Management of patients with TB/HIV Gunta Kirvelaite

Management of patients with TB/HIV Gunta Kirvelaite Riga East Clinical hospital, Centre for tuberculosis and lung diseases. Head of outpatient department. MDR TB physician. WHO Collaborating Centre for Research and training in Management of MDR TB Latvia

Plan of presentation Models of outpatient care for TB and TB/HIV patients. Directly observed treatment therapy. Adherence, defaulters tracing in TB control. Role of multidisciplinary team. Collaboration between doctors TB/HIV/IDU and social services.

Models of outpatient care for TB and TB/HIV patients. Directly observed treatment therapy. Adherence, defaulters tracing in TB control. Role of multidisciplinary team. Collaboration between doctors TB/HIV/IDU and social services.

Models of patient care Hospitalization for all treatment time (hospital-based inpatient treatment). Hospitalization during TB intensive phase/ ambulatory treatment for continuation phase. Clinic-based ambulatory treatment (patients attend a health-care facility). Community based ambulatory treatment (provided by a worker in the community). Home based treatment (treatment at patients home provided by medical worker). with short hospitalizations if there is a real need

Patients with TB/HIV and MDRTB should be treated using mainly ambulatory care rather than models of care based principally on hospitalization. Given the specialized care required for the cotreatment of PLHIV with MDRTB, hospitalization for the first 2 weeks of co-treatment would simplify monitoring for overlapping toxicities and side effects, provided that these patients can be isolated while hospitalized. This approach should be weighted against the risk of increased nosocomial transmission in particular in high HIV-prevalent settings. For this reason, outpatient management and community models should be included into the TB and HIV programs.

PLHIV potential exposure to people who are infectious can be minimized by reducing or avoiding hospitalization where possible, reducing the number of outpatient visits, avoiding overcrowding in wards and waiting areas, prioritizing community-care approaches for TB management.

Specialized inpatient ward for sick and complicated patients Community-care approach: roles and responsibilities Outpatient clinic for stable patients Community based care provided by trained lay and health care workers can achieve comparable results and may result in decreasing nosocomial spread of the TB. Health centre Provide injections in some cases, manage minor side effects, follow up contacts Treatment supporter Supervise doses including injections at health centre, provide injections (in some cases), record doses, accompany the patient to all medical consultations, screen the patients family for HIV and TB The patient Hold monthly box of drugs, takes doses under supervision of supporter, attend monthly consultations

Treatment supporter: local health centre nurses, paid or in some cases volunteer; CHWs; former and current patients; associations; local NGOs; community volunteers and others. With an efficient network for community-based care, the patient will be able to return to ambulatory treatment sooner, resulting in less nosocomial transmission, reduced hospitalization.

Models of outpatient care for TB and TB/HIV patients. Directly observed treatment therapy. Adherence, defaulter tracing in TB control. Role of multidisciplinary team. Collaboration between doctors TB/HIV/IDU and social services.

We cannot predict who will take medications as directed, and who will not People from all social classes, educational backgrounds, ages, genders, and ethnicities can have problems taking medications correctly.. Anyone can forget or neglect to take their medications Studies show that 86-90% of patients receiving DOT complete therapy, compared to 61% for those on selfadministered therapy.

This approach was first adopted in studies in Madras, India, and Hong Kong as early as the 1960s (Bayer 1995), and a number of specialists now widely recommend DOT for the control of tuberculosis (Bass 1994;Maher 1997; Chaulk 1998; Enarson 2000). Indeed, Frieden and Sbarbaro state that it is essential and that it prevents relapse occurring and drug resistance developing (Frieden 2007).

TB treatment can seem difficult -- it requires taking 2-4 or more medicines for at least 6 months. Most people have trouble remembering to take their medicines, or they stop taking their medicines when they start to feel better. When this happens, a person with TB could get sick again, and the TB germs could become resistant to the medicines. Given the duration of treatment of MDR- and XDR-TB (18 24 months), and the large number of pills and multiple dosing times necessary for concomitant treatment TB/HIV, a high level of commitment from both the HCW and patient is required.

Treatment for TB and cure from TB Treatment for PLHIV Responsibility falls upon medical people due to fact that TB is airborne transmitted. Not transmitted by air. It is patient s responsibility to take medicine or not.

What is DOT? DOT=Directly Observed Therapy=a health care worker or other designated individual watches the patient swallow every dose of the prescribed TB drugs ( supervised swallowing ). It is recommended that all TB cases be on DOT. DOT is especially critical for HIV-infected patients and patients with drug-resistant TB. This observation helps ensure that the correct dosage of the drug is taken at the right time, and also that patients do not sell their drugs.

DOT works best when used with a patient centered case management approach, including such things as: helping patients keep medical appointments; providing ongoing patient education; offering incentives and/or enablers; connecting patients with other specialists consultations and social services or transportation. Case management is a patient-centered strategy. Co-management of patients on ART and MDR/XDR-TB is complicated, and for this reason it is essential that HCWs are trained to recognize potential and additive toxicity due to the concomitant regimens.

Who can deliver DOT? It is important that DOT be carried out at times and in locations that are as convenient as possible for the individual patient. Therapy may be directly observed in a medical office or clinic setting, but can also be observed by an outreach worker in the field (e.g., patient s home, place of employment, school, LTHC, HRP or other mutually agreed-upon place).

What does the DOT worker do? DOT includes: verifying -- is medication given to correct person delivering the prescribed medication checking for side effects watching the patient swallow the medication documenting the visit answering question giving support (emotional, psychosocial, material)

Directly Observed Therapy (DOT) Each case is closely monitored 18

There may be some important barriers to accessing clinic-based ambulatory care, including distance to travel and other costs to individual patients. Shifting costs from the service provider to the patient has to be avoided, and implementation may need to be accompanied by appropriate enablers.

Enhanced case management Care Assess Teach Enhanced case management (ECM) a seamless care having both clinical and psycho-social care elements; Manage TB/HIV patients--- with complex needs--- are offered ECM.

Material support Full treatment free of charge; No charge for HIV, TB and an ancillary drugs. An enablers to tackle the material barriers to delivery and intake of the drugs Nutrition Cooperation agreements with the Riga Municipality Welfare Department Transport compensations from and back to home (2 $) Coupons for food (2 $) 22

The ambulatory head nurse Supervise patients tracing back process in all department DOT office nurses Responsible for reporting about patients who did not came at DOT office until the end of each day The office nurse The DOT provider at home Responsible for patient tracing back management in Riga The nurse s assistant The training nurse DOT office 24

Weekly team meeting Every office nurse reports about non adherent patients during the last week Each case is discussed separately: What was done? Which team members were involved in problem solving? The result: is positive or no? What else is possible to do in each case? 25

It is reasonable also to provide DOT for both antitb medications and ART, with the notion that DOT is just one element of a package aimed at improving adherence to treatment. Elements of the package include disease education, socioeconomic interventions, psychological support and management of side effects. Recommendation for TB and HIV programmes should coordinate their efforts to provide a patient-centred package to improve adherence.

People living with HIV and diagnosed with drug-susceptible or drug-resistant TB should be regarded as eligible for ART regardless of CD4 count. ART should be started as soon as possible after initiation of TB or M/XDR-TB treatment. These recommendations are both included in the 2010 WHO ART guidelines and in the WHO guidelines on programmatic management of MDR- TB update 2011. How to manage it all together, especially in case of IDU?

ECM is coordinated by the named case worker and delivered by a multidisciplinary team Patient centered close cooperation TB physician HIV specialist Narcologist TB consilium for DRTB ART consilium DOT provider at home training nurse psychologist office nurse DOT nurses in DOT cabinets TB drugs &ART methadone harm reduction social worker Municipality Welfare Department nurse assistant for patients tracing back 29

Summary What is DOT and how does it work? DOT means that a health care worker meets with a person who has TB to help him or her remember to take the medicines to treat TB (and, may be---hiv?). The health care provider watches the patient take each drug dose. DOT is convenient and easy to arrange, and --- it can fit into your daily routine. Staff motivation and supervision: training and management processes that aim to improve how providers care for people with tuberculosis.

Reminder systems and late patient tracers in the diagnosis and management of TB: routinely reminding patients to keep an appointment and actions taken when patients fail to keep an appointment Education and counseling for promoting adherence to the treatment of active TB: provision of information or one-to-one or group counseling about TB and the need to attend for treatment Incentives and reimbursements: money or cash in kind to reimburse expenses of attending services, or to improve the attractiveness of visiting the service. Contracts: written or verbal agreements to return for an appointment or course of treatment Peer assistance: people from the same social group helping someone with TB return to the health service by prompting or accompanying them.

References: 1. Management of HIV-infected patients with MDR and XDR-TB in resource-limited settings F. Scano,at all INT J TUBERC LUNG DIS 12(12):1370 1375 2008 2. Management of MDR TB: A field guide. PIH_WHO_2008 3. Interactive Core Curriculum on Tuberculosis (Web-based), CDC, 2004 www.cdc.gov/tb/webcourses/corecurr/index.htm 4. DOT Essentials: A Training Curriculum for TB Control Programs, Francis J. Curry National Tuberculosis Center, 2003