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No. 1, 2012

TB PROGRAM EVALUATION NETWORK UPDATE

Known HIV Status Evaluation Project in Colorado

Background
The Colorado Department of Public Health and Environment (CDPHE) TB Program has statewide responsibility for the screening, treatment, and control of TB in that state. Colorado comprises 64 counties with populations ranging from several hundred to over half a million persons. For the years 2006 through 2010, Colorado’s reported TB case counts were 124, 111, 103, 85, and 71. There were 8 TB/HIV patients in 2006 (7.5% of total TB cases); 3 in 2007 (3.3% of total), 2 in 2008 (2.2% of total), 4 in 2009 (5.5% of total), and 8 in 2010 (8.8% of total), which was the highest annual percentage of co-infection in the previous decade. During 2006-2010, the average prevalence rate of HIV infection among TB cases of all ages was 3.8%. Given that the majority of TB cases occurring in Colorado are among the foreign-born population, often coming from areas that are not only endemic with TB but also HIV, Colorado chose to develop an evaluation plan to improve the HIV testing rates to meet the national objective of 88.7% by 2015. It is important to note that before the monitoring of “Known HIV Status” through the National Tuberculosis Indicators Project (NTIP) as a national objective, HIV testing was only stressed in those cases 15 years of age and older.

Table 1. Annual HIV Testing Rates among Active TB Cases in Colorado, 2006–2011

Year

Active TB Cases Reported

Children with active TB <15 years old

Cases with Known HIV Status

% of Cases w/ HIV Status Known

2006

124

7

110

88.7

2007

111

7

93

83.8

2008

103

10

88

85.4

2009

85

11

73

85.9

2010

71

5

68

95.8

2011*

69

8

61

88.4

*Data are preliminary

The goals of Colorado’s Known HIV Status evaluation project were to examine, evaluate, and improve TB control and prevention activities as they relate to HIV testing and known HIV status of all active TB patients in the state and to develop capacity building and technical assistance activities as needed for local health department staff. During 2010, the focus was on assessing the education and training needs of county health department TB control staff specific to HIV testing. The initial assumption was that there was a cohort of public health nurses, probably rural, that were uncomfortable with HIV testing and the discussion of risk behaviors (sexual and drug-taking), leading to lower-than-desired HIV testing rates. As the survey results would show, we had much to learn.

First Steps
When the Deputy TB Program Manager joined the program in the summer of 2010, he was tasked with scaling up the HIV testing evaluation project. A line list of previous and current active TB cases with no accompanying HIV test result was created and analyzed in hopes of ascertaining trends or deficiencies in acquiring HIV test results from patients. The next step was developing a knowledge, attitudes, and practices (KAP) survey to administer to local health department TB staff related to HIV testing of active TB patients, with an eye toward informing the development of methods, activities, or policies to improve the HIV testing rate among active TB patients.

The TB Program sought the expertise of Dr. Susan Luerssen, a member of the CDPHE HIV/STI Section’s Research and Evaluation Unit, to help develop a survey with succinct and measurable language that minimized ambiguity in the survey answers (the final survey questions are available at the TB-PEN wiki page http://tbpen.pbworks.com/w/page/4124488/FrontPage or from Pete Dupree at peter.dupree@state.co.us or 303-692-2677). Questions covered regional, institutional, and survey-takers’ personal capacity and beliefs around HIV testing, as well as questions designed to probe for both individual and systemic barriers to HIV testing. A link to the confidential online survey was sent out to all TB Program partners throughout the state, with an explanation of why the survey was being offered and how the information would be used. In early 2011, the survey was offered anonymously online for 2 weeks; 41 completed surveys were submitted and analyzed.

TB in Colorado

Survey Results
Addressing personal and agency capacity, only 34% of the respondents personally provided HIV testing services in their role in TB control; 61% of the respondents noted that someone in their health department offered such services. For those respondents who stated that no HIV testing services were offered in their agency, the primary reason given was that another agency nearby offered it; the second most common reason was a lack of funding. When looking at established HIV testing policies and procedures, only 27% answered in the affirmative; another 27% said “do not know,” which is a concern in itself. Of the remaining 46%, a majority stated that they referred to CDPHE’s or the Denver Metro TB Clinic’s TB manual in such circumstances since their agency did not have such policies/ procedures regarding HIV testing of all active TB patients. Of those respondents whose agency offered HIV testing services, 35% offered conventional venipuncture testing using ELISA or Western Blot methodology, 46% offered rapid finger prick or oral transudate HIV testing, and the remainder gave differing answers such as “we let MD decide test type.”

10. Is HIV testing offered to all patients with active TB disease at your agency?

Yes

20

49%

No

11

27%

Don't Know

10

24%

Survey Analysis
Below is an excerpt from the responses to two key questions from the survey, followed by a brief analysis:

The “no” responses are critical. Coupled with the responses to Question #11 below, we find that the TB Program has not been directive enough or has otherwise left the HIV testing imperative ambiguous. The 10 “Don’t Know” responses to this basic service are equally concerning.

11. If no, please explain the circumstances under which a patient with active TB disease would not be offered an HIV test, or list any barriers your agency faces to offering HIV tests to all patients with active TB disease.

19 total responses presented as the top 3 recurring themes

#1 response: The cost; two types of responses: 1) expense to the local HD and 2) patient lacks funds to pay for an HIV test.
#2 response: ignorance of HIV testing directive
#3 response: no HIV or TB cases in county

Scariest response: “We don’t get many active or latent cases so we don’t think to ask about HIV nor are we usually prompted by the state to do so.”

When comparing these survey results to the table of annual HIV testing rates (Table 1), it’s apparent that the knowledge gap regarding the importance of HIV testing of all active TB patients is shrinking or has disappeared entirely, and that our assumptions that there was HIV testing resistance from some nurses was completely wrong. Given the findings here, a clear and concise policy on HIV testing of active TB patients is needed to avoid any further confusion. There were repeated responses that some survey-takers were unaware of any HIV testing requirement. The fault for this falls to CDPHE’s TB Program.

It is necessary to make abundantly clear what’s expected of TB case managers, public health nurses, and even primary care providers caring for TB patients. Simply put, if they are offering care and treatment to a patient with active TB disease, that patient should be offered and given an HIV test as a part of his/her continuum of care (or there needs to be a recorded HIV test result in the past 3 months).

This policy might be framed as a protocol, complete with an algorithm to guide the TB/public health staff. The protocol should guide the staff person through different scenarios, such as the patient has no primary care provider; the health department has neither in-house HIV testing services nor funds for off-site testing; or the patient cannot pay out of pocket yet has no health insurance. With HIV testing, CDPHE will begin to meet one of its key program evaluation objectives, “Active TB patients without a recent (last 3 months) HIV test result will be identified and addressed by TB Program staff (via RVCTs and/or weekly Case Management) with the appropriate TB nurse case manager overseeing that patient’s care and treatment.”

It may ultimately suffice to simply continue the chorus loud and clear—the HIV status of every active TB patient in Colorado will be known, regardless of patient age, race, gender, socioeconomic status, or country of origin, based on established medical and public health standards. It is unacceptable to discover, late in the regimen of a patient who is not improving, that the patient is and has been HIV-infected during treatment. If a patient refuses an HIV test, at least it can be assured they’ve been given the opportunity to be tested; they would have to sign a waiver stating that they’d been given educational material about the importance of knowing one’s HIV status, a copy of which would be kept by the TB Program. Their documented refusal would be prefaced by the educational component highlighting the dangers of coinfection such that the TB patient can make an informed decision about his/her long-term health. An HIV test result available in 20 minutes via rapid testing would be an enticement to those unsure or ambivalent about being tested.

Survey Limitations
Because this was an anonymous KAP survey, it’s not possible to assess how many respondents came from large urban TB clinics, with experienced case management skills due to a consistent volume of TB cases, and how many came from more rural public health agencies working with smaller populations that don’t see a high volume of active TB or HIV. This was a convenience survey and may not be representative of the statewide TB control staffs’ knowledge, attitudes, and practices around HIV testing.

Next Steps
An HIV testing policy is being incorporated into the updated CDPHE TB Manual that is currently being drafted by Colorado’s TB Program. A referral network for agencies not offering HIV testing is being considered and a laboratory HIV testing courier service (using the existing TB specimen courier service) is being developed. The courier service would transport whole blood to the state lab for HIV testing in a timely manner in situations where the local health department nor nearby agencies have a rapid HIV testing capacity.

—Submitted by Pete Dupree, MPH
Colorado Dept of Public Health and Environment
TB PEN

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