Improving the Integration of TB and HIV/AIDS Services in RussiaRussia ranks 12th among the world’s 22 countries with high tuberculosis burdens (WHO Global TB Report 2006), and the TB burden is complicated by the HIV/AIDS epidemic in Russia, which is one of the fastest growing in the world (UNAIDS 2004). In 2004, through the USAID-funded Quality Assurance Project, URC began working with Russian health authorities and the American International Health Alliance (AIHA) to assist the Russian Federation to address these dual epidemics by designing and establishing comprehensive local systems for HIV/AIDS care, treatment and support, including components to integrate TB and HIV/AIDS services, in four urban pilot areas: Krasnogvardeisky District in St. Petersburg City; Engels City in Saratov Oblast; Togliatti City in Samara Oblast; and Orenburg City in Orenburg Oblast. Some of the key problems URC has worked to overcome include a lack of information about TB/HIV co-infection, low rates of TB screening among HIV-positive patients, and insufficient TB preventative treatment for HIV patients. While continuing to support teams in Togliatti and Engels, URC is currently working t scale up successes achieved over the last two years in all eighteen districts of St. Petersburg plus three bordering cities in Leningrad Oblast, and four cities in Orenburg Oblast: Orenburg, Gai, Novotroitsk, and Orsk. These successes include a new screening algorithm for detecting TB among HIV-positive patients, improved reporting and information exchange, newly designed data collection tools, and VCT training for TB specialists to increase detection of HIV among TB patients during post-treatment follow-up. URC-supported teams, working in close coordination with the WHO High Level Working Group on Tuberculosis, will continue to work on monitoring effectiveness of IPT (izoniazid preventative treatment) in HIV-positive clients. The timeframe for these activities is January 2007 through July 2008. During the pilot phase of this project, after the initial trainings and team meetings, teams of clinical and social service providers in each project site were supported through technical updates and onsite coaching to strengthen TB-HIV service integration. In addition, URC has supported these teams by conducting inter-regional round tables and technical meetings on IPT in Moscow and St. Petersburg to facilitate an exchange of ideas on the organization of TB/HIV co-infection care and treatment between the project sites and to provide an opportunity for the teams to receive advice, feedback and answers from national and international experts on the teams’ work, share relevant domestic and foreign experiences, and adopt best practices. Efforts of the site teams to establish stronger coordination between traditionally separate HIV/AIDS and TB services in Russia have built on the findings of a USAID-funded assessment of the status of TB-HIV co-infection and existing HIV/AIDS and TB programmatic linkages. TB-HIV improvement teams (comprising representatives from TB clinics, AIDS centers, polyclinics, and narcology clinics, and NGOs) formed in early 2005 in all four cities identified and implemented a variety of improvements in their local systems of care. Changes introduced in all sites include:
The new care delivery models developed by the project teams have successfully been adopted by health authorities in all the project sites. Furthermore, in the city of Engels, they were evaluated by the Saratov Oblast Ministry of Health and Social Support, and in February 2006 the Ministry issued an order extending the care delivery model to all Oblast municipalities, providing a good example of intentional scale-up initiated by local authorities. In spring 2007, the Oblast MOH in Orenburg issued Oblast order #666 “On improving TB screening and TB preventive therapy among HIV patients”. The order stipulates: Cooperation and exchange of information on HIV patients between AIDS Center, TB services and polyclinics; algorithm of HIV screening among HIV patients by X-ray, tuberculin testing and microscopy; TB preventive therapy among HIV patients; and data collection and analysis on a regular basis.
As a result of this increased focus on TB/HIV integration, the percentages of HIV-positive patients tested for TB and of TB-positive patients tested for HIV have risen steadily. The system of TB screening among HIV patients at primary care settings developed and tested by the project teams in Togliatti has become a sustainable practice institutionalized by Healthcare Department Order #165 as of August, 2005. Since then, TB screening coverage of the target group has continued to grow. The number of HIV patients having undergone X-ray screening in the first 11 months of 2007 has increased by 30% compared to 2006.
The district teams in St. Petersburg involved in the scale-up activity started to adapt the system of TB screening among HIV positives at primary care originally developed and tested by Krasnogvardeisky District of St. Petersburg. Following verification of the HIV patient database between the AIDS Center and district polyclinics, district infectious disease specialists started to actively encourage patients who have not been in the health care system to visit the polyclinic for a check-up. The district infectious disease specialists are now responsible for TB screening among HIV patients in the polyclinic. The graph “HIV patients screened for TB at the selected polyclinics in three districts of St. Petersburg (absolute numbers by quarter)” demonstrates that almost no testing for TB among HIV positives was done before the scale-up collaborative on TB/HIV began. Provision of TB screening at primary care level expands access to the services to places which are convenient for patients. In Engels by the end of 2006, all patients with HIV/TB eligible for ART were covered by the therapy. Such coverage with ART became possible due to systematic team work of TB dispensary specialists, polyclinic infectious disease specialists and the Oblast AIDS Center on improving TB screening among HIV positive clients, counseling on HIV/TB co-infection, as well as coordination of efforts on ART provision for this group of patients.
There were no official guidelines on IPT in Russia in 2006. The QAP-supported teams in the four pilot sites have done pioneering work developing consensus and algorithms for izoniazid preventive treatment (IPT). Patient record form for IPT was developed with participation of Federal HIV/TB Center. Over 300 HIV positive patients now receive IPT in the project regions. It was agreed to analyze the new practice of IPT across regions to identify best strategy for IPT in HIV clients. Preliminary results have been reported in 2007 at the 38th Annual Conference of the International Union Against Lung Diseases and Tuberculosis (IUALDT), Cape Town, South Africa. in Orenburg, Oblast authorities recognized the need to create an office for a TB specialist within the AIDS Center. The AIDS Center specialist hired by the Orenburg Oblast AIDS Center in 2005 provides counseling and identifies eligible patients for IPT, administers IPT and follow-up on patients on IPT. The number of clients including new client is permanently growing. Preliminary results of the IPT practice in Orenburg include the following: IPT hepatotoxicity is a myth; the majority of patients on IPT showed weight gain and improved immune status without ART; IPT is effective method to improve prospects for HIV clients. Currently the IPT practice being adapted to the local environments in the tree cities of the Orenburg Eastern Zone – Orsk, Novotroitsk and Gai.
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