Abstract
Ninety-two clinics were surveyed in 2005 as part of a baseline assessment of HIV activities in Tuberculosis (TB) clinics in Kinshasa, Democratic Republic of Congo. Some HIV activities were implemented in 58% of TB clinics. The majority of health had ≥ 1 health care worker (HCW) trained in either HIV counseling or testing (71%). Fifty-three clinics offered counseling and testing to TB patients; twenty-two (42%) routinely offered HIV CT to all patients, while others used selective criteria. While most offered on-site counseling (92%) and testing (77%), not all 53 clinics had a HCW trained in counseling and only 31 had access to a counseling room. Cotrimoxazole prophylaxis was offered in 51% of clinics; antiretroviral treatment in 17%. Shortcomings in human resources, infrastructure and quality of services were revealed. Strengthening those clinics already implementing HIV activities could be prioritized to achieve the goals set forward by the Global Plan to Stop TB.
Introduction
Tuberculosis (TB) and HIV infection coexist in many people worldwide, especially in sub-Saharan Africa. In 2006, there were 9.2 million new TB cases, of which 700,000 were co-infected with HIV; and 1.7 million TB deaths, of which 200,000 were attributable to HIV co-infection. 1 The Democratic Republic of Congo (DRC) is ranked as the 10th highest globally burdened by TB, with approximately 237,000 new cases annually, of which 9.2% are estimated to be HIV co-infected. 2 The DRC national TB programme, which was officially launched in 1980, coordinates more than 900 TB diagnosis and treatment clinics in roughly 515 health districts countrywide, and has successfully implemented the directly observed treatment strategy (DOTS). 1
The astounding scale of the dual TB/HIV epidemics demands urgent action and the expansion of TB activities beyond DOTS. In response to a request for guidance on which TB/HIV activities to implement and under which circumstances, the World Health Organization (WHO) published several key documents such as the Interim Policy on Collaborative TB/HIV Activities and the Guide to Monitoring and Evaluation for Collaborative TB/HIV Activities. 3,4 The monitoring and evaluation (M&E) guide recommends that, prior to the large-scale implementation of activities, data should be collected in order to provide the background information on which to base future activities. Data on the disease burden and the broad environmental, political and socioeconomic situation, which may help explain changes in indicator values and assist in their interpretation, are often available from other sources, such as the Demographic Health Surveys, WHO and UNAIDS documents. An initial analysis is necessary in order to compile a baseline record of activities and services which will allow programmes to respond to local needs and capabilities, and which will enable the M&E of the progress made towards reaching the programme targets following the implementation of any new activities.
As part of a larger project aimed at reducing the burden of HIV among patients with TB in Kinshasa, DRC, such a baseline assessment was performed of the collaborative TB/HIV activities in the area. The full project consists of five phases. In phase I, a pilot study was conducted which compared the uptake and perceptions of the different models of HIV counselling and testing (CT) for patients with TB. The results were presented during a workshop with health-care workers (HCWs) and stakeholders. At this meeting, the routine provider-initiated HIV CT model for patients with TB was selected as the preferential model for large-scale implementation. In phase II, all clinics providing care for patients with TB in Kinshasa were surveyed in order to identify the human and infrastructural capacity requirements needed for the collaborative TB/HIV activities. In phase III, training needs were assessed, performance-based training materials developed, and HCW were schooled in the necessary knowledge and skills. In phase IV, routine provider-initiated HIV CT was established in 14 TB clinics to determine if there were any barriers to the large-scale implementation of routine HIV CT and to measure the programme's impact. In phase V, antiretroviral treatment will be integrated into the TB clinics. We report on phase II, the baseline assessment of collaborative TB/HIV activities at TB clinics in Kinshasa, DRC.
Methods
All 92 TB clinics in the city of Kinshasa were surveyed on site between March and May 2005 using a structured questionnaire developed in collaboration with the DRC national TB programme (the questionnaire can be requested by email). It contained 66 questions, including multiple choice and open-ended questions, and was administered in face-to-face interviews by eight trained research staff. The first part solicited information on the health-care centres in which TB clinics are integrated and focused attention on the human resources, training of HCWs in HIV CT, and the workload of the TB clinic. The director of the health-care centre was interviewed in order to complete this part of the questionnaire. The second part of the survey contained questions about the existence and characteristics of the HIV CT and other collaborative HIV activities for patients with TB during the year prior to the survey. Each clinic was also asked to provide the number of patients offered or recommended HIV CT among the 30 most recently registered TB patients at the time of the survey. The TB clinic staff was interviewed in order to complete this section of the questionnaire.
The data were entered in an Excel spreadsheet and subsequently exported to STATA version 9 for descriptive analyses. A linear-risk regression model was used to evaluate the relationship between the presence of HCWs trained in HIV CT and the use of HIV CT at the TB clinics. The characteristics of the clinics, including clinic type (primary, hospital and private), number of TB staff, and the availability of physicians were evaluated as potential confounders. Assumptions of constancy were evaluated using stratified analyses and Wald's chi-square test for homogeneity, confounding was analysed using backward selection and change in estimate effects. Covariates that resulted in a > 5% change in prevalence difference (PD) estimates were retained in the final multivariate model.
Results
Human resources for collaborative tuberculosis/HIV activities
Table 1 provides an overview of the human resources at the 92 health centres stratified by clinic type. The majority of the TB clinics was integrated in primary health-care centres and had one or two HCWs involved in TB patient care. Only half (51%) had access to a physician on site for one to five times a week. Most health centres (75%) had at least one of their HCWs trained in HIV counselling or testing (71% in HIV counselling and 60% in HIV testing); 34% had three or more HCWs trained in counselling (data not shown).
Human Resources for HIV activities in 92 TB clinics in Kinshasa, according to clinic type, surveyed during March and May 2005
TB, tuberculosis; HCWs, health-care workers; HIV CT, counselling and testing for HIV
aPhysician reported to be available on site at least one day per week
Activities to decrease the burden in TB patients
Fifty-three (58%) TB clinics reported offering or recommending HIV testing to patients with TB during the year preceding the survey. The proportions of TB clinics offering or recommending HIV CT did not differ by type of TB clinic – those integrated in primary health-care centres (60%), hospitals (55%) or private clinics (43%). Figure 1 shows the proportion of patients with TB who were offered CT, from the 30 most recently registered patients. Overall 32% (870 of the 2760 TB patients) had been offered or recommended HIV CT.
Proportion of TB patients offered HIV counseling and testing in 92 TB clinics, Kinshasa, DRC 2005. Proportion calculated among the 30 most recent registered patients with TB at each clinic at the time of the survey. Denominator was calculated as maximum of 780 TB patients registered over the 92 clinics for an overall proportion of 28%
Table 2 highlights the characteristics of the 53 clinics that offered or recommended HIV CT to patients with TB. Twenty-three of the 53 (43%) clinics routinely offered CT to all patients with TB, while the others used selective criteria such as the suspicion of an HIV infection, the lack of response to TB treatment and a history of TB treatment. Forty-one (77%) clinics offered on-site HIV testing, and 49 (92%) offered on-site counselling (either at the TB clinic or the health centre), even though 31% did not have access to a counselling room. Approximately one in four (26%) clinics charged patients for the HIV test. Only one clinic asked patients to make a financial contribution for HIV pre-test counselling. HIV CT was usually offered at the start of the TB treatment (83%) and the patient was informed of their HIV results after a mean of one to three days. HIV test results were typically discussed by the patient and the TB nurse (31%) or physician (62%). The majority (87%) of TB clinics informed patients of their HIV result, and recorded the results in a non-standardized notebook (55%).
Characteristics of services at 53 TB clinics implementing collaborative TB/HIV activities in Kinshasa, Democratic Republic of Congo in 2005
HIV, human immunodeficiency virus; TB, tuberculosis; HCW, health care worker; CT, counseling and testing
aClinics may use more than one criteria
bMissing data, percentage calculated based on centers with data available
cClinics may record in > one place
dPatients may be offered/referred > one form of care, treatment, or support
Some clinics (30/53) offered care to, or referred HIV co-infected patients with TB for care, treatment and support, including cotrimoxazole prophylaxis (51%), nutritional support (28%), psychosocial support (13%) and antiretroviral treatment (17%).
The impact of training health-care workers in HIV counselling and testing
Most of the health centres that offered HIV CT to patients with TB had at least one HCW trained in CT. However, 17% did not have any HCWs trained in counselling and/or testing; one in four (23%) did not have anyone trained in HIV counselling; and one in three (32%) did not have anyone trained in HIV testing. The TB staff at clinics that offered HIV CT was more often trained in counselling (53%) rather than testing (25%). Among the 39 TB clinics that did not offer or recommend HIV CT to their patients, 25 (64%) had one or more HCWs trained in HIV counselling and/or testing, of which 11 had a TB HCW (nurse or assistant) trained in HIV CT. Overall, the prevalence for offering HIV CT to patients with TB was 64% in clinics where at least one HCW was trained in counselling and/or testing compared to 39% in clinics where none of the HCWs was trained in HIV CT. The prevalence of HIV activities at TB clinics was highest among those clinics with TB staff trained in HIV CT (73%). There was a positive association between the presence of trained HCWs and the recommendation for HIV CT of patients with TB (crude PD = 25%; 95% confidence interval [CI] 2–48%). The strength of association did not change when the analysis was restricted to the presence of trained TB staff (crude PD = 26%; 95% CI 7–46%), or when adjusted for potential confounders such as clinic type and physician availability (adjusted PD = 22%; 95% CI 2–46%).
Discussion
This situation analysis demonstrated that, as of mid 2005, and prior to the receipt of financial support from the Global Fund for the implementation of collaborative TB/HIV activities, some HIV activities had already been implemented in more than half (58%) of the TB clinics in Kinshasa, DRC. At the time of the survey, an estimated one in four TB patients was offered or recommended HIV CT, and half of HIV co-infected TB patients had access to cotrimoxazole prophylaxis. Many gaps in human resources, health service infrastructure and quality of services were, however, revealed.
Our survey identified both a shortage of HCWs trained in HIV CT and an underutilization of trained staff: 25 centres with HCWs trained in HIV CT were currently not offering HIV CT to patients with TB – a gross underutilization of human resources – but nine clinics were reported to engage in collaborative TB/HIV activities but lacked the trained staff. The required number of counsellors per health centre has not been established, but a sufficient number is essential to ensure the appropriate pre- and post-test counselling. In our survey, the majority of centres had at least one HCW trained in HIV counselling, but only 33% had three or more. The majority (83%) of clinics offering HIV CT had an HCW on site trained in HIV CT, but only 55% of the TB clinics had TB staff on site trained in HIV counselling and/or testing.
Many countries have reported insufficient staff to achieve the WHO targets for TB control of 70% case detection and 85% cure. 1 As collaborative TB/HIV activities are only beginning to be implemented in most countries, it is unclear to what extent the implementation of these new activities will require increased numbers of trained health-care workers at TB clinics. A study in Malawi found significant deficiencies in the quantity and quality of staff required to cope with the burden of the TB/HIV epidemic. 5
Our survey identified many other shortcomings of HIV activities at TB clinics. The majority of clinics used selective criteria for offering HIV CT, such as a clinical suspicion of HIV, TB treatment failure or relapse, and only 42% of clinics offered routine HIV CT to all patients. Many (40%) clinics did not have access to a counselling room. One in four clinics charged patients for their HIV test, and one clinic even charged for HIV counselling thus creating a financial barrier to the uptake of HIV testing. Thirteen percent of TB clinics were not informed of the HIV result, and there was no standardized recording system. These shortcomings have a significant effect on public health. Insufficient numbers of adequately trained staff can lower the numbers accepting CT, and lead to substandard HIV CT testing practices. 4 Limited infrastructures can cause problems for patients, due for example to the cost of travel, and can mean that counselling in a private setting is unavailable. It also represents missed opportunities for the provision of care, treatment and support. The lack of standard TB registers and TB treatment cards that capture HIV activities hamper effective M&E.
Several limitations to the study should be noted. First, whilst this survey comprehensively assessed the 2005 situation in Kinshasa, no TB clinics outside of the capital were included. Second, we only assessed the number of HCW trained, not the quality of their training or the quality of the CT given. We did not ascertain whether HIV CT was being conducted equitably, with consent and with the necessary confidentiality. Lastly, we estimated the number of patients offered HIV testing as reported by the HCWs but not the proportion tested, nor the proportion of patients who had received their results. We assessed the access to care, but did not evaluate the numbers of HIV-infected individuals who were actually receiving cotrimoxazole prophylaxis or other care, treatment and support.
The Global Plans' ‘ambitious but realistic’ targets for the African regions with high HIV seroprevalence (≥ 4%) include the requirement that 51% of TB patients in DOTS programmes should be counselled and tested for HIV by 2006 and 85% by 2010. 6 They also state that 45% of HIV co-infected TB patients should be receiving antiretroviral treatment by 2006, and 59% by 2015. The Global Plan acknowledges that the major constraints preventing these targets being met in many African countries will be the poor health-care systems – for example, inadequate infrastructures, inadequate access to health-care facilities, insufficient numbers of staff and poor development of the human resources, insufficient and substandard laboratory services, and limited links between national TB programmes and HIV programmes as well as with other public and private health-care providers. 6 This study confirmed the need for significant investments in human resources and health facility infrastructures if the targets set by the new Global Plan to Stop TB are to be achieved.
Conclusion
In 2005, one in four TB patients were tested for HIV in Kinshasa, but many shortcomings were identified and opportunities for care, support and treatment for people living with HIV/AIDS were limited. The major barriers to the success of the programme are: weak health-care systems insufficient numbers of HCWs trained in HIV CT the inefficient use of skilled staff limited availability of counselling rooms the poor access to care and support for people living with HIV/AIDS.
Prioritizing the need to build on and improve the service provided by the clinics already implementing HIV/TB collaborative efforts, may make it possible for the DRC National TB and HIV programmes to achieve the 2006 Global Plan to Stop TB targets in Kinshasa. This will require the effective and dynamic collaboration of the National TB and HIV programmes within the DRC, and the mobilization of domestic and external resources.
Footnotes
Acknowledgements
Funding was provided by the Centres for Disease Control and Prevention, Atlanta (UNC-GAP project CDC U62 CCU422). We are grateful to the interviewers and the HCWs of the TB clinics in Kinshasa. We also thank Martine Tabala, Felicien Llenda, Richard Mangala, Willy Atungi, Lisette Kapinga, Adel Mumpassi and Eugenie Mugoyo for their support. Without their enthusiasm and dedication this study could not have been carried out.