Vietnam| TB/HIV Collaborative-Thai Binh Province
To pilot-test a model for TB/HIV integration activities at the provincial level in eight districts of the Thai Binh Province in Vietnam and to promote partnerships between the TB program and other public and private health providers in order to maximize coverage of the DOTS program.
The NTP asked HCI to work in Thai Binh Province in April 2007 due to high TB/HIV co-infection rates and the lack services for this population. A rural province, Thai Binh, has a population of over 1.8 million people. The prevalence of HIV infection among adults aged 15–49 years was estimated to be around 0.3% in 2005 and in September 2006, it was reported that 2188 people had been found to be HIV positive. Annually, approximately 1600–1800TB cases are detected, and of them, 1100 were new smear-positive cases. HCI, in collaboration with National Target Program (NTP) and Thai Binh Department of Health (DOH), developed an 18-month work plan to pilot-test a model for TB/HIV integration activities at the provincial level and in all the eight districts in the province. HCI also supported strengthening partnerships between the TB program and other public and private health providers in order to maximize coverage of the DOTS program. A number of activities were planned for the collaborative to expand TB/HIV integration, these included efforts for: policy development; capacity building; maintaining the continuum of care; quality assurance of services; support for public and private partnerships; strengthening the monitoring and evaluation system; and conducting information, education, and communication activities.
The key measurements for the collaborative followed the standardized package of TB/HIV services to monitor levels of provider initiated counseling and testing, voluntary counseling and testing, and treatment and care. These measures included the following:
• The proportion of patients with TB receiving HIV counseling
• The HIV testing rate among patients with TB
• TB screening rates among people with HIV
• Case detection rates of TB/HIV patients
At the national level, HCI assisted the MOH (NTP and VAAC) to develop a national framework, guidelines, and training modules on TB/HIV integration. At the provincial level, HCI supported the province in disseminating TB/HIV guidelines among TB and HIV health facilities. In addition to the above, a referral system was established between TB and HIV/AIDS programs. Referral and feedback forms were developed and implemented in all public TB and HIV health facilities.
The collaborative work was done in eight districts of the Thai Binh Province in Vietnam, which has population of 1.8 million people.
HCI worked with the DOH to establish a collaborative mechanism (“the TB/HIV Collaborative”) for improving TB/HIV management. A provincial TB/HIV task force was established to promote collaboration between TB and HIV program managers. Chaired by the DOH, the task force met monthly to lead the quality improvement process for TB/HIV integration in the province. Coaching visits were provided to the sites to support technical work as well as QI implementation.
At the beginning of the project, HCI conducted TB/HIV training for provincial trainers from ten provinces being supported by the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), including Thai Binh. HCI, in collaboration with the GFTB program, also provided training on the TB/HIV Collaborative to TB and HIV health workers in the province. Sixty health workers from all provincial and district TB and HIV facilities in Thai Binh were trained on HIV counseling and testing. In addition, general practitioners working at out-patient clinics of public health facilities and private general practitioners practicing in the province were trained on TB and the referral system. Training on TB case detection and treatment and the TB/HIV Collaborative was provided to communal heath workers from three districts (Dong Hung, Kien Xuong, and Thai Binh City). All district TB control teams have been reorganized under the district preventive medicine centers, with technical support from general hospitals. A re-training course for health workers was organized with the purpose of enhancing skills and capacity in TB detection, TB diagnosis and management, and TB/HIV integration activities. HCI later provided two training courses on infection control for all staff of the provincial TB hospital and health workers from TB control teams and infectious diseases departments of all districts.
After 18 months of implementation, the standardized package of TB/HIV services, including provider initiated counseling and testing, voluntary counseling and testing, and treatment and care, was available in all the participating district health facilities. The proportion of TB patients receiving HIV counseling increased remarkably, to 99%, compared with the baseline of 47%. The HIV testing rate among TB patients also increased from 38% to 90%. TB screening was provided to 563 people with HIV during the project period, yielding TB diagnosis in 16% of screened people. With these improvements, the case detection of TB/HIV increased considerably, from only 33 patients in 2006 to 66 in 2007 and 77 in the first three quarters of 2008. The HIV prevalence among all TB patients increased from 1.9% in 2006 to 3.7% (66/1774) in 2007 and 5.4% (77/1421) in 2008 (data from first three quarters). Apart from the quality improvement of TB/HIV services, the interventions contributed to a significant improvement in overall TB case detection. The overall TB notification rate increased from 93 per 100,000 population in 2006 to 97 in 2007 and to 104 in 2008.
Quality of services has been enhanced through capacity building as well as the use of QI tools. The key indicators are tracked at facility, district, and provincial levels on a regular basis to show trends in uptake as well as quality of services. Results of the data review are used for problem solving at all levels. This routine monitoring has resulted in:
• Uninterrupted availability of HIV test kits to improve the HIV testing rate among TB patients
• Establishment of additional VCT sites in areas where services are most needed
• Implementation of prophylaxis for opportunistic infections (OIs)
• Referrals of co-infected patients