Healthcare delivery for HIV-positive people with tuberculosis in Europe

Abstract

Background: In a 2013 survey, we reported distinct discrepancies in delivery of tuberculosis (TB) and HIV services in eastern Europe (EE) vs. western Europe (WE).

Objectives: To verify the differences in TB and HIV services in EE vs. WE.

Methods: Twenty-three sites completed a survey in 2018 (EE, 14; WE, nine; 88% response rate). Results were compared across as well as within the two regions. When possible, results were compared with the 2013 survey.

Results: Delivery of healthcare was significantly less integrated in EE: provision of TB and HIV services at one site (36% in EE vs. 89% in WE; P = 0.034), and continued TB follow-up in one location (42% vs. 100%; P = 0.007). Although access to TB diagnostics, standard TB and HIV drugs was generally good, fewer sites in EE reported unlimited access to rifabutin/multi-drug-resistant TB (MDR-TB) drugs, HIV integrase inhibitors and opioid substitution therapy (OST). Compared with 2013, routine usage of GeneXpert was more common in EE in 2018 (54% vs. 92%; P = 0.073), as was access to moxifloxacin (46% vs. 91%; P = 0.033), linezolid (31% vs. 64%; P = 0.217), and bedaquiline (0% vs. 25%; P = 0.217). Integration of TB and HIV services (46% vs. 39%; P = 1.000) and provision of OST to patients with opioid dependency (54% vs. 46%; P = 0.695) remained unchanged.

Conclusion: Delivery of TB and HIV healthcare, including integration of TB and HIV care and access to MDR-TB drugs, still differs between WE and EE, as well as between individual EE sites.

Keywords: HIV; clinical management; coinfection; eastern Europe; tuberculosis; western Europe.

Fig 1

Organization and integration of healthcare services in eastern and western Europe. TB, tuberculosis; OST, opioid substitution therapy; DOT, directly observed therapy.

Fig 2

Health Care Index. Delivery of health care; composed of 13 components from the questionnaire (Question 1, 2, 7, 8, 12, 14, 20, 26, 27, 28, 40, 41 and 43). 1 point granted if the following criteria were met: Question 1: HIV and TB services located within one hospital. Question 2: HIV and TB usually treated by the same doctor. Question 7: OST available for all in need. Question 8: All patients diagnosed with TB offered HIV testing. Question 12: No fee for HIV services Question 14: Initiation of ART treatment as soon as possible after TB diagnosis. Question 40: Usage of any form of DOT. Question 41: Patient follow-up at the same hospital for the entire period of TB treatment. Question 43: Procedures in place to prevent loss to follow-up. TB diagnostics; composed of 4 questions from the questionnaire (question20, 26, 27 and 28). 1 point granted if the following criteria were met: Question 20: HIV patients regularly screened for active TB disease. Question 26: NAAT, culture, microscopy followed by NAAT/culture or NAAT followed by culture is standard diagnostic procedure for TB. Question 27: Access to rapid TB diagnostic test. Question 28: DST routinely performed for all positive cultures. DST; composed of 3 components i.e. capability to test for resistance to i) first-line drugs, ii) cycloserine OR terizidone, and iii) at least one injectable AND at least one fluroquinolone. Drug availability; composed of 6 components i.e. unlimited availability to i) first-line drugs, ii) linezolid, iii) clofazimine, iv) bedaquiline, v) cycloserine OR terizidone, vi) and at least one injectable AND at least one fluroquinolone. Missing values; Site no. 2, 8 and 10 had 1 missing value, and site no. 19 had 3 missing values. One Eastern European site excluded from this analysis due to 9 missing values.

Fig 3

Organization and integration of healthcare services in eastern Europe from 2013 to 2018. TB, tuberculosis; OST, opioid substitution therapy; DOT, directly observed therapy.

Fig 4

Development of drug availability in eastern Europe in 2013 and 2018. PAS, Para-aminosalicylsyre.