ADMINSTRATIVE ORDER
No. 2014 – 0005
REVISED POLICIES AND GUIDELINES IN THE COLLABORATIVE APPROACH
OF TB AND HIV PREVENTION AND CONTROL
I. RATIONALE
In
2008, the Department of Health (DOH) issued Administrative Order No. 2008 –
0022 otherwise known as the “Policies and Guidelines in the
Collaborative Approach of TB and HIV Prevention and Control.” This was
drafted and disseminated by the TB HIV Collaborative Committee formed through
DOH – Department Personnel Order No. 2006 – 1869. The A.O. aimed at initiating
measures to address the dual burden of tuberculosis (TB) and human
immunodeficiency virus (HIV) and avert future scenario of a syndemic. Since
then, various pilot initiatives were implemented by the National
Tuberculosis Control Program (NTP), the National STI and AIDS Prevention and
Control Program (NASPCP) and key private interest groups.
Considering
the increasing trend of TB–HIV co–infection and the need to scale–up TB –HIV
collaborative initiatives, a Joint Assessment and Planning for TB–HIV
Collaboration was held in September 2012 among DOH Program Managers, Center for
Health Development – Metro Manila , World Health Organization, donor agencies,
civil society organizations, including people living with HIV, Local Government
Units (LGU) and implementing facilities (Social Hygiene Clinics, DOTS Centers,
HIV Treatment Hubs and PMDT treatment facilities).
Anchored
on the learning and insights from current TB–HIV initiatives in the country and
the 2012 World Health Organization 12–point Agenda for TB–HIV Collaboration, 5th
AIDS Medium Term Plan and 2010 – 2016 Philippine Plan of Action to Control
Tuberculosis, new protocols have been adopted and concomitant changes to
policies and guidelines are imminent for scale–up and full implementation. This
A.O. is therefore, being released.
II. OBJECTIVES
This
A.O. is issued to update the policies and guidelines with the end in view of
decreasing the burden of TB among People Living with HIV (PLHIV) and the burden
of HIV among TB patients.
Further,
this issuance is geared to establish various mechanisms for collaboration
between the NTP and NASPCP in identified areas for implementation, providing
guidelines for cross–referral of TB to HIV and HIV to TB, define the roles and responsibilities
of key stakeholders at all levels, and eventually strengthen Directly Observed
Treatment Short Course (DOTS) services in the treatment hubs, Social Hygiene
Clinics and HIV Testing and Counseling in the DOTS facilities.
III. SCOPE /
COVERAGE
This
Order shall apply to both public and private DOTS facilities; PMDT Treatment
facilities, Social Hygiene Clinics and Treatment Hubs identified by the DOH to
implement these guidelines.
Provision
of Provider Initiated HIV counseling and Testing among registered TB patients
shall be implemented in HIV high prevalence areas (Category Sites A and B) and
all PMDT treatment facilities while management of TB among PLHIV shall be
implemented nationwide.
IV. DEFINITION
OF TERMS
A. Client–initiated
HIV testing and counseling (also called Voluntary Counseling and Testing or
VCT) – involves individuals actively
seeking HIV testing and counseling at a facility that offers these services.
B. Provider–initiated
Counseling and Testing (PICT) –
refers to HIV testing and counseling which is recommended by health care
providers to persons attending health care facilities, as a standard component
of medical care.
C. DOTS
Center – are all health centers
nationwide and some hospitals, prisons, other government clinics, and private
clinics that are providing TB services (diagnosis through sputum examination,
treatment and counseling).
D. HIV
Treatment Hub – a hospital facility
providing prevention, treatment, care and support services to People Living with
HIV (PLHIV) including but not limited to Voluntary HIV counseling and Testing
(VCT), clinical management, patient monitoring and other care and support
services. May also be a DOTS center.
E. HIV
Testing Centers – are facilities
accredited by the Bureau of Health Facilities and Services (BHFS), capable of
performing HIV testing by medical technologists that have undergone the
training on HIV testing Proficiency.
F. Social
Hygiene Clinic (SHC) – full–time
Sexually Transmitted Infection (STI) clinics or part – time STI clinics
integrated in Rural Health Units (RHUs) and City Health Offices (CHOs).
G. HIV
positive – a person with HIV
infection as indicated by the presence of antibodies against HIV on a test of
blood or tissue; synonymous with sero– positive.
H. TB/HIV
Diagnostic Committee – is composed of
the Chiefs of the HIV and DOTS Clinic, a Radiologist and other experts in the
treatment hub who decide the management of difficult cases of patients with
TB–HIV co–infection based on the NTP and NASPCP policies and guidelines.
I. STD/AIDS
Cooperative Central Laboratory (SACCL)
– is the DOH designated National Referral Laboratory for HIV and Sexually
Transmitted Infections. It is operated by San Lazaro Hospital – Department of
Health.
J. Category A
and B – are areas for prioritization
based on the number of reported cases, HIV prevalence, Most at Risk Population
(MARP) size, results of the Rapid Assessment of HIV vulnerability and presence
of multiple risks as categorized by the National Epidemiology Center.
K. GeneXpert – a rapid diagnostic tool/machine that provides TB
test result less than 2 hours and can diagnose drug resistant TB within the
same period.
V. POLICY
STATEMENT
A. A collaborative approach for NTP and NASPCP is
necessary to pursue stronger cross–referral mechanisms to reduce disease burden
among TB patients and PLHIV. The mechanisms for collaboration shall focus on
the following:
1. Coordination between NTP and NASPCP shall be through
the Infectious Disease Office;
2. Proper caseholding and management of patients with TB
HIV co–infection;
3. Engagement of CHDs, LGUs, private sector, and affected
communities for TB/HIV collaborative activities;
4. Conduct of annual joint planning among all
stakeholders;
5. Capacity building for public and private DOTS
facilities, PMDT Treatment facilities, HIV Treatment Hubs, Social Hygiene
Clinics and Laboratory facilities; including CHDs and LGUs;
6. Focused monitoring and evaluation of collaborative
activities.
7. Build up surveillance of Tb among PLHIV and of HIV
among TB patients
B. Patients diagnosed with Drug Susceptible (DS) TB in
DOTS facilities in Category A and B areas and patients diagnosed with Drug
Resistant (DR) TB in PMDT Treatment facilities shall undergo Provider–Initiated
HIV Counseling and Testing (PICT). Likewise, PLHIV at the Social Hygiene
Clinics and Treatment hubs shall be screened for TB.
C. Registered TB patients outside Category A and B areas
shall be informed of the benefits of HIV testing and shall be referred to the
Social Hygiene Clinics for testing.
D. All diagnosed patients with TB HIV co–infection shall
be assured of confidentiality of their status.
E. Continuation of treatment for TB and HIV shall be
ensured at all times especially during referral of cases for TB and HIV
services.
F. All facilities (DOTS facilities, PMDT Treatment
facilities, Treatment hubs) providing TB HIV services shall submit quarterly
TB–HIV reports to PHO/CHO and then to CHDs. CHDs to collate and submit to IDO.
G. Data on TB HIV collaboration shall be shared among
IDO, NEC and other stakeholders.
H. Joint capacity building activities on cross–referral
mechanism shall be developed and packaged to capacitate health workers involved
in the management and treatment of TB and HIV. This shall be conducted at all
levels, from DOH retained hospitals to Centers for Health Development and the
LGU managed facilities.
I. All stakeholders of TB HIV collaborative activities,
including NTP and NASPCP shall support and encourage TB HIV operational
research specific and/or related to the issues encountered by the program. This
is for the purpose of developing evidence base for efficient and effective
implementation of the collaborative program.
J. Safety and health of health workers from HIV and TB
infection shall be promoted through the use of guidelines for infection
control.
VI. IMPLEMENTING
GUIDELINES
A. Screening
and Management of HIV among Confirmed TB cases
1. Screening
of HIV among Confirmed TB patients
a. All patients diagnosed with drug susceptible pulmonary
and extra–pulmonary TB in the DOTS facilities in high prevalence areas (CAT A
and B) shall undergo PICT, and upon counseling, that patient is further
informed of his/her right to refuse HIV testing. Likewise, PICT will be done to
all patients diagnosed with drug resistant pulmonary and extra–pulmonary TB in
the PMDT Treatment facilities.
b. All patients shall be provided with information on HIV
and TB/HIV co– infection, counseling and testing. Those patients who do not
agree to undergo testing may still avail of other HIV services.
c. Patients who agreed for testing shall be requested to
sign the informed Consent Form.
d. Patients who refuse HIV Ab testing (opt–out) shall be
offered HIV counseling and testing again during consequent consultation visits
during the first three months of anti–TB treatment.
e. Patients with HIV reactive result shall be provided
with individual post – test counseling and shall be referred to STD/AIDS
Cooperative Central Laboratory (SACCL) for confirmatory HIV testing.
f. HIV testing procedures shall follow SACCL guidelines,
being the national reference laboratory for STI/HIV.
g. SACCL shall send back the test result to the referring
physician of the DOTS facility or Treatment Center.
h. Patients with confirmed positive result shall undergo
baseline laboratory tests (CBC, urinalysis, liver function test and CD4 count)
prior to referral to the treatment hubs.
i. The DOTS facility and PMDT Treatment facility shall
facilitate the conduct of the baseline laboratory tests and the subsequent
referral of confirmed positive cases to a Treatment Hub for evaluation and
definitive management of HIV/AIDS.
2. Caseholding
a. The management of HIV positive cases shall be based on
NASPCP guidelines for the clinical management of HIV infection and AIDS.
b. Treatment for drug–susceptible TB of PLHIV shall be
done at the referring DOTS facility or at the Treatment Hub. Medical Staff at
the DOTS Center shall be informed of the HIV status of the PLHIV so that staff
can provide appropriate care and support.
c. Treatment of PLHIV with drug resistant TB shall be
done in PMDT treatment Center / Satellite Treatment Centers.
B. Screening
and Management of TB among HIV–infected individuals
1. For People
Living with HIV
a. All PLHIV at the
Social Hygiene Clinic or Treatment Hub shall undergo TB screening: symptomatic
screening (cough of any duration, fever, night sweats, loss of weight), and
Chest X–ray. If symptomatic, sputum shall be collected for Xpert/MTB RIF.
b. TB screening for
PLHIV shall be done upon HIV diagnosis and every follow up visit.
c. TB treatment
shall start once the patient is found to have active TB based on the GeneXpert
test (TB Rif susceptible, TB Rif Resistant) or with radiographic findings
consistent with TB or with extra–pulmonary TB based on clinical and laboratory
diagnosis.
d. TB treatment
shall be based on the NTP policies and guidelines.
e. PLHIV with MTB
Rif Resistant shall be referred to the PMDT treatment facilities.
f. PLHIV with no
active TB (no symptoms, negative for TB in Xpert MTB/RIF and CXR) shall be
given Isoniazid Preventive Treatment (IPT) for 6 months.
C. Recording
and Reporting of TB–HIV cases
1. All TB and HIV facilities shall maintain patient
records and reports that could generate data on TB–HIV indicators:
a. For TB patients
who were screened for HIV
(1)
Number and
percentage of TB patients tested among registered patients
(2)
Number and
percentage of TB patients with HIV + result among those tested
(3)
Number and
percentage of HIV + TB patients started on Co– trixomazole Preventive Therapy
(4)
Number and
Percentage of HIV + TB started on ART
b. For PLHIV who
were screened for TB
(1)
Number and
percentage of PLHIV who are screened for TB upon enrollment to HIV care
(2)
Number and
percentage of PLHIV who are screened for TB during the last visit
(3)
Number and
percentage of PLHIV started TB treatment among those detected
(4)
Number and
percentage of PLHIV who completed TB treatment
(5)
Number and
percentage of PLHIV started IPT
(6)
Number and
percentage of PLHIV completed IPT
2. Existing flow and timeliness of reports for both NTP
and NASPCP shall be followed.
3. Confidentiality of records and reports shall be
ensured by all health care workers.
D. Joint
Capability Building for Health Personnel Involved in TB and HIV Prevention and
Control Program
1. All health workers in facilities providing HIV
counseling and testing shall be oriented on TB/HIV collaboration, AIDS LAW and
referral of cases.
2. Physicians and nurses of DOTS clinics, Treatment
Centers/Satellite Treatment Centers, Treatment Hubs and Social Hygiene Clinics
shall be capacitated on Provider Initiated HIV Counseling and Testing including
Infection Control, Directly Observed Treatment Short Course (DOTS) and referral
of drug resistant TB cases. DOTS Health Center physicians and nurses shall be
trained on Basic HIV Prevention and Control for better management of PLHIV undergoing
TB treatment and IPT in their DOTS Center.
3. Medical Technologist who will conduct HIV screening
test shall be trained and certified by SACCL NRL or its authorized training
facilities.
4. NTP and NASPCP staff shall continuously build its
capacity on TB–HIV program management (Program Planning, Implementing, M&E
and Documentation).
E. Monitoring
of Clinical Status
TB–HIV
co–infection shall be managed by physicians trained on TB–HIV case management.
DOTS facilities, Treatment Centers, SHC and Treatment Hubs shall maintain close
coordination on patient’s co–management (including recording and reporting) in
consideration of adverse drug reactions, treatment adherence, effective and
efficient referral and feed–backing.
F. Quality
Assurance
1. All laboratory facilities (public and private) shall
have a Quality Assurance System in place.
2. All DOTS facilities doing HIV testing, SHC and
Treatment Hubs (public and private) shall participate in the External Quality
Assurance Program provided by SACCL annually.
G. Infection
Control
Treatment
Facilities shall implement an infection control plan based on the DOH “Standard
for Infection Control” and NTP “Guidelines on Infection Control for
Tuberculosis and other Airborne Infectious Diseases in Healthcare Facilities,
Congregate Settings and Households.”
Laboratory
Facilities shall implement an infection control plan based on WHO “Laboratory
Biosafety Manual” and “National TB Laboratory Biosafety Guidelines.”
VII. ROLES AND
RESPONSIBILITIES
A. The
National Center for Disease Prevention and Control shall:
1. Formulate/revise
plans and policies for TB and HIV collaboration in coordination with or as
endorsed by TB/HIV TWG.
2. Conduct Training
of Trainor for CHD staff.
3. Advocate the LGUs
and other partners to support the programs in coordination with the CHD.
4. Provide logistic
requirements in support of the operations of the health facilities.
5. Provide technical
assistance to peripheral levels including the private sector.
6. Conduct joint
monitoring, supervision and evaluation of the implementation of the TB HIV
collaboration activities in coordination with the CHDs and partners.
7. Collect and
consolidate reports for both TB and HIV facilities and laboratories.
8. Accept/approve
the conduct of researches as may be necessary.
B. The
National Epidemiology Center shall:
1. Joint the conduct of regular monitoring and evaluation
(systemic data collection, documentation, analysis and evaluation, reporting)
with IDO, CHDs and partners.
2. Provide technical assistance to programs to enhance
and standardize recording and reporting forms and management of data.
3. Analyze and disseminate reliable and timely
information on program performance based on indicators in section 3.
C. The TB/HIV
Technical Working Group shall:
1. TB–HIV TWG shall meet quarterly and as may be needed.
2. Review program performance and identify priority problems, gaps and challenges.
3. Deliberate on evidence–based/best practices and models
on possible solution to problems, gaps and challenges.
4. Recommend to NCDPC changes on protocols, policies and
practices to improve joint program implementation
5. Identify and/or approve research proposals/concepts on
TB–HIV.
D. The Center
for Health Development shall:
1. Oversee implementation of TB–HIV collaboration in LGU.
2. Facilitate conduct of capacity building of
implementers and other stakeholders.
3. Ensure availability and adequacy of logistics.
4. Monitor and evaluate the implementation of TB HIV
collaboration.
5. Conduct mentoring and coaching of implementers.
6. Collate, analyze and submit reports to DOH central
office.
7. Lead advocacy activities for TB HIV program adoption
in LGUs, including the private sector.
E. The
Provincial/City Health Offices shall:
1. Manage and implement TB–HIV local program.
2. Provide human resource/ financing support and
conducive policy environment for program implementation.
3. Monitor and evaluate local program implementation
particularly TB HIV public and private facilities and laboratories.
4. Submit report to CHD.
F. Health
Facilities
1. The DOTS
facilities and PMDT facilities shall:
a. Conduct case
findings on HIV among TB patients through PICT.
b. Facilitate
baseline laboratory tests (CBC, urinalysis, liver function test and CD4 count)
for ARV eligibility.
c. Refer and
co–manage TB and HIV co–morbidity
d. Ensure quality
recording and reporting to Provincial/City Health Offices.
e. Provide technical
assistance to Treatment Hubs and Social Hygiene Clinics and TB care and
treatment.
2. The Social
Hygiene Clinic shall:
a. Conduct case finding and screening of TB among PLHIV.
b. Refer Tb cases to DOTS facilities or PMDT facilities
or manage cases if capable.
c. Facilitate baseline laboratory tests (CBC, urinalysis,
liver function test and CD4 count) for ARV eligibility.
d. Ensure quality recording and reporting to
Provincial/City health offices.
3. The
Treatment Hubs shall:
a. Conduct case
findings and screening of HIV and TB among PLHIV.
b. Provide care,
support and treatment to PLHIV co–infected with TB.
c. Ensure quality
reporting and recording to CHD and NEC.
d. Provide technical
assistance to the TB DOTS on HIV care and treatment
4. Laboratories
a. The Xpert
Centers shall:
(1)
Provide Xpert
testing for PLHIV.
(2)
Participate in
QA/EQA.
(3)
Prepare and
submit laboratory reports to Provincial/City Health Offices
b. The Microscopy
Centers shall:
(1)
Provide HIV rapid
testing for TB patients
(2)
Participate in
QA/EQA
(3)
Prepare and
submit laboratory report to Provincial/City Health Offices.
G. Reference
Laboratories
1. The NTRL
shall:
a. Maintain
laboratory network for TB.
b. Conduct training
on QA and biosafety.
c. Oversee QA/EQA
for TB laboratory services.
d. Conduct regular
monitoring, supervision and evaluation.
H.
The
Development Partners shall:
1. Mobilize
resources for TB–HIV collaboration activities.
2. Provide technical
support in planning, implementing and monitoring and evaluating TB HIV
collaborative activities.
I. The
Support Groups shall:
1. Mobilize
resources and assist PLHIV in the provision of medical and social needs.
2. Act as treatment
partners of PLHIV for antiretroviral and tuberculosis treatment once trained by
Treatment Hub HACT Teams.
3. Conduct education
and awareness campaigns on the importance of addressing TB problems among their
community members.
4. Provide stigma
reduction activities in the TB and HIV facility settings.
VIII. MONITORING
AND EVALUATION
Monitoring
and evaluation shall be done in various levels as mentioned in the roles and
responsibilities of the different stakeholders. Joint program assessment and planning
shall be done annually and appropriate researches shall be conducted by either
or both program as necessary.
IX. FUNDING
Funding
for the conduct of activities for TB HIV collaboration shall be from DOH, CHD,
LGU and Donor groups.
X. REPEALING
CLAUSE
Provisions
of Administrative Order No. 2008 – 0022 and other related issuances that
are inconsistent or contrary to the provisions of this Order are hereby
rescinded or modified accordingly.
XI. EFFECTIVITY
This
Order shall take effect immediately upon approval.
ENRIQUE T. ONA, MD
Secretary of Health
No comments:
Post a Comment