(ii) reducing late ART initiation: PLHIV initiated on ART at CD4 count less than 100 have decreased from 63% in 2009 to 37% in 2013;
(iii) TB screening in PLHIV to rule out active TB, and providing IPT to those without contraindications.
IPT in Vietnam was started in 2009 and now nearly 20,000 PLHIV are treated with IPT. Intensified TB case finding in HIV care settings by screening PLHIV for TB at every visit to HIV clinic and referring suspected cases to TB clinic for further investigation has also helped a lot. There are 32 GeneXpert machines that have been rolled out in Vietnam as of 2014 and around 60%-70% of TB patients have received provider-initiated HIV counselling and Testing (PICT) services in TB settings.
Speaking about ART and TB treatment for HIV-TB co-infected people, Dr Long said that about 60% of co-infected people are on ART and TB treatment which is higher as compared to previous years but still short of the 100% target. Government subsidy for travel costs for the poor people and ethnic minorities, from home to healthcare facilities and food subsidy during hospitalization has also been instrumental in shaping the response.
Dr Long said that one of the challenges that needs to be addressed ahead is to provide ART and TB treatment to remaining 40% TB-HIV co-infected people in Vietnam. He said that TB and HIV services should be integrated in the existing healthcare system and decentralised to the PHC level. He stressed on increasing the number of districts providing PICT, ART, MMT needle/syringe and TB DOTS at one stop. There is a need for clear and specific guidelines to lead coordination and have good linkages between TB and HIV settings to improve provision of timely ART for coinfected patients. Also joint monitoring and evaluation of TB-HIV collaborative activities will further help programme outcomes.
India
Dr BB Rewari of the National AIDS Control Programme in India informed that India accounts for 10% of global HIV-TB burden and is home to the second largest number of HIV-infected TB cases, next only to South Africa. 5% of TB patients are estimated to be HIV-infected. 69% of TB patients knows their HIV status. About 90% TB-HIV co-infected patients are provided cotrimoxazaole prophylaxis therapy (CPT) and 90% of TB-HIV patients are receiving ART.
Speaking about successful HIV-TB interventions, Dr Rewari said that since 2011,India has had a public health approach to implement TB-HIV collaborative activities through working groups and TB-HIV coordination committees at national, state and district levels. There is a 100% coverage of PICT in TB patients. Rapid diagnostics for detection of TB and MDR-TB in PLHIV and GeneXpert were launched at 70 sites in 22 states to improve early diagnosis of TB among PLHIVs.
Dr Rewari said that challenges still remain. Annual notification remains less than 50% of the estimated HIV associated TB cases (130,000/year). Mortality is high and 42000 co-infected patients (15%) die every year. Only 6724/13232 (51%) of the designated microscopy centres (DMCs) have co-located HIV testing facilities. Late diagnosis of HIV and that too at low CD4 count is another formidable challenge. Dr Rewari also pointed out to the leaky care cascade for HIV as it is very difficult to track lost to follow up (LFU) patients. Airborne infection control is difficult due to over-congested health facilities, said Dr Rewari. Another challenge is that cases with extra pulmonary TB (EPTB) might be getting missed. Also there is a poor detection of TB among children living with HIV.
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