HIV and poverty drive the tuberculosis (TB) epidemic in Kenya, with a ten-fold increase in registered TB cases since 1987. In the eastern slums of Nairobi, an epicenter of the dual HIV/TB epidemic, the Eastern Deanery of the Nairobi Catholic Diocese has provided health care through seven clinics since the early 1990s. In 2001, a partnership between the Eastern Deanery AIDS Relief Program (EDARP), the Kenya National Leprosy and TB Program (NLTP) of the Ministry of Health, and HHS/CDC established integrated HIV and TB services in these clinics. Initially, TB patients were referred to freestanding counseling and testing centers; however, only one in eight patients referred for counseling and testing actually sought testing.
To improve uptake and better integrate the services, in 2003 physicians assistants began to provide diagnostic counseling and testing at the time of TB diagnosis. Despite this change in procedure, many TB patients were not tested for HIV. With Emergency Plan support, the program began in 2004 to routinely offer HIV counseling and testing to all outpatients believed to have TB. Nurses conducted the testing, using simple HIV rapid tests done in the presence of the patients.
Of 1,917 patients offered HIV counseling and testing over 19 months, 85% accepted during their initial clinic visit - and nearly all of those who came for follow-up due to active TB eventually accepted testing. The expansion of testing has accompanied the rapid expansion of care and antiretroviral treatment (ART) in the program, helping to identify patients who are eligible to start ART.
Lessons learned from this project have informed national policy and strategy, serving as a model for integrating TB and HIV services. The USG team estimates that offering testing to the 400,000 patients believed to have TB annually in Kenya can be expected to result in 300,000 accepting testing, potentially leading to 100,000 referrals for HIV care per year. The majority of these people would be eligible for ART. Manpower constraints in TB clinics have slowed the application of these lessons throughout the country, but they have informed the Kenya National Guidelines for HIV Testing in Clinical Settings and established a best practice model that is now being duplicated around the country. Offering diagnostic testing for HIV and TB routinely at the first patient contact is more acceptable to patients, more efficient for staff, and results in better management of both diseases.
This advance is making a difference for people in the slums of Nairobi. Salome Majuma (name and details changed to protect her identity) is a woman in her early 40's who was diagnosed with HIV and TB in May 2004. At the time of diagnosis, she began her 8 month course of TB treatment and cotrimoxazole prophylaxis to prevent other opportunistic infections. In February 2005 she began ART and visits the clinic monthly to collect her medications, provided with Emergency Plan support. Her tuberculosis is now cured and her health improved - offering a hopeful future.
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