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Access Barriers to Comprehensive Care for People Affected by Tuberculosis and Human Immunodeficiency Virus Coinfection in Peru, 2010–2015*

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Access Barriers to Comprehensive Care for People Affected by Tuberculosis and Human Immunodeficiency Virus Coinfection in Peru, 2010–2015* Pan American Journal Original research of Public Health Access barriers to comprehensive care for people affected by tuberculosis and human immunodeficiency virus coinfection in Peru, 2010–2015* Lisset García-Fernández,1 Carlos Benites,1 and Byelca Huamán1 Suggested citation (Original Article) García-Fernández L, Benites C, Huamán B. Barreras para el acceso a la atención integral de las personas afectadas por la coinfección por tuberculosis y virus de inmunodeficiencia humana en Perú, 2010–2015. Rev Panam Salud Publica. 2017;41:e23. ABSTRACT Objective. Identify the programmatic barriers that hinder access to comprehensive care of patients with tuberculosis and human immunodeficiency virus (TB/HIV) coinfection. Methods. This is a mixed-method study. Qualitative research was conducted via in-depth interviews with key actors and the quantitative component involved cross-sectional descriptive analysis of programmatic data from 2010-2015 on tuberculosis and HIV programs at health facilities in the cities of Lima and Iquitos. Results. Twenty-two key actors in seven establishments were interviewed. The iden tified barriers were: little or no coordination between tuberculosis and HIV teams, separate manage- ment of tuberculosis and HIV cases at different levels of care, insufficient financing, limited or poorly trained human resources, and lack of an integrated information system. It was found that HIV screening in TB patients increased (from 18.8% in 2011 to 95.2% in 2015), isoniazid coverage of HIV patients declined (from 62% to 9%), and the proportion of deaths among TB/ HIV coinfection cases averaged 20%. Conclusions. There is poor coordination between HIV and TB health strategies. Management of TB/HIV coinfection is framented into different levels of care, which has an impact on comprehensive patien care. As a result of this research, a technical document was prepared to establish joint procedures that should be implemented to improve comprehensive care of TB/HIV coinfection. Keywords Coinfection; tuberculosis; HIV; Peru. People infected with the human im- Andean region of Latin America it is CD4 counts below 200, need to receive munodeficiency virus (HIV) are 29 118.4 per 100 000 population (2). In con- prophylaxis with isoniazid, as recom- times more likely to develop tuberculo- trast, the worldwide incidence of tuber- mended in various management guide- sis than those who do not have HIV (1). culosis in people without HIV is 98.7 lines (3–5). Globally, the incidence of tuberculosis per 100 000 population (2), while in the In 2013, there were 1.1 million people in people living with HIV (PLH) is Andean region of Latin America it is with tuberculosis/HIV (TB/HIV) coin- 105.2 per 100 000 population, and in the 117.9 per 100 000 population. Further- fection in the world (1). Deaths from tu- more, PLH who do not receive antiret- berculosis in PLH dropped from 540 000 * Official English translation provided by the Pan roviral therapy (ARVT) are at nine in 2004 to 360 000 in 2013 (6). However, American Health Organization. In the case of dis- times greater risk of contracting tuber- tuberculosis remains the leading cause of crepancy between the two versions, the Spanish original shall prevail. culosis than patients who do receive death in PLH around the globe (6). 1. National Health Strategy on the Control and treatment (2). The difference is 15 times In Peru, 1,094 cases of TB/HIV coinfec- Prevention of Sexually Transmitted Infections and greater in individuals with CD4 counts tion (7) were reported in 2014—an overall HIV/AIDS. Ministry of Health, Peru. Please direct correspondence to Lisset García-Fernández, of less than 200 cells/mL (2), so all TB/HIV coinfection rate of around 3% [email protected] AIDS patients, especially those with (8). The tuberculosis and HIV epidemics Rev Panam Salud Publica 41, 2017 1 Original research García-Fernández et al. • Access barriers to comprehensive care for people affected by TB/HIV coinfection in Peru also have a shared epidemiological distri- comprehensive care of patients with TB/ key agents for research, to understand bution (8). Programmatic data indicate HIV coinfection. Information was gath- barriers in health systems that obstruct that HIV and tuberculosis are concen- ered from services that provide care to implementation as well as to identify trated mainly in urban areas along the tuberculosis and HIV patients, to iden- solutions to these barriers. Embedded coast and in the jungle region, and affect tify any programmatic gaps in TB/HIV research on program implementation in particular men in the economically ac- coinfection care. That information serves supports the effectiveness of existing tive population (7, 9). Accordingly, the as input for preparing and implementing processes and effective health policies proportion of TB/HIV coinfection is a joint national policy addressing the through the utilization of research con- higher in the Loreto (6.4%), Callao (6.3%), TB/HIV problem. ducted as a part of the implementation and Northern Lima (5%) regions (8). process (Figure 1). A detailed description To reduce the problem of TB/HIV MATERIALS AND METHODS of implementation of the research meth- coinfection, since 2004, the World Health odology can be found in the iPIER con- Organization (WHO) (10) and other in- This study is part of a new initiative: cept paper on barriers to timely access to ternational organizations (11) have rec- “Improving Program Implementation comprehensive care for people affected ommended implementing collaborative through Embedded Research (iPIER)”, by TB/HIV coinfection in Peru. activities on TB/HIV. The WHO recom- developed by the Alliance for Health A mixed-method study was conducted. mendations focus on implementing (or Policy and Systems Research (AHPSR), It consisted of a qualitative component to strengthening) integrated services for in collaboration with the Pan American identify barriers in caring for patients TB/HIV coinfection, reducing the TB/ Health Organization (PAHO). The iPIER with TB/HIV coinfection, and a quantita- HIV disease burden, and providing early model makes program implementers tive component to identify programmatic ARVT (10). As a result, gains have been made around the globe, with access to ARVT for patients with TB/HIV coinfec- FIGURE 1. Research flow chart tion rising from 47% in 2012 to 65% in Health policy and program 2013 (6). In Latin America, ARVT cover- - Existence of national HIV and TB strategies age was 76%; however, in the countries - Known incidence and foci of TB/HIV coinfection of this region, collaboration between tu- berculosis and HIV programs has been hindered by the lack of joint national pol- icies and the absence of integration activ- Problems and barriers to implementation ities at the operational level (12). Problems: The Ministry of Health of Peru, through - Patients do not receive early comprehensive care the national health strategies for tubercu- - Low HIV screening coverage in PAT and INH chemoprophylaxis coverage losis and HIV/AIDS, is tasked with pre- Barriers: venting and controlling these health - Weak interaction between the two strategies for case diagnosis problems. The National Tuberculosis and clinical management Standard (13) and National HIV Standard - Poor programmatic and operational coordination among the (14) outline what interventions should be different levels of care (information, logistics, etc.) implemented for each of these diseases. - Separate technical standards for the diagnosis and management of TB and HIV cases. However, reports show low coverage in the coinfection indicators, which suggests difficulties in implementing and coordi- Implementation strategy nating care for patients with TB/HIV - Analyze access barriers to diagnosis and management of coinfection by the two programs (which coinfected patients are called “strategies” in Peru). - Address the training needs of TB and HIV health teams at the One of the main difficulties in caring intervention sites - Standardize programmatic information at the national, regional, for patients with TB/HIV coinfection is and local levels that care is provided separately for tu- - Hold workshop to review barriers and build consensus for berculosis and HIV. Furthermore, most coordinating operational activities among the different levels of care patients with TB/HIV coinfection are - Hold coordination/management meetings between the two strategies treated for tuberculosis in a primary care - Devise a joint work plan facility, but receive ARVT in another fa- cility, generally at the secondary or terti- Changes in the health policy or program ary level. There is not a detailed - Preparation of a single standard of care for patients with TB/HIV understanding of which elements pre- coinfection vent the tuberculosis and HIV health - Consensus-based programmatic and operational information at strategy teams from coordinating actions the national, regional, and local levels (continuing training, to improve care for patients with TB/ screening, treatment, information system, etc.) HIV coinfection. - Greater interaction between the TB and HIV programs - Preparation of an intervention plan The objective of this research was to identify programmatic barriers to HIV, human immunodeficiency virus; TB, tuberculosis; INH, isoniazid; PAT, people affected by tuberculosis. 2 Rev Panam Salud Publica 41, 2017 García-Fernández et al. • Access barriers to comprehensive care for people affected by TB/HIV coinfection in Peru Original research gaps. The
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