HIV Testing and Treatment Among Tuberculosis Patients --- Kenya, 2006--2009

HIV Testing and Treatment Among Tuberculosis Patients --- Kenya, 2006--2009
Weekly
November 26, 2010 / 59(46);1514-1517

In resource-limited settings, high case-fatality rates are seen among tuberculosis (TB) patients with human immunodeficiency virus (HIV) infection, especially during the early months of TB treatment (1). HIV prevalence among TB patients has been estimated to be as high as 80%--90% in some areas of sub-Saharan Africa (2). In 2004, the World Health Organization (WHO) recommended increasing collaboration between HIV and TB programs (3). Since then, many countries, including Kenya, have worked to increase TB/HIV collaborative activities. In 2005, the Kenya Division of Leprosy, Tuberculosis, and Lung Disease (DLTLD) added questions regarding HIV testing and treatment to the existing TB surveillance system.* This report summarizes HIV data collected from Kenya's extended TB surveillance system during 2006--2009. During this period, HIV testing among TB patients increased from 60% in 2006 to 88% in 2009, and the prevalence of HIV infection among TB patients tested decreased from 52% to 44%. In 2009, 92% of HIV-infected TB patients received cotrimoxazole prophylaxis for the prevention of opportunistic infections (4). Although these data highlight the increase in HIV services provided to TB patients, only 34% of HIV-infected TB patients started antiretroviral therapy (ART) while being treated for TB. Innovative interventions are needed to increase HIV treatment among TB patients in Kenya, especially considering the 2009 WHO guidelines recommending that all HIV-infected TB patients be started on ART as soon as possible, regardless of CD4 count (5). Although these guidelines have not yet been implemented in Kenya, officials are working to identify methods of increasing access to ART for TB patients.

In 2004, the Kenya Ministry of Health (which in 2008 became the Ministry of Public Health and Sanitation [MOPHS]) established the TB/HIV Coordinating Committee to help develop policy and guidance for implementation of TB/HIV collaborative activities. The committee recommended using the existing national TB program infrastructure to expand HIV counseling and testing services† to TB patients. In addition, the committee recommended using provider-initiated testing and counseling, an "opt-out" model in which HIV testing is performed routinely unless the patient declines. Because cotrimoxazole prophylaxis has been shown to reduce opportunistic infections and to decrease morbidity and mortality for HIV-infected TB patients, the committee recommended that TB clinics offer cotrimoxazole prophylaxis to all HIV-infected TB patients (i.e., those with documentation of a positive HIV test result in the facility TB register) (6). Finally, the committee recommended that HIV-infected patients be referred to separate HIV care and treatment clinics for additional HIV care and evaluation for eligibility for ART.§

DLTLD is responsible for overseeing clinical activities at approximately 2,200 TB diagnostic and treatment facilities and for collecting routine surveillance data. Provincial and district TB/leprosy coordinators manage the network of TB facilities. District coordinators receive quarterly reports regarding all patients with active TB disease who are newly registered (i.e., currently diagnosed with active TB disease and receiving TB treatment) at each TB clinic, compile this information into quarterly aggregate district reports, and then forward the reports to the provincial coordinators, who submit the information to DLTLD.

In 2005, DLTLD added key HIV-related information to the local TB facility register and the district-level reporting forms: HIV testing status for TB patients, HIV test results, and receipt of cotrimoxazole prophylaxis, which are available directly from TB clinic records, and information about ART during TB treatment, which generally is based on patient reports of care received at separate HIV clinics (8). By January 1, 2006, all TB districts in Kenya had added these HIV variables to the routine TB surveillance reporting forms. For this report, data collected through the extended TB surveillance system during 2006--2009 were analyzed.

From 2006 to 2009, the total number of newly registered TB patients reported each year decreased 5%, from 115,234 to 110,015 (Table). The prevalence of HIV testing among TB patients increased from 60% (of 115,234 patients) to 88% (of 110,015 patients), and the prevalence of HIV infection among TB patients tested decreased from 52% (of 69,337 tested) in 2006 to 44% (of 96,280 tested) in 2009. In 2009, HIV prevalence among TB patients varied widely by province, ranging from 5% in North Eastern Province to 70% in Nyanza Province (Figure).

Provision of cotrimoxazole prophylaxis to HIV-infected TB patients remained high throughout this period; 87% received cotrimoxazole in 2006, and 92% in 2009. During the same period, the percentage of HIV-infected TB patients receiving ART increased from 26% to 34% (Table).
Reported by

J Sitienei, MD, H Kipruto, Kenya Div of Leprosy, Tuberculosis, and Lung Disease, Ministry of Public Health and Sanitation. L Nganga, MD, M Ackers, MD, J Odhiambo, MD, Global AIDS Program (Kenya). K Laserson, ScD, Center for Global Health, Kenya. AK Nakashima, MD, Global AIDS Program (Atlanta); S Modi, MD, EIS Officer, CDC.

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HIV Testing and Treatment Among Tuberculosis Patients --- Kenya, 2006--2009