August 8, 2008
ADMINISTRATIVE ORDER
No. 2008 – 0022
POLICIES AND GUIDELINES IN
THE COLLABORATIVE APPROACH OF TB AND HIV PREVENTION AND CONTROL
Tuberculosis
(TB) and HIV co–infection is a serious challenge to every TB and HIV control program.
Since HIV weakens the immune system, people with TB infection are at very high
risk of developing TB as a disease. It is estimated that HIV–infected persons
have 5 to 10% annual risk and 30% lifetime risk of developing TB disease. While
the HIV epidemic potentially fuels and further magnifies TB epidemic, TB
significantly impacts the quality of life of People living with HIV (PLHIV)
being the most common co–infection and one of the main causes of AIDS related
deaths.
Philippines
are one of the countries with high burden of tuberculosis but with low
prevalence of HIV. Based on the 2007 DOH estimate, there are 7,490 Filipino
adults living with HIV, for a national prevalence of 0.168%. A study of TB
patients at San Lazaro Hospital revealed that out of 160 patients, 10 or 6.25%
tested positive for HIV. Cognizant of these facts and the issue of
underreported cases, the DOH sees the need to heighten efforts to address the
joint burden of both diseases and avert future scenario of an epidemic.
Thus,
a collaborative approach for this purpose is now being implemented. In 2006, TB
HIV Collaborating Committee was formed through the Department Personnel Order
No. 2006 – 1869 to ensure proper collaboration between the National
Tuberculosis Control Program (NTP) and National AIDS / STIs Prevention and
Control Program (NASPCP). One of the roles and functions of the TB/HIV
Collaborating Committee is to formulate policies and guidelines on the
establishment of cross–referral mechanisms between NTP and NASPCP to provide
access for TB HIV services and to standardize management of TB HIV co–infection
to ensure quality of care among cases with TB HIV co–infection.
II. OBJECTIVES
This
Administrative Order is issued with the end 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 toward establishing various mechanism for collaboration
between the NTP and NASPCP in identified areas for implementation, providing
guidelines for cross–referral of TB to 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
and HIV Testing and Counseling in the DOTS facilities.
III. SCOPE /
COVERAGE
This
Order shall apply to DOTS facilities and treatment hubs identified by the DOH
to implement these guidelines.
Implementation
of these guidelines shall be in stages, with initial implementation in the DOTS
facilities of Caloocan, Makati, Malabon, Manila, Marikina, Mandaluyong,
Paranaque, Pasay, Pasig and Quezon City. Treatment hubs shall include San
Lazaro Hospital, Philippine General Hospital and Research Institute for
Tropical Medicine. More implementation sites will be added over time to achieve
the vision of a nationwide implementation by 2015.
IV. DEFINITION
OF TERMS
1. Client – initiated HIV testing counseling (also called
Voluntary Counseling and Testing or VCT) involves individuals actively seeking
HIV testing and counseling at a facility that offers these services.
2. Provider – initiated Counseling and Testing (PICT) refers to
HIV testing and counseling which is recommended by health care providers to
person attending health care facilities, as a standard component of medical
care.
3. 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.
4. HIV
Testing Center – 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.
5. 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).
6. 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.
7. HIV TB
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.
V. GUIDING
PRINCIPLES
1. A collaborative approach for NTP and NASPCP, it 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:
a. Proper coordination between the two DOH programs
through the TB/HIV Collaborating Committee.
b. Revitalizing case holding and management of patients
of both NTP and NASPCP
c. Enhancing Local Government Units (LGU) and community
involvement in collaborative TB/HIV activities
d. Conduct of joint planning and capacity building
e. Focused monitoring and evaluation of collaborative
activities
2. All health care workers involved in the management of
TB and HIV patients shall offer diagnostic and treatment care to both patients.
3. Patients diagnosed with TB and MDR–TB in the DOTS
facilities shall be offered HIV Counseling and Testing. PLHIV at the VCT Center
or Treatment hubs shall likewise be screened for TB.
4. Patient diagnosed with TB and MDR–TB and those PLHIV
with signs and symptoms of tb shall be assured of confidentiality of their
cases.
5. Quarterly reports on TB/HIV collaboration shall be
submitted to the Infectious Disease Office (IDO) through channels.
6. Joint capacity building activities on cross–referral
mechanisms 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
(CHD), and the LGU managed health facilities.
7. All stakeholders of collaborative TB/HIV activities,
including both 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 program as well as collaborative activities.
VI. IMPLEMENTING
GUIDELINES
1. Screening
and Management of HIV among Confirmed TB Cases
a. Screening
of HIV among Confirmed TB patients
(1) All patients diagnosed with TB and MDR Tb in the DOTS
facilities shall be offered HIV counseling and testing.
(2) All patients shall be given group education. However
individual pre–test counseling can be provided if necessary.
(3) Patient who agreed for testing shall be requested to
sign the Informed consent form.
(4) Screening procedures will follow the National
Reference Laboratory STD AIDS Center Cooperative Laboratory Guidelines.
(5) Patients with HIV positive result shall be provided
adequate information on access to HIV treatment.
(6) Patients who refuse HIV Ab testing (opt–out) shall be
offered HIV counseling and testing again anytime during consequent consultation
visits, depending on the assessment of the health care provider.
(7) Individual post–test counseling shall be conducted by
the physician or nurse in the DOTS facility to all TB patients who have
undergone HIV testing.
b. Case
holding
(1) The management of HIV positive cases shall be based on
NASPCP guidelines for the clinical management of HIV infections and AIDS.
(2) Continuation of treatment for TB of PLHIV shall be
done at the referring DOTS facility or at the DOTS facility of the treatment
hubs, at the convenience of the patient.
2. Screening
and Management of TB among HIV–infected individuals
For HIV infected patients with signs and symptoms of TB
a. All PLHIV at the VCT center or treatment hub who has
signs and symptoms of TB shall be screened for TB following the NTP Guidelines,
including sputum TB culture and Drug Sensitivity Testing (DST).
b. TB treatment shall commence once the patient is sputum
AFB or culture positive with radiographic findings are negative or
inconclusive, the patient shall be referred to the HIV TB Diagnostic Committee
who will meet regularly to discuss the management of cases with TB HIV co–infection.
However, the attending physician of the Treatment Hub may still treat the
patient for tuberculosis according to his or her best clinical judgement.
c. Treatment for tuberculosis shall follow NTP policies
and guidelines.
For HIV–infected patients with no signs and symptoms of TB
a. All PLHIV at the VCT center or Treatment Hub with no
signs and symptoms of TB shall be screened for TB following the NTP Guidelines,
including sputum TB culture and DST.
b. PLHIV with no active TB shall be given Isoniazid
Preventive Treatment (IPT). Treatment shall be done at the Treatment Hub. IPT
shall be given to patients that do not have cough of 2 weeks or more, sputum
smears and cultures are negative for AFB and Chest X–ray findings are negative
for Tuberculosis
c. PLHIV with chest x–ray findings consistent with active
TB shall be treated according to NTP policies and guidelines.
3. Recording
and Reporting of TB and HIV cases
a. Confidentiality of records and reports shall be
ensured by all health care workers.
b. Existing records and reports of NTP and NASPCP shall
be utilized.
c. Data collection for both diseases shall reflect the
following indicators:
For TB patients who were screened for HIV Testing
(1) Proportion of TB patients tested for HIV infection
(2) Proportion of TB clinics offering HIV testing which
does not require referral of patients to another facility
For PLHIV who were screened for TB
(1) Proportion of PLHIV screened for TB at initial
diagnosis
(2) Proportion of PLHIV screened for TB at most recent
visit
(3) Proportion of people diagnosed with HIV infection who
receive IPT
(4) Proportion of people with both TB and HIV receiving Co–trimoxazole
Preventive Therapy (CPT)
(5) Proportion of people with both TB and HIV receiving Anti–retroviral
Therapy (ART) during TB treatment
(6) Proportion of hub HIV treatment facilities which offer
on–site TB screening and diagnosis
4. Joint
Capability Building for Health Personnel Involved in TB and HIV Prevention and
Control Program
a. Physicians and Nurses of DOTS facilities shall be
trained on Provider Initiated HIV Counseling and Testing including standard
precaution.
b. Midwives, Barangay Health Workers (BHWs) and other
treatment partners shall undergo Basic Orientation on AIDS and Republic Act
8504 also known as the Philippine AIDS Prevention Control Act of 1998.
c. Medical
Technologists at the DOTS facilities shall undergo training on Basic HIV rapid
testing. Laboratory testing on site shall be supervised by a HIV proficient
medical technologist.
d. Treatment hub Staff and Care and Support NGO shall be
trained on NTP Policies and Guidelines.
5. Monitoring
of Clinical Status
Overall
clinical monitoring of PLHIV on TB treatment shall be done through the
Treatment Hubs. Attending physicians at the Treatment Hubs shall ensure that
patients regularly return for follow–up every 2 weeks during the intensive
phase and once a month during the continuation phase. Physicians assigned in
DOTS facilities can also be consulted for co–management of TB treatment
concerns.
6. Quality
Control and Quality Assurance
a. All DOTS facilities including DOTS clinics at the
Treatment HUBS shall be part of the External Quality Assurance for Sputum
Microscopy by the province/city where the facility is located.
b. Quality Assurance for HIV testing center shall be done
by SACCL.
c. All DOTS facilities, SHCs and Treatment Hubs shall
participate in the External Quality Assurance Program for HIV undertaken by
SACCL annually.
7. Infection
Control
Infection
control guidelines of the World Health Organization recommendations in
Tuberculosis Infection Control in the Era of Expanding HIV Care and Treatment
shall be adapted.
VII. ROLES AND
RESPONSIBILITIES
1. The
Department of Health
a. The
National Center for Disease Prevention and Control shall:
(1)
Formulate plans
and policies in coordination with the TB/HIV collaborating Committee.
(2)
Advocate toe the
Local Government Units, Chiefs of Hospitals and other partners to support the
program in coordination with the Center for Health Development.
(3)
Oversee and
ensure the dissemination of this guideline at all levels in coordination with
the CHDs, the LGUs, TB/HIV Coordinating Committee and partners.
(4)
Initiate and
develop training programs relative to the implementation of this policy,
including the join capacity building activities of both programs and the cross–referral
mechanisms between TB and HIV program as indicated in this policy. Provide
technical assistance including training of LGU staff in coordination with
partners.
(5)
Provide logistics
assistance in terms of HIV testing kit through the Global Fund.
(6)
Collate and
analyze data from submitted reports and provide feedback on findings and
recommendations to the concerned staff.
(7)
Monitor and
evaluate the implementation of this policy in coordination with the TB/HIV
Collaborating Committee.
b. The
National Epidemiology Center shall:
(1) Maintain and update the HIV registry.
(2) Provide updates on the surveillance of TB HIV
co–infection to the NCDPC.
c. The
Centers for Health Development shall:
(1)
Oversee the
implementation of this policy, particularly collaborative approach and cross–referral
mechanisms for the two programs at the local levels, including government and
private health facilities.
(2)
Facilitate the
conduct of the trainings and activities on the collaborative approach for the
TB and HIV prevention and control program.
(3)
Collate submitted
reports from the PHO/CHO and submit to the Infectious Disease Office of the
Department of Health.
(4)
Monitor and
evaluate implementation regularly based on agreed indicators.
2. The TB/HIV
Collaborating Committee shall:
a. Formulate
policies /guidelines for the operationalization of the TB/HIV Collaboration
through the TB HIV Technical Working Group (TWG)
(1) Establish cross–referral mechanisms between NTP and
NASPCP to provide access for TB/HIV services.
(2) Standardize management of TB/HIV co–infection to
ensure quality of care among cases with TB/HIV co–infection
b. Provide Technical
Assistance through collaboration of key stakeholders involved in the management
of cases with TB/HIV co–infection.
c. Provide a forum
for the discussion of issues and concerns on the operationalization of the
TB/HIV collaboration
d. Set the
directions for TB/HIV Collaboration vis–a–vis NTP and NSPCP policies and
guidelines.
3. The Local
Government Units shall:
a. Allow all health workers involved in the NTP and
NASPCP to undergo capability building activities on TB/HIV collaboration
related activities.
b. Ensure
that there are physicians, nurses, midwives and medical technologists at the
DOTS facility.
c. Implement the program according to agreed plan
d. Prepare, analyze and submit reports required by DOH
e. Evaluate and monitor implementation of plan
VIII. FUNDING
Funding
for the activities (training, HIV counseling and testing, monitoring and
evaluation) to implement TB/HIV collaboration shall be initially provided by
the TB and HIV component of the Round 5 Global Fund to fight AIDS, TB and
Malaria. The NTP shall provide anti–TB drug for identified TB cases and NASPCP
shall provide Anti–retroviral (ARV) drugs for identified HIV cases).
IX. MONITORING
AND EVALUATION
Monitoring
of DOTS facilities and Treatment Hubs shall be done by the CHD NTP and STI
Coordinators in coordination with the TB/HIV Collaborating Committee, to keep
track of the overall progress of the TB–HIV implementation based on the
indicators.
X. EFFECTIVITY
This
Order shall take effect immediately upon approval.
FRANCISCO T. DUQUE III,
MD, MSc
Secretary of Health
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