Picture1A recently released report by USAID-funded ‘Strengthening Tuberculosis Control’ project analyses gaps in HIV/TB services in Ukraine. The research was undertaken by the USAID-funded STBCU project (implemented by Chemonics International) and its partner the Global Tuberculosis Institute at Rutgers, the State University of New Jersey (GTBI).

The situation with HIV/TB co-infection in Ukraine remains very serious. UNAIDS reports that TB is the most significant AIDS-related disease and cause of death in Ukraine. In 2012, TB was diagnosed in 5,541 (55%) out of the total 10,085 new AIDS cases. Late presentation for treatment and low ART coverage contribute to AIDS-related deaths in Ukraine. The 2013 WHO Global TB report indicated that 75% of TB patients in Ukraine had documented HIV status in 2012.

The report, TB/HIV CO-INFECTION SERVICES GAP ANALYSIS, presents findings of the comprehensive gap analysis of TB/HIV co-infection services, to assess existing models of referral and collaboration among TB and HIV service institutions and organizations that provide care to patients with a dual diagnosis of HIV/TB in Ukraine. The report reveals that there are both strengths and gaps in management of TB and HIV in Ukraine. The aim of the analysis, conducted in 10 USAID-supported regions (the Autonomous Republic of Crimea, Dnepropetrovsk, Donetsk, Kharkiv, Kherson, Lugansk, Odessa, Zaporizhzhia, and the cities of Kyiv and Sevastopol), was to develop observations and recommendations for institutional and practical improvements to enhance TB/HIV collaborative activities at the regional level.

Integration of TB/HIV health services: significant variability at the oblast level

The TB/HIV health services are provided by two separate systems in Ukraine – the TB Department and AIDS Centers. The TB facilities and AIDS Centers at the oblast level have attempted to address the co-infected TB/HIV individuals attending the two services in the simplest possible referral manner within the two complex operational systems.

There is significant variability in integration of TB/HIV services within the project’s 10 target regions. For example, some locations offer coordinated care with ARVs available at TB facilities (based on the “one stop shopping” principle with infectious disease (ID) specialists, ARVs and laboratory tests available onsite), while in other facilities patients have to go to multiple departments to obtain services and medication. Coordinated care is more likely to be available at the central level or in oblast centres, and much less likely to be available at the rayon level. At the oblast level and their main cities, TB facilities have access to an infectious disease specialist onsite, and AIDS Centres have access to a TB specialist, though the mechanism for this access and frequency of visits vary.

Some remote rayons and towns do not provide sufficient access to TB/HIV co-infection services. This includes services such as CD4 count, viral load, ART and Opioid Substitution Therapy (OST). Often patients need to travel to the oblast centre for HIV testing which results in delays in diagnosis and treatment. Additionally, limited access to services at the rayon level contributes to default during the outpatient phase of TB treatment when patients leave oblast city centre TB dispensaries to more remote towns.

The use of rapid tests for HIV in TB patients in outpatient phase is very limited. This may be due to lack of capacity for health care providers in terms of pre- and post-counselling or lack of understanding of the advantages of rapid testing for effective management of TB/HIV co-infected patients and improved impact on patient outcomes. In many sites, this is attributed to the fact that TB institutions are not part of Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) programs that supply express-tests and provide training to the personnel.

Ukraine has no national-level TB/HIV co-infection indicators. They differ by regions. This does not allow for comparing and analyzing indicators at the central level. Data for local indicators are collected sporadically, the data may remain unanalysed, and the conclusions are not always brought to the attention of the oblast health administration.

Potential of non-government organisations in providing TB/HIV support services

NGOs’ potential in providing TB/HIV patient support is not fully realized. Specifically, mobile primary healthcare points provided by NGOs (which provide screening for STI, HIV and Hepatitis C Virus among vulnerable groups) are not significantly involved in the coordinated TB/HIV care effort including TB screening and follow up for co-infected patients.

There are no regulations that describe and direct the collaboration between TB, HIV and primary health care (PHC) facilities or non-governmental organizations (NGOs) that provide support to people living with HIV (PLWH). This results in developing local orders at the regional level which do not cover every aspect of TB/HIV collaboration and/or do not take into consideration the role of PHC facilities.

Barriers to care

Barriers to care exist for patients in diagnosis and treatment of TB/HIV. These include difficulty in obtaining necessary diagnostic tests (cost, transportation, and difficulty accessing multiple sites), lack of knowledge or inaccurate understanding, fear of stigma and discrimination at health care facilities, and lack of access to substitution treatment onsite at inpatient TB and HIV sites.

Barriers also exist for continuation of care including ART and completion of TB treatment after discharge from inpatient facilities, especially for patients from smaller towns.

Recommendations
The report presents the best practices and successful approaches from the project’s 10 target regions and lessons learned that can inform developing plans and approaches to improve both TB and HIV management practices in Ukraine.

The key recommendations include:

– Develop National order on collaboration between TB, HIV and PHC facilities, including protocols on referral.

– Review National order on TB with respect to diagnosis and treatment of TB in people living with HIV or AIDS and revise as needed to include appropriate guidance on diagnosis and treatment of extra-pulmonary TB.

– Review the Law of Ukraine “On combating HIV-related diseases and on legal and social protection of PLWH” to consider the possibility for information exchange between health professionals (TB specialists, HIV specialists and family doctors), specifying the situations where this information must remain confidential and when it can be shared.

– Develop and implement a TB/HIV training plan which includes clinical and programmatic content for TB specialists, HIV specialists and primary healthcare providers.

– Decentralize TB/HIV co-infection services. Using ARV decentralization as an example, steps should taking to consider TB/HIV care decentralization with creation of the TB decentralized sites with special focus on coordination with ARV specialists.

– Expand the involvement of primary healthcare providers in TB/HIV detection and management.

– Explore options for electronic data transfer and referral system to replace paper and telephone based system where possible

– Develop unified indicators common for TB and HIV specialists, for effective monitoring and evaluation.

– Identify approaches to cover the need for ART and co-trimoxazole. One potential method is to improve and increase the government’s collaboration with international projects.

– Use rapid tests for HIV diagnostics in TB patients at the outpatient stage and at the consultation appointments with TB specialists, supported by appropriate legal framework. This should include use of second rapid test to confirm diagnosis.

– Administer IPT by HIV specialists.

– Use the capacities of mobile primary healthcare sites of the NGOs for TB/HIV co-infection support, HIV testing and sputum collection.

– Improve monitoring of TB/HIV patients referred to different facilities. Ensure availability of contact information of both services. Internal orders should be issued by facilities to maintain feedback between the services.

– Involve NGO resources to TB/HIV patient follow-up and support, informing persons from risk groups about TB/HIV issues, referral of clients suspicious for TB/HIV co-infection for diagnostics and treatment.

– Increase access to diagnostics for extra-pulmonary TB, including CT scans and MRI’s;

– Ensure access to psychological services and substitution management therapy for patients with TB/HIV during inpatient stays.

– Develop a policy or amend current policy for health care worker safety to include NGO workers who will be working with TB patients.The report also underlines an existing potential to involve both primary health care facilities and NGOs to improve access to care for patients.

The full text of the report is available here: