom 196 (67%) tested HIV positive. In 2006, during the third phase, after staff members in the chest clinic had been trained in PITC, the percentage of TB patients receiving HIV counseling increased to 93% (709 of 761 patients); of those counseled, 618 (87%) were tested, and 412 (67%) tested HIV positive.

In the Dambwa and Maramba clinics, during the first phase in September 2004--June 2005, when patients were referred off-site for VCT, 970 new TB patients were identified, and 196 (20%) were counseled; of these, 174 (89%) were tested, and 150 (86%) tested HIV positive. In the second phase (July 2005--March 2006), after counselors were made available in the clinics, the percentage of TB patients who were counseled increased to 62% (602 of 965); of these, 501 (83%) were tested, and 358 (71%) tested HIV positive. During April--December 2006, after the clinical staff had been trained and had implemented on-site PITC, 494 (86%) of the TB patients were counseled; of these, 396 (80%) were tested, and 301 (76%) tested HIV positive.

By sex, the percentage of TB patients agreeing to HIV testing was similar at the three clinics: 83% among males and 85% among females in Maramba and Dambwa clinics and 82% among males and 78% among females in the chest clinic. The percentage of tested patients who had positive HIV test results was similar by sex at the two urban clinics (79% among males and 78% among females) and at the hospital chest clinic (70% among males and 74% among females).

TB patients who tested HIV positive at the hospital chest clinic were referred to an HIV care and treatment clinic in a building approximately 200 meters away. In 2005, receipt of antiretroviral therapy (ART) was documented for 118 (60%) of the 196 HIV-positive TB patient referred to treatments; these 118 patients met the ART eligibility criterion (i.e., CD4 cell count of <200 cells/µL) of the Zambian national HIV/AIDS program. In 2006, a total of 370 (90%) of the 412 HIV-positive TB patients were referred for HIV care and treatment, and ART was documented as having begun for 106 (29%) of those referred. These are minimum estimates of ART eligibility and uptake because documentation of CD4 counts and ART was inconsistent.

At the two urban clinics, a total of 538 HIV-positive TB patients were referred for HIV care and treatment during September 2004--December 2006. Initially, these patients were referred to Livingstone General Hospital's ART clinic. Later, patients were referred to ART clinics established on-site at Maramba and Dambwa clinics. Follow-up treatment information often was not available for patients referred from the two urban clinics. However, in 2006, of 230 HIV-positive TB patients referred by the urban clinics to ART clinics, 86 (37%) were documented as having commenced ART; of these, 50 (58%) were female.

Reported by: A Mwinga, MD, N Mwananyambe, C Kanene, M Bulterys, MD, CDC Global AIDS Program Zambia; C Phiri, MD, Southern Provincial Health Office; N Kapata, MD, V Mukonka, MD, Ministry of Health, Zambia. P Nadol, MPH, M Patel, MPH, A Nakashima, MD, Global AIDS Program, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Editorial Note:

Persons with TB disease and HIV infection are at greater risk for morbidity and mortality than those with either TB disease or HIV infection alone. Identifying those TB patients with HIV infection can get them into HIV care and treatment sooner and improve their prospects for survival. Introduction of routine HIV testing and counseling for TB patients in countries with high rates of TB and HIV can be challenging for TB programs and overextended clinic staffs. However, the pilot study described in this report demonstrates the feasibility of providing HIV testing and counseling as part of the routine management of TB patients in Zambia.

Until TB clinic staffs were trained in PITC, TB patients in the pilot study were offered HIV testing using the VCT model, which limited the number of TB patients who could be offered testing because of a lack of trained counselors and the long duration of pretest counseling sessions. Providing transportation allowances to part-time counselors enabled VCT to be provided on-site and increased the proportion of patients offered VCT in the two urban clinics, but this method was not considered sustainable over the long term. Assigning full-time VCT counselors to TB clinics also was not considered to be sustainable. Implementation of PITC on-site by TB clinic staff members in 2006 resulted in an increase in the percentage of TB patients being tested for HIV or maintenance of high rates of testing. In addition, training TB staff members to use HIV rapid test kits enabled same-day results and eliminated the need for patients to return to clinics to pick up test results. Finally, shifting the task of HIV testing from laboratorians to other health-care personnel surmounted the problem of shortages of trained laboratory workers. PITC by TB clinic staff using rapid tests was considered the most economical and sustainable approach in the long term.

Since 2007, the Zambian Ministry of Health has recommended that all TB clinic staff members be trained in PITC, including the use of HIV rapid tests, and that these services be implemented in TB clinics throughout the country. A national TB/HIV coordinating committee developed specific guidelines, and a training manual for PITC was created based on a CDC training module and supported by the U.S. President's Emergency Plan for AIDS Relief. During 2007, training in PITC was provided using a training-of-trainers approach to ensure availability of training teams throughout the country. PITC for TB patients has now begun in all 72 districts of Zambia.

Although the pilot study demonstrated that by using PITC, larger percentages of TB patients can be tested for HIV, ensuring follow-up of patients with ART clinics remains a challenge. Because staffs at TB and ART clinics are overextended with patients, referral forms often are not completed and returned to the referring units; therefore, documentation of uptake of referrals to HIV care and treatment is incomplete. In the future, use of individual-level electronic medical records might provide a better means of ensuring that data on HIV care and TB care are shared with providers of TB and HIV services (8). Also, initiation of one-stop services with greater integration of TB and HIV care might improve follow-up.

The pilot study demonstrated that PITC in TB clinics is both acceptable and feasible for patients and clinic staffs. The high percentage of TB patients who tested positive for HIV underscores the need to implement PITC in TB clinical settings in sub-Saharan African countries with high prevalence of both diseases. Expansion of PITC to other clinical settings will contribute to the effective scale-up of HIV prevention and care measures in those areas of the world that are in greatest need (9).

References

1. Frieden TR, Sterling TR, Munsiff SS, Watt CJ, Dye C. Tuberculosis. Lancet 2003;362:887--99.
2. DeCock KM, Chaisson RE. Will DOTS do it? A reappraisal of tuberculosis control in countries with high rates of HIV infection. Int J Tuberc Lung Dis 1999;3:457--65.
3. Corbett EL, Marston B, Churchyard GJ, DeCock KM. Tuberculosis in sub-Saharan Africa: opportunities, challenges, and change in the era of antiretroviral therapy. Lancet 2006;367:926--37.
4. World Health Organization. Global health atlas: country profiles on tuberculosis. Geneva, Switzerland: World Health Organization. Available at http://www.who.int/globalatlas/predefinedreports/tb/index.asp?strselectedcountry=zmb.
5. World Health Organization. Guidance on provider-initiated HIV testing and counseling in health facilities. Geneva, Switzerland: World Health Organization; 2007. Available at http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf.
6. World Health Organization. The Stop TB strategy: building on and enhancing DOTS to meet the TB-related millennium development goals. Geneva, Switzerland: World Health Organization; 2006. Available at http://www.who.int/tb/strategy/en/index.html.
7. World Health Organization. Guidelines for implementing collaborative TB and HIV programme activities. Geneva, Switzerland: World Health Organization; 2003. Available at http://www.who.int/tb/publications/2003/en/index1.html.
8. Stringer JS, Zulu I, Levy J, et al. Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. JAMA 2006;296:782--93.
9. DeCock KM, Marum E, Mbori-Ngacha D. A serostatus-based approach to HIV/AIDS prevention and care in Africa. Lancet 2003;362:1847--9.

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