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. 2020 Sep 21;10(3):104-110.
doi: 10.5588/pha.20.0014.

Implementing TB preventive treatment within differentiated HIV service delivery models in global programs

A T Boyd  1 , B Moore  1 , M Shah  1 , C Tran  1 , H Kirking  1 , J S Cavanaugh  1 , T Al-Samarrai  2 , I Pathmanathan  1
Affiliations

Implementing TB preventive treatment within differentiated HIV service delivery models in global programs

A T Boyd et al. Public Health Action. .

Abstract
in English, French, Spanish

Global HIV program stakeholders, including the US President's Emergency Plan for AIDS Relief (PEPFAR), are undertaking efforts to ensure that eligible people living with HIV (PLHIV) receiving antiretroviral treatment (ART) receive a course of TB preventive treatment (TPT). In PEPFAR programming, this effort may require providing TPT not only to newly diagnosed PLHIV as part of HIV care initiation, but also to treatment-experienced PLHIV stable on ART who may not have been previously offered TPT. TPT scale-up is occurring at the same time as a trend to provide more person-centered HIV care through differentiated service delivery (DSD). In DSD, PLHIV stable on ART may receive less frequent clinical follow-up or receive care outside the traditional clinic-based model. The misalignment between traditional delivery of TPT and care delivery in innovative DSD may require adaptations to TPT delivery practices for PLHIV. Adaptations include components of planning and operationalization of TPT in DSD, such as determination of TPT eligibility and TPT initiation, and clinical management of PLHIV while on TPT. A key adaptation is alignment of timing and location for TPT and ART prescribing, monitoring, and dispensing. Conceptual examples of TPT delivery in DSD may help program managers operationalize TPT in HIV care.

Les parties prenantes du programme mondial VIH, notamment le plan américain PEPFAR (US President’s Emergency Plan for AIDS Relief), entreprennent des efforts afin de s’assurer que les personnes vivant avec le VIH (PLVIH), éligibles, recevant un traitement antirétroviral (TAR), reçoivent également un traitement préventif TB (TPT). Dans la programmation PEPFAR, cet effort pourrait nécessiter de fournir le TPT non seulement aux PLVIH nouvellement diagnostiquées dans le cadre de l’initiation de la prise en charge du VIH, mais également aux PLVIH stables déjà traités par TAR à qui on n’aurait pas encore offert le TPT. L’expansion du TPT survient au même moment comme une tendance à offrir une prise en charge du VIH davantage centrée sur la personne à travers une prestation de services différenciée (DSD). Dans la DSD, les PLVIH stables sous TAR bénéficient d’un suivi clinique moins fréquent ou sont soignés hors du modèle traditionnel en structures de santé. Le décalage entre la prestation traditionnelle du TPT et la prestation de soins dans des DSD innovantes peut nécessiter des adaptations aux pratiques de prestation du TPT pour les PLVIH. Ces adaptations incluent des éléments de planification et d’opérationnalisation du TPT dans la DSD, comme la détermination de l’éligibilité au TPT et sa mise en route et la prise en charge clinique des PLVIH sous TPT. Une adaptation majeure est l’alignement en termes de temps et de lieu pour la prescription, le suivi et la délivrance du TPT et du TAR. Des exemples conceptuels de délivrance du TPT dans la DSD aideraient les gestionnaires de programme à rendre opérationnel le TPT au sein de la prise en charge du VIH.

Los interesados directos del Programa Mundial del VIH, incluido el Plan de Emergencia del Presidente (de los Estados Unidos) para el Alivio del Sida (PEPFAR), emprenden ahora esfuerzos encaminados a garantizar que las personas con infección por el VIH (PLVIH), que siguen un tratamiento antirretrovírico (TAR) y que reúnen las condiciones, reciban un ciclo de tratamiento preventivo de la TB (TPT). En la programación del PEPFAR esta iniciativa puede necesitar la provisión de TPT no solo a las personas con un diagnóstico reciente de infección por el VIH, como parte del inicio de la atención del VIH, sino también a las PLVIH, con experiencia de tratamiento y que se encuentran estables recibiendo el TAR, a quienes tal vez no se haya propuesto antes el TPT. La ampliación del TPT ocurre de manera simultánea con la tendencia a ofrecer una atención del VIH más centrada en la persona mediante la prestación diferenciada de servicios (DSD). En la DSD, las PLVIH, estables con el TAR, pueden tener encuentros de seguimiento clínico menos frecuentes o recibir atención por fuera del modelo tradicional en los consultorios. La discordancia entre la provisión tradicional del TPT y la prestación de atención en el marco innovador de la DSD exige adaptaciones de las prácticas de prestación del TPT a las PLVIH. Las adaptaciones incluyen componentes de planeación y puesta en práctica del TPT en la DSD, como la determinación de los criterios para recibir el TPT, el inicio del mismo y el manejo clínico de las PLVIH mientras reciben el TPT. Una adaptación primordial es la coordinación del ritmo y el lugar de prescripción, supervisión y suministro del TPT y el TAR. La presentación de ejemplos teóricos de provisión del TPT en el marco de la DSD puede ayudar a los gerentes de programas a poner en práctica el TPT en la atención del VIH.

Keywords: HIV treatment; differentiated service delivery; tuberculosis preventive treatment.

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Conflict of interest statement

Conflicts of interest: none declared.

Figures

FIGURE 1.
FIGURE 1.
Ratio of the number of PLHIV targeted for TPT completion to the number of PLHIV targeted to initiate ART—29 PEPFAR programs, October 2019–September 2020.*† * 18 PEFPAR-supported country or regional programs in which the ratio of number of PLHIV targeted for TPT completion to number of PLHIV targeted to initiate ART is >1, indicating more PLHIV are targeted for TPT completion than PLHIV initiating ART. In these programs, achieving TPT targets may require provision of TPT to PLHIV already stable on ART and who may be receiving HIV care through differentiated service delivery. † Data source: PEPFAR Data for Accountability, Transparency, and Impact fiscal year 2020 targets, except for PLHIV targeted for TPT completion from Kenya and Nigeria, which come from Country Operational Plan 2019 planning level letters for fiscal year 2020 targets. PLHIV = people living with HIV; TPT = tuberculosis preventive treatment; ART = antiretroviral treatment; PEPFAR = US President’s Emergency Plan for AIDS Relief.
FIGURE 2.
FIGURE 2.
TPT delivery for stable PLHIV in DSD: conceptual example of a facility-based model. PLHIV stable on ART are enrolled in a DSD model that consists of 3-month ART prescribing (fast-track medication pick-up and screening for presumptive TB, AEs, and adherence at the pharmacy) and 6-month clinic visits. When these PLHIV start TPT after appropriate TB screening and evaluation, as well as counseling on benefits of TPT and on potential TPT-related AEs using standardized education materials, a 1-month supply of TPT is given at their routine 6-month clinic visit. They return 1 month later for a TPT assessment (screening for presumptive TB, AEs, and adherence) at the facility. If no presumptive TB, serious AEs, or adherence concerns are identified, PLHIV are given a 2-month supply of TPT. They then return 2 months later for their regularly scheduled ART fast-track visit, where they undergo a TPT assessment by the pharmacist in addition to collecting 3 months of ART and TPT (if no presumptive TB, serious AEs, or adherence concerns are identified). At the next 6-month clinic visit, a TPT assessment and evaluation for completion is conducted by the clinician. This model has the following benefits: stable PLHIV on ART only ‘break’ their regular cycle of 6-month facility visits once, 1 month after initiating TPT. ART = antiretroviral therapy; TPT = TB preventive treatment; TB = tuberculosis; AE = adverse event; PLHIV = people living with HIV; DSD = differentiated service delivery.
FIGURE 3.
FIGURE 3.
TPT delivery for stable PLHIV in DSD: conceptual example of a community-based model. PLHIV stable on ART are enrolled in a DSD model that consists of 6-month clinic visits with TPT dispensed monthly in the community. At the routine 6-month clinic visit, PLHIV are counseled on benefits of TPT and on potential TPT-related AEs using standardized education materials, then given a 1-month supply of TPT. They receive a TPT assessment (screening for presumptive TB, AEs, and adherence) 1 month later at a clinic visit or a community-based group meeting. If no presumptive TB, serious AEs, or adherence concerns are identified, they are given another 1-month supply of TPT along with ART. They continue to receive a TPT assessment at each of their group meetings at Months 2–5. At the next 6-month clinic visit, a TPT assessment and evaluation for completion is conducted by the clinician. The advantage of this model is that stable PLHIV on ART only ‘break’ their regular cycle of 6-month facility visits once if the program decides they must go to a clinic for their 1-month TPT assessment. Of note, this model can be adapted for community ART groups as well, with all eligible PLHIV in the group potentially initiating and completing TPT together, which may reinforce adherence and reporting of possible presumptive TB or TPT-related AEs. ART = antiretroviral therapy; TPT = TB preventive treatment; TB = tuberculosis; AE = adverse event; PLHIV = people living with HIV; DSD = differentiated service delivery.
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