Referral Guidelines for TB/HIV co-management. (First Edition)

Transcription

1 Referral Guidelines for TB/HIV co-management (First Edition) Government of Lesotho April

2 REFERRAL GUIDELINES FOR TB/HIV CO-MANAGEMENT INTRODUCTION Many TB patients are infected with HIV. Many people living with HIV fall ill with TB at some point in their lives. Co-infection is the norm, not the exception. Yet co-infected patients often have difficulties accessing needed TB- or HIV-related services in a timely fashion. Though many aspects of TB and HIV care have been integrated into primary care services, there are some aspects of the two programmes that will continue to be vertical. For this reason, clear guidelines about referral between the two programmes are essential. Table 1 lists the roles and responsibilities of each programme for the management of the TB/HIV co-infected patient. Depending on the level of integration at a specific health facility, however, the location where a patient will receive treatment and the staff that delivers that treatment will vary. Table 1: TB programme HIV testing and Counseling TB treatment Cotrimoxazole preventive therapy Treatment of opportunistic infection Initiation of ART HIV/AIDS programme Screening for active TB Diagnosis of active TB Continuation of ART in cured TB patients Isoniazid preventive therapy At district or CHAL hospitals, TB and ART Officers must work together for effective management and monitoring of TB/HIV co-infected patients. It is also essential that the TB and ART Officers meet at least weekly to review the status of referrals and transfers between their clinics, and at least quarterly to review the TB/HIV monitoring indicators. 2

3 MANAGEMENT OF THE TB/HIV CO-INFECTED PATIENTS TB patients who need HIV Care/ART Up to 80% of patients on treatment for TB are co-infected with HIV. All of them require HIV care, which includes HIV counseling and testing, prevention and treatment of opportunistic infections, and initiation of ART. Often, TB patients do not receive these services or receive them later than they should. For example, TB patients may not be offered HIV testing, or are offered HIV testing months after TB treatment has started. A TB patient may not be offered ART even though they are eligible for it under national guidelines. One of the reasons why these problems happen is that TB patients are routinely referred to another facility for HIV Care or ART. Even if the patient is referred to another clinic within the same facility, this may require additional time and expense for the patient, and thus the patient may not receive the services he/she needs. For these reasons, integration of HIV care and treatment services within the TB Clinic is essential. The other reason to integrate services rather than refer between clinics is because TB patients are infectious, and should be separated from other HIV-positive patients who do not have TB. The TB patient, therefore, should receive HIV care and treatment services in the same place where he/she receives TB treatment; he/she should not be referred to any other location, even within the same facility (as in the case of a district hospital). Integration of HIV prevention, care and treatment within the TB Clinic at the district hospital level The TB Clinic should offer HIV counseling and testing to all TB patients who have not already been diagnosed with HIV. It should also offer prevention and treatment of opportunistic infections, provide cotrimoxazole prophylaxis and initiate ART when appropriate 1. All these services will be provided by the TB/HIV nurse and the medical officer. If a TB/HIV nurse is not available, the ART nurse should rotate through the clinic to assist the TB officer in providing these services within the TB Clinic. After the TB patient has completed TB treatment, the TB Clinic should transfer the patient to the HIV Care/ART Clinic. The original ART card should be kept in the HIV Care/ART Clinic, while a copy of the ART card should be kept in the TB Clinic. The date of transfer should be entered in the remarks column against the patient s name in the district TB register as well as on the patient s HIV Care/ART Clinic card. 1 All TB patients who are HIV-positive are eligible for ART and should be initiated on ART within 2-4 weeks of initiation of TB treatment. 3

4 Integration of HIV prevention, care and treatment within the TB Clinic at the health centre level The health centre nurse should offer HIV counseling and testing to all TB patients who have not already been diagnosed with HIV. Since all health centres that provide TB diagnostic and treatment services should also provide HIV care and treatment services, including ART, there is no need to refer TB patients to another facility immediately after diagnosis of HIV coinfection. The health centre nurse should provide prevention and treatment for opportunistic infections as appropriate and initiate ART within 2-4 weeks of initiation of TB treatment. The health centre care provider (health worker) should follow strictly the infection control measures as listed in the IC guideline and IC template plan. HIV Care patients who need TB treatment HIV-positive patients are at high risk for developing active TB. Many patients are diagnosed with HIV when they have advanced immune-suppression. They may have atypical symptoms of active TB and diagnosis of TB may be difficult. Patients with smoldering TB may be started on ART, only to start having TB symptoms as their immune systems awaken. For this reason, routine screening for TB should be intensified at all ambulatory care untis that have TB suspects, including OPD, MCH and HIV services at. There are many TB patients that are missed by health facility staff because they come for other reasons and do not complain about respiratory symptoms. Routine screening for TB, using a standardized TB screening tool as described in the Intensive case finding and the infection control section, will increase TB case-finding and decrease the risk of TB transmission in the clinic at the same time. All patients attending the HIV Care/ART Clinic should be routinely asked about symptoms of TB at every visit. The HIV Care/ART Clinic should identify TB suspects, register them in the TB suspect register and collect sputum specimens for testing. At least three sputum specimens should be taken from each TB suspect, in line with the National TB guidelines. The first sputum specimen should be collected on the spot during the first encounter with the TB suspect. The TB suspect should produce a second sputum specimen early in the morning at home on day 2 (the following day) and deliver this specimen to the clinic. A third sputum specimen should be collected on the spot during the second encounter with the TB suspect on day 2. The first sputum specimen from HIV-positive TB suspects should be split, with half sent for smear microscopy and half sent for either TB culture or GeneXpert testing. The second and third sputum specimens from HIV-positive TB suspects should be sent for smear microscopy only. The attending health worker is responsible for ensuring collection of 3 sputum specimens from every TB suspect, and for sending these specimens to the laboratory for testing. In case of a negative sputum lab testing, a chest X-ray is indicated. All 4

5 laboratory and radiological tests should be ordered from the HIV Care/ART Clinic. TB suspects should not be referred to any other clinic for diagnosis of TB in order to expedite diagnosis of patients and to minimize the amount of time that potentially infectious patients spend in high-risk areas such as waiting rooms. At the district hospital level, the HIV Care/ART Clinic should routinely screen all patients for TB symptoms and diagnose active TB according to National TB guidelines. It is of utmost importance that HIV-positive patients diagnosed with TB initiate TB treatment. This could be achieved through different models of TB/HIV co-management, varying from integration of TB prevention, diagnosis and treatment within the HIV Care/ART Clinic to the implementation of a formal referral system between the HIV and TB services. Where integration of TB treatment within the HIV service is not possible, HIV-positive patients diagnosed with active TB should be formally transferred to the TB Clinic for TB treatment, along with a copy of their HIV Care/ART Cards. A note should be made on the original HIV Care/ART cards and the HIV Chronic Care/ART register of where the patient is transferred to and when. The transferring health care worker should ascertain that the patient reaches the TB Clinic and note this in his/her HIV care/art card. Integration of TB screening, diagnosis, IPT, treatment and infection control within the HIV service at the district hospital level: As is the case for the health center level, HIV services within the district hospitals can offer TB treatment to ensure enrolment into TB treatment and to contribute to TB infection control.. Also comparable with the integration of ART within the TB Clinic is the transfer of data by keeping the TB card within HIV/ART file and entry of the patient s details in the TB register. At the health centre level, the health centre nurse should routinely screen all patients for TB symptoms (i.e. cough of any duration, fever, drenching night sweats and unexplained weight loss) and diagnose active TB with sputum testing and chest x-ray, in accordance with National TB guidelines. There are health centres that provide HIV Care/ART that do not initiate TB treatment. Special efforts need to be made to strengthen the capacity of the local personnel in order to initiate TB treatment in these facilities; in the mean time, such health centres should refer the diagnosed TB cases to the district hospital or to another health centre for initiation of TB treatment. Where TB treatment is initiated in another health facility, arrangements should be made as soon as possible to transfer the patient back to the referring health facility. Otherwise, the health centre nurse should initiate TB treatment as soon as possible by contacting the District TB Coordinator or nearest TB officer for supply of anti-tb drugs for the patient. 5

6 DIFFERENT MODELS OF IMPLEMENTING TB/HIV INTEGRATION Model I: Complete integration within 1 TB/HIV Clinic (or Infectious Diseases Clinic) Model with one-stop service under one and the same roof TB patient VCT, CTX OI, CD4 Integrated TB/HIV Clinic TB officer = HIV nurse ICF/ IPT / Infection control AFB- ART AFB- HIV- TB diagnosis HIV- TB patient TB suspect Unknown HIV status 1. All services are offered in one clinic. 2. No separate HIV Clinic or TB Clinic. 3. The integrated TB/HIV TB Clinic treatment offers services for HIV-positive patients (with or without TB) and/or TB patients (HIV-positive or -negative). AFB- Table 2: Management of the TB/HIV co-infected patient in the model with complete integration (Infectious disease clinic) TB/HIV service HIV counseling and testing Cotrimoxazole preventive therapy Prevention and treatment of opportunistic infections Antiretroviral therapy Isoniazid preventive therapy (IPT) Screening for active TB 6

7 Diagnosis of active TB TB treatment TB Infection control Model II: Integration of TB/HIV C&T within TB and HIV services One-stop shop in both TB and HIV Clinics Integrated TB/HIV Clinic in both the TB Clinic and the HIV Clinic with: 1. Integration of HIV care and treatment within the TB Clinic. 2. Integration of TB screening, diagnosis, IPT, treatment and infection control services within the HIV Care/Treatment Clinic. All services are offered in both clinics. One-stop service provided in two separate clinics with TB/HIV co-management in both. Specific clinic dates can be organized in the HIV Clinic for HIV-positive and TB/HIV co-infected patients, and in the TB Clinic for TB/HIV co-infected patients and HIV-negative TB patients. 7

8 VCT, CTX OI, CD4 TB Clinic/Ward TB/HIV nurse With support from ART nurse HIV Care/ART Clinic ART nurse With support from TB nurse ICF / IPT / Infection control TB diagnosis ART HIV- TB treatment TB patients initiated on in TB Integration Clinic are of ART within TB Clinic can happen under different forms with: ART referred to the ART Clinic prescription, initiation AFBafter completion of TB and follow up by trained TB officer (preferred) treatment. OR prescription, initiation and follow up by ART nurse in support of TB Clinic at pre-defined dates (TB/HIV Clinic within TB Clinic) ART can be stored and dispensed within the TB Clinic (preferred) OR the TB/HIV co-infected patient can obtain ART from the HIV Clinic following prescription obtained from TB Clinic TB treatment Integration of TB treatment within HIV Clinic can happen under different forms with: prescription, initiation and follow up by trained ART nurse within HIV clinic (preferred) OR prescription, initiation and follow up by TB officer in support of ART Clinic at pre-defined dates within HIV clinic (TB/HIV Clinic within ART Clinic) TB drugs can be stored and dispensed within the ART Clinic (preferred) OR the TB/HIV co-infected patient can obtain TB drugs from the TB Clinic following prescription obtained from ART Clinic 8

9 Table 3: Management of the TB/HIV co-infected patient in the one-stop model (integration within TB and HIV service) TB service HIV counseling and testing Cotrimoxazole preventive therapy Prevention and treatment of opportunistic infections TB treatment Initiation of ART HIV/AIDS service Screening for active TB Diagnosis of active TB TB treatment Isoniazid preventive therapy ART, including continuation of ART in cured TB patients TB Infection control Model III: Partial integration with TB/HIV integration in the TB Clinic One-stop shop in TB Clinic only Integrated TB/HIV Clinic in the TB Clinic but not in the HIV Clinic: 1. Integration of HIV care and treatment, including ART within TB Clinic. 2. Integration of TB screening, diagnosis, IPT and TB infection control within HIV Clinic but 3. No integration of TB treatment within the HIV Clinic. 4. Patients are referred from HIV Clinic to TB Clinic to start and continue TB treatment 9

10 TB Clinic/Ward HIV Care/ART Clinic VCT, CTX OI, CD4 ART TB/HIV nurse or ART nurse Health worker TB officer HIV- ART nurse/health worker ICF / IPT / Infection control TB diagnosis ART Integration of ART within TB Clinic can happen under different forms with: After treatment completion prescription, initiation and follow up by trained TB officer (preferred) OR prescription, initiation AFBand follow up by ART nurse in support of TB Clinic at pre-defined dates (TB/HIV Clinic within TB Clinic) ART can be stored and dispensed within the TB Clinic (preferred) OR the TB/HIV co-infected patient can obtain ART from the HIV Clinic following prescription obtained from TB Clinic A strong referral system with a tracking system for PLWHA referred from ART Clinic to TB Clinic is essential in this model. 10

11 Table 4: Management of the TB/HIV co-infected patient in the partial integration modelvice in TB clinic but not on the HIV clinic) TB service HIV service HIV counseling and testing Cotrimoxazole preventive therapy Prevention and treatment of opportunistic infections TB treatment Initiation of ART Screening for active TB Diagnosis of active TB Isoniazid preventive therapy ART, including continuation of ART in cured TB patients TB Infection control Model IV: incomplete integration with strengthened referral linkages in both directions 1. In the HIV Clinic: a. Integration of TB screening, diagnosis IPT, and infection control. b. Patients are referred to TB Clinic for TB treatment. 2. In the TB Clinic: a. Integration of VCT, CTX, CD4 and OI. b. Patients are referred to HIV Clinic for ART. 11

12 VCT, CTX OI, CD4 TB Clinic/Ward TB/HIV nurse or ART nurse Health worker TB officer HIV Care/ART Clinic ART nurse/health worker ICF / IPT / Infection control TB diagnosis HIV- ART After treatment AFB- A strong completion referral system is key to ensure TB/HIV co-management. TB/HIV co-infected patients who are diagnosed with HIV by the TB Clinic must be registered immediately in the HIV Care/ART Clinic, and ART should be initiated within 2-4 weeks of TB treatment initiation. TB/HIV co-infected patients who are diagnosed with TB by the HIV Care/ART Clinic must be registered immediately in the TB Clinic, and TB treatment should be initiated immediately. If the patient is not yet on ART, then ART should be initiated by the HIV Care/ART Clinic within 2-4 weeks of TB treatment initiation. Table 5: Management of the TB/HIV co-infected patient in the incomplete integration model TB service HIV/AIDS service HIV counseling and testing Cotrimoxazole preventive therapy Prevention/treatment of opportunistic Screening for active TB Diagnosis of active TB Isoniazid preventive therapy 12

13 infections TB treatment Initiation of ART for TB patients Continuation of ART in cured TB patients 13

14 TRANSFER BETWEEN CLINICS IN A DISTRICT HOSPITAL As previously stated in these guidelines, TB/HIV patients generally do not need to be referred or transferred from one clinic to another. Offering one-stop service is preferred, both in the TB Clinic and the HIV Clinic. Integration of HIV prevention, care and treatment within the TB Clinic, including ART, will ensure comprehensive treatment and care for TB/HIV co-infected patients within the TB Clinic and eliminate the need for referral from the TB Clinic to the HIV Care/Treatment Clinic. Integration of TB screening, diagnosis, IPT, treatment and infection control within the HIV Care/Treatment Clinic will obviate the need to refer from the HIV Clinic to the TB Clinic. If model IV is adopted, patients need to be referred form the HIV Care/ART Clinic to the TB Clinic after diagnosis of active TB. Once TB treatment is completed, patients should be transferred back again to the HIV Care/ART Clinic for lifelong care. Table 6 lists the indications for transfer within the district hospital: Table 6: Indications for transfer between clinics within a district hospital From TB Clinic to HIV Care/ART Clinic: From HIV Care/ART Clinic to TB Clinic: After completion of TB treatment, the patient should be referred from the TB Clinic to the HIV Care/ART Clinic and be given a copy of his/her HIV Care/ART card and TB treatment card to bring to the HIV Care/ART Clinic. Patients diagnosed with active TB at the HIV Care/ART Clinic should be referred to the TB Clinic and be given a copy of his/her HIV Care/ART Card to bring to the TB Clinic. 14

15 TRANSFER FROM DISTRICT HOSPITAL TO HEALTH CENTRE TB patients are commonly transferred from the district hospital to the health centre, typically after a patient is diagnosed with TB at the district hospital and is to complete TB treatment at a health centre closer to his/her home. TB/HIV co-infected patients should also be transferred to a health centre for completion of TB treatment, but this should be the nearest health centre to the patient s home that can provide both TB treatment and initiate ART. It is critical that TB/HIV co-infected patients be initiated on ART within 2-4 weeks of starting TB treatment. All HIV-related laboratory testing done at the district hospital up until the time of transfer (e.g. HIV test, CD4) should be recorded on the patient s TB treatment card. At the time of transfer from the district hospital to the health centre TB Clinic: A copy of the TB treatment card should be sent to the health centre TB Clinic. The patient should be instructed to take his/her Bukana and a photocopy of his/her TB treatment card to the health centre TB Clinic. The district hospital TB officers / health workers should verify that no losses to followup occur during the transfer and referral process. They are responsible for completing referral/transfer forms, calling the receiving health centre TB Clinic, and tracing patients who do not present to the health centre TB Clinic. 15

16 TRANSFER FROM HEALTH CENTRE TO DISTRICT HOSPITAL All health centers should have the capacity to: diagnose TB according to the national TB Guidelines (see the standard operating procedure for collection and transport of sputum specimens) initiate anti-tb treatment for all sputum smear positive, TB culture positive or GeneXpert positive TB patients provide bacteriological, radiological and clinical monitoring of response to TB treatment Sputum specimens should be collected at the health centre by health centre staff. Riders for Health should transport sputum specimens from the health centre to the district hospital, and sputum test results from the district hospital back to the health centre. TB suspects/cases should not be sent to the district hospital for sputum testing. The health centre should provide newly diagnosed TB cases with TB treatment using the kits that it has in stock. If the health centre does not have a stock of TB treatment kits, the kits should be requested from the district hospital and delivered to the health centre by Riders for Health. TB suspects/cases should only be referred to the district hospital if additional testing that cannot be provided by the health centre is required, including chest x-rays or collection of specimens other than sputum. Once TB is confirmed or excluded at the district hospital, other diagnostic investigations may be conducted at the health centre. 16

17 TB REFERRALS FROM THE COMMUNITY An important way to increase community TB case-finding is to train community health workers to screen community members for TB symptoms. Community health workers should be instructed to refer any person with cough for two or more weeks to the nearest health centre. At the health centre, TB suspects will be entered within the TB suspect register and will be evaluated and investigated as clinically indicated. Many patients defer presenting to the clinic until they are very sick. Community health workers can identify and refer TB suspects, thereby reducing delays in their diagnosis and treatment. Community actors There are a number of community actors that may have contact with a TB suspect/case before a community health worker or health facility staff, and who may have an interest in making sure that these TB suspects/cases receive proper evaluation and treatment. These community actors include: traditional healers, traditional birth attendants and communitybased organizations. In areas where community actors have been trained to recognize TB suspects, they should be instructed to refer them to the health centre through the community health workers. Community Referral Forms The community health worker should fill out a referral form (see Appendix) and accompany the TB suspect to the health centre. The community health worker should also keep a log of all TB suspects referred to the health centre (see Appendix). Note that both the referral form and the log of TB suspects could also be used for non-tb referrals, after the community health worker has been trained to do so. Health centre nurses should maintain a file of community referral forms to provide a record at the health centre of all the TB suspects referred from the community to the health centre for TB screening. Health centre nurses should return the referral feedback slip to the community health workers to confirm that they have seen the referred patient. The community health worker should maintain a file of referral feedback slips so that they can determine who has been lost to follow-up and needs to be again referred to the health centre. Feedback on referrals and losses to follow-up may be provided to community health workers and health centre nurses at monthly meetings. 17

18 Annex 1 Referral guidelines COMMUNITY REFERRAL FORM Name of Client: Age: Sex: Village: Chief: Name and Phone number of contact of client: Date of referral: Name of Clinic: Category of patient: TB suspect TB patient HIV test Pregnancy Malnutrition Other (Specify): Reason for referral: Sputum examination HTC HIV Care/support ART CPT IPT Pregnancy Test Nutrition demonstration/support Other (Specify): Referred by: TBA Traditional healer Community-based organization Community Leader Community member Name of Community Health Worker: Village/Address: Phone number of village Health Worker: 18

19 Annex 2 Referral guidelines SAMPLE PAGE FOR VILLAGE HEALTH WORKER REFERRAL NOTEBOOK Date Name of client Age Sex Village address Name of Clinic Reason for referral / Remarks 19

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