Joint tuberculosis/HIV services in Malawi: progress, challenges and the way forward
Rhehab Chimzizia, Anthony Harriesb
In the base paper, Laserson & Wells suggest that the greatest challenge to achieving global TB targets is the ever-expanding HIV epidemic and the resulting increase in HIV-associated TB, particularly in sub-Saharan Africa. Malawi, in southern Africa, is a poor country that has a huge HIV epidemic, and serves as an appropriate case study.
In Malawi, which has a population of 12 million, an estimated 790 000 adults are living with HIV, there are 80 000 AIDS-related deaths each year and 170 000 HIV-infected persons are in need of antiretroviral therapy.1 The HIV epidemic has had a large negative impact on TB control services in the country. TB case notifications have risen from 5000 per year in 1985 to more than 25 000 per year for the past five years. An increase in the number of cases of TB that recur after treatment completion has contributed to this burden.2 There has been a disproportionate increase in the number of patients with smear-negative pulmonary TB and extra-pulmonary TB, the diagnosis of which is not easy in a resource-constrained environment.3 Case fatality rates in patients with smear-positive pulmonary TB have risen from 5% in 1985 to more than 20%, and are even higher among those with smear-negative TB, who are more severely immunosuppressed.3 According to the last national survey, 70% of TB patients are infected with HIV.4
The government of Malawi has tried to respond to this challenge. Malawi was one of three African countries to pilot the WHO ProTEST initiative (1999–2002), which promoted HIV testing and counselling among TB patients as an entry point to HIV prevention, treatment and care services.5 Subsequently, and with the support of bilateral and multilateral donors, a three-year TB/HIV plan (2003–2005) was developed and integrated into the five-year national TB control plan (2001–2005). The principal objectives were to scale up HIV testing among TB patients and, for HIV-positive TB patients, to provide cotrimoxazole preventive therapy and facilitate access to antiretrovirals.
What progress has been made between 2003 and 2005? From routine data collected and reported within the national programmes for TB and antiretroviral therapy, the proportion of TB patients tested for HIV increased from 15% in 2003 to 47% in 2005. During this time, the majority (90% or more) of HIV-positive TB patients started cotrimoxazole preventive therapy. In 2005, just over 20% of new patients starting antiretroviral therapy had active TB or a past history of TB. However, because the national database for antiretroviral therapy does not disaggregate patients with active TB or a past history, it is difficult to know how many HIV-infected TB patients starting anti-TB treatment that year also started antiretroviral therapy.
Despite progress, challenges to implementation remain. Less than half of all TB patients were tested for HIV in 2005, the main barriers being irregular supplies of HIV-testing reagents, staff forgetting to refer patients or patients themselves not undergoing HIV testing and counselling after being registered and placed on anti-TB treatment. Ways to improve HIV-testing uptake need to be found, including the integration of HIV testing into the TB registration process itself.6
Since cotrimoxazole is regularly out of stock in peripheral hospital pharmacies, the national TB programme procured its own supply for patients on anti-TB treatment. The challenge is the continuation of preventive therapy after completion of anti-TB treatment. In this regard, the health ministry is now implementing a national policy of long-term preventive therapy for all eligible HIV-infected patients (including those with TB) with cotrimoxazole procured via the Global Fund to Fight AIDS, Tuberculosis and Malaria.
HIV-positive patients with TB are potentially eligible for antiretroviral therapy if they are in either WHO clinical stage 3 (pulmonary TB) or stage 4 (extra-pulmonary TB).7 It is preferable to perform a CD4-lymphocyte count before considering antiretroviral therapy; however, in Malawi there is a shortage of laboratories with this capability, and hence national guidelines recommend that all HIV-infected TB patients be considered for antiretroviral therapy.8 Every year, an estimated 19 000 HIV-infected TB patients are registered for anti-TB treatment, but currently only a small proportion access antiretroviral therapy.
There are several reasons for this. The policy is to start TB patients on antiretroviral therapy after they have completed the initial phase of anti-TB treatment, by which time the sickest patients have died and survivors may feel well enough not to need antiretroviral therapy. In the continuation phase, anti-TB treatment is decentralized to health centres, while antiretroviral therapy tends to be administered by central, district and mission hospitals, and therefore access to antiretrovirals is difficult for patients receiving their anti-TB treatment at health centres.9 Offering earlier antiretroviral therapy to TB patients and expanding the availability of antiretroviral therapy to health centres are ways of potentially solving these problems.
Finally, the monitoring systems for HIV and TB need to explicitly include the relevant parameters.6 For example, TB monitoring tools, including cohort reports, should include data on numbers of TB patients who have been tested for HIV, who are HIV-positive, and who have started cotrimoxazole or antiretroviral therapy. Only in this way will staff managers know whether TB/HIV interventions are making a difference to treatment outcomes. ■
- HIV and syphilis sero-survey and national HIV prevalence estimates report. Lilongwe: Ministry of Health; 2005.
- AD Harries, RB Chimzizi, TE Nyirenda, J van Gorkom, FM Salaniponi. Preventing recurrent tuberculosis in high HIV-prevalent areas in sub-Saharan Africa: what are the options for tuberculosis control programmes? Int J Tuberc Lung Dis 2003; 7: 616-22.
- NJ Hargreaves, O Kadzakumanja, CJ Whitty, FM Salaniponi, AD Harries, SB Squire. Smear-negative pulmonary tuberculosis in a DOTS programme: poor outcomes in an area of high HIV-prevalence. Int J Tuberc Lung Dis 2001; 5: 847-54.
- JH Kwanjana, AD Harries, F Gausi, DS Nyangulu, FM Salaniponi. TB-HIV seroprevalence in patients with tuberculosis in Malawi. Malawi Med J 2001; 13: 7-10.
- Stop TB. Department. Report of a “lessons learnt” workshop on the six ProTEST pilot projects in Malawi, South Africa and Zambia. Geneva: WHO; 2004 (WHO/HTM/TB/2004.336).
- AD Harries, M Boxshall, S Phiri, J van Gorkom, R Zachariah, SB Squire, et al. Providing HIV care for tuberculosis patients in sub-Saharan Africa. Int J Tuberc Lung Dis 2006; 10: 1306-11.
- Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access. Recommendations for a public health approach (2006 version). Geneva: WHO; 2006.
- Treatment of AIDS. Guidelines for the use of antiretroviral therapy in Malawi, second edition. Lilongwe: Ministry of Health; 2006.
- R Zachariah, R Teck, O Ascurra, P Gomani, M Manzi, P Humblet, et al. Can we get more HIV-positive tuberculosis patients on antiretroviral treatment in a rural district of Malawi? Int J Tuberc Lung Dis 2005; 9: 238-47.
- The National Tuberculosis Control Programme, Community Health Sciences Unit, Ministry of Health, Private Bag 65, Lilongwe, Malawi.
- HIV Unit, Ministry of Health, Lilongwe, Malawi.