This activity relates to the following activities: #9032, #9017, #8819, #8992, #9006, #9046, and #9010.

HIV in sub-Saharan Africa is causing an increase in incidence and prevalence of HIV-related tuberculosis (TB), with 75% of incident TB cases occurring in HIV-infected individuals. TB/HIV integration in the Lusaka district will build on the progress achieved in 2006 by strengthening and expanding TB/HIV integration activities. Available data confirms that 60-70% of TB patients in Lusaka district are HIV-infected, and 80% meet eligibility criteria for immediate ART.

When the MOH began opening HIV clinics in 2004, the immediate and overwhelming demand for care and treatment hampered the ability to integrate HIV care with other services. Even though co-infection rates were high, adequate systems were not in place to encourage TB patients to learn their HIV status or to refer dually infected patients from the TB clinic to the ART clinic. As a result, two vertical systems continue to exist within each health facility and movement between these two vertical systems is complicated and many co-infected patients do not receive the coordinated care they need or are lost to follow-up. Encouraging TB patients to learn their HIV status and integrating services is essential to improving clinical outcomes of co-infected patients.

Lusaka Province has 4 districts. Lusaka district is an urban district and notifies more than 90% of the TB cases in the Province, and one-third of the national cases. The other 3 districts are mainly rural. The USG has funded CIDRZ to provide technical and financial support to the Lusaka District for the implementation of TB/HIV activities. In FY 2007 the USG will provide direct support to the Lusaka Province Health Office to scale up TB/HIV activities in the remaining 3 districts.

Through a partnership with CIDRZ in FY05 and FY06, a number of TB/HIV integration activities were introduced and piloted at two Lusaka district clinics. Initially, 30 staff in two district clinics involved in TB/HIV care were identified and trained in the rationale for service integration. In separate trainings, TB nurses learned how to conduct Diagnostic Counseling and Testing (DCT) "opt-out testing" and staff from the Outpatient department (OPD) and Voluntary Counseling and Testing (VCT) program were trained to screen all patients for TB.

As part of a new patient triage system, all TB patients were requested to undergo DCT as part of their enrollment in TB treatment. If the patient accepted testing, blood was drawn for a rapid HIV test and, if positive, an immediate CD4 count was done which expedited both enrollment at the ART clinic and the decision to start ART. To date, our data confirms that DCT is an effective way to identify and refer TB/HIV co-infected patients. Initial findings from the pilot clinics show high rates of HIV testing (65% accepted) and seropositive results (80% of those tested) and demonstrate the need for DCT as standard part of TB care.

In order to enhance TB case findings, the VCT program initiated a TB screening program through the use of a screening questionnaire. All clients needing referral for further TB diagnostic investigations were escorted to the laboratory for a sputum smear. Of the 2,515 patients accessing VCT, 2,454 (97.6%) also accepted a TB screening. Of these 2,454, 1,482 (60.4%) were HIV positive and 451 (30.4%) of these also received a positive TB screen, making them 4.7 times as likely to have a positive TB screen than HIV negative patients. The Out-Patient Department (OPD) initiated a similar TB screening program. The lessons learned at the two pilot clinics have prepared the ground work for expansion in the next fiscal year.

In FY 2007 TB/HIV integration services will expand to all 15 Lusaka district government clinics with both TB and HIV treatment services, which currently provide care for 87% of TB patients in the district. The focus of FY 2007 activities is to expand the integrated TB/HIV services in Lusaka district based on lessons learned in two pilot clinics. The priorities are to; 1) improve early identification of co-infected patients using DCT; 2) increase the numbers of co-infected patients receiving optimal co-management at the ART clinic; 3) increase TB screening at multiple entry points into the health center system including the Out Patient Department (OPD), VCT program, maternal and child health (MCH) program, and the ART clinics; and 4) continue careful data collection to inform

optimal treatment strategies and decisions.

In integrated care, TB will no longer be managed in a vertical fashion but instead will be treated as an opportunistic infection (OI) in the ART clinic. In the future, once identified as co-infected, patients will enroll directly in the HIV clinic where they can be adequately co-managed. All TB patients will continue to be registered in the Zambian National TB Program.

In addition to testing for HIV in TB patients, there is a need for systematic TB screening in HIV-positive patients in all service delivery areas where HIV testing is done such as PMTCT, STI and OPD. The 15 district clinics targeted for expansion currently have over 37,500 patients enrolled in their HIV clinics, with enrollment projected to increase to approximately 68,000 patients by February 2008. As part of the integration activities, all patients enrolled in the ART clinics will receive a TB screen at enrollment and every 6 months thereafter to ensure prompt diagnosis and treatment. Before wide spread screening can occur, the present capacity of sputum smear microscopy within the district requires assessment. To do this a survey of existing laboratory TB diagnostic capacities in all 15 Lusaka district clinics will be conducted to identify lab strengths and weaknesses and, make recommendations for improving diagnosis and functioning using World Health Organization (WHO) guidelines. Based on this assessment, fluorescent microscopy and TB culture will be integrated into present diagnostic algorithms and systems. Additionally co-trimoxazole preventive therapy will be offered to all TB/HIV co-infected patients as per Zambian national guidelines. Isoniazid prophylaxis for latent TB is presently not included in Zambian National Guidelines.

Of the targeted 14,000 TB patients in the district, 65 % will receive HIV counseling and testing over the period February 2007 to February 2008.

Of the 68,000 patients receiving HIV services over the period February 2007 to February 2008, 80% will receive routine screening for TB disease at least once

All TB/HIV integration activities are designed to be sustainable and operate within the current district clinic structure. CIDRZ is working hand-in-hand with MOH staff to integrate services within the confines of staff capacity and room availability and will continue efforts to expand and strengthen collaboration with them. Rather than providing services directly, CIDRZ is training district nurses, doctors, clinical officers, treatment supporters, and peer educators as well as helping them re-organize their systems for greater efficiency and to ensure sustainability of the services. Monitoring of the data and supportive supervision will be provided in conjunction with the District Health Management Team. CIDRZ is a member of the National TB/HIV coordinating body.

Plus-up funds for the amount of $1,210,000 is being requested to ensure geographical coverage of TB/HIV services in the Lusaka district. Funds will be used to strengthen routine HIV testing of all TB patients and TB screening of HIV-infected patients as well as strengthening the referral links between TB and HIV services. Funding will also be used for infrastructure renovations, enhanced diagnosis of smear negative TB, and technical support.

Related activities: This activity is linked to CIDRZ HTXS

In 2006, an intensive, coordinated community outreach project will start in the Lusaka community of Mtendere. Nicknamed "Save Mtendere!" this community education project aims to dramatically increase the population tested for HIV through intensive community mobilization, including door-to-door counseling and testing (CT) for families. This is a critical adjunct to rapidly expanding HIV care and treatment, as attitudes and perceptions towards HIV begin to change.

In the year prior to "Save Mtendere," just over 1,000 people voluntarily tested for HIV in the Mtendere Health Center. We will survey this center as well as other major VCT centers within the Mtendere community to assess whether the community mobilization increases demand for VCT. As community activities are just starting in Mtendere, the expected increases in demand are unknown.

In 2007, we propose to continue activities within the Mtendere community, and expand the program using lessons learned from Mtendere to two additional communities. One will be an additional community in the Lusaka District, due to the widespread accessibility of antiretroviral therapy (ART). Another intensive community program will start in a provincial capital (a peri-urban area, e.g., Chipata, Mongu, or Livingstone). These settings pose very different challenges for community outreach and require effective community mobilization messages and methods.

Principle activities of the project are community mobilization and participation and development of innovative, community-based modes of communication. Community leaders and support group members have requested bicycles and a vehicle equipped with loudspeakers in order to reach greater numbers of people. We propose to produce "chitengi'" (art on fabric materials), locality-specific billboards and signs, and develop other community messages promoting: (1) hope with the availability of treatment; (2) importance of mutual care and support; (3) availability of testing in the community; and (4) importance of lifelong adherence to treatment.

Plans include training all community mobilization volunteers and clinic-based coordinators, who will monitor their activities and ensure consistency of messages. These coordinators will also provide a central link between community volunteers and members of the community. These clinic-based messages and activities will be coordinated with other United States Government funded organizations conducting community outreach.

Due to the anticipated increased demand in voluntary counseling and testing (VCT), Tulane will also work closely with government facilities for HIV CT. Since 2001, the Center for Infectious Disease Research in Zambia (CIDRZ) has supported the GRZ in providing voluntary testing of hundreds of thousands of clients in antenatal and ART clinics. This support has included training counselors, supporting extra staffing, and supporting back-up supplies of HIV test kits. This component has an indirect benefit on reducing patient volume within the HIV care and treatment sites. Currently, there is a demand for VCT at this access point; as a result, staff spend a significant proportion of time at the ART clinics conducting CT sessions.

Local VCT centers within the district clinics and stand-alone sites will be consulted to measure the impact of these activities. Monitoring the demand for VCT before and after implementation of community outreach will provide a crude measure of effectiveness.