Integrating TB-HIV services with maternal and child healthcare

Nenet L Ortega, CNS Special Correspondent
TB is the third leading cause of death for women worldwide in their childbearing years. Maternal TB leads to poor outcome for the mother and child, especially when the mother is infected with HIV. Intensified case finding, isoniazid preventive therapy (IPT), and infection control ("3 Is") remain the cornerstones of TB-HIV collaborative activities, but have not been systematically integrated into maternal and child healthcare (MCH) settings.

TB thus is an important women's issue but  has  not been given enough  recognition. TB is also the leading opportunistic infection among women living with HIV.  According to WHO, infant and  maternal mortality in women living with HIV and TB increase by almost 300% and, if  not properly addressed during pregnancy, may lead to perinatal death/stillbirth, premature or low birth weight babies.

Integrating TB and HIV services into maternal and neonatal child health (MNCH) services can save lives of mothers and children. This integration of services is highly recommended, especially in high burden countries. The  inter-connection  of maternal, newborn and child health service  opens an important avenue for the  integration of TB and HIV services  holistically—the one stop shop approach-- and contributes to:
(i) reduction in new TB and HIV infections,
(ii) immediate access to diagnosis and treatment and improves over all MCH outcomes.

Several cost effective, life saving MNCH-TB-HIV integrated service packages have been introduced in countries with a high burden of TB and/or HIV. Lessons from these examples of integrated packages of services can be replicated in other areas. Countries piloting the approach can scale up the intervention strategies.

‘TB in pregnancy’ study in Kenya was focused on detecting active TB among HIV infected women. TB detection has been integrated into the ongoing prevention of mother to child transmission (PMTCT) services in two of the PMTCT clinics in western Kenya. All pregnant women coming in for ante natal care are screened for TB (regardless of their HIV status ) on the basis of WHO recommended TB symptoms -- fever, cough, weight loss, night sweats.  Among the pregnant women, 288 were HIV infected, and were enrolled in the study. Apart from their symptomatic TB screening HIV, their CD-4 count, and whether they are on ART were considered. These are  determinants of their immune suppression and potential TB infection. According to Lisa Cranmer, screening women just on the basis of TB symptoms is not enough. Based on her study, combination methods of TB diagnosis among HIV positive pregnant women should be used to really determine active TB. Using the combined urine lipo arabino mannan (LAM)  dip strips and Xpert has proved to be more useful in detecting TB among HIV positive pregnant  women. Clearly, the integration of TB services in a PMTCT clinic saves lives of mothers and newborns, and  prevents further transfer of infection to household members.

The Elizabeth Glaser Pediatric AIDS Foundation is implementing TB case finding and initiation of isoniazid preventive therapy (IPT) in maternal, newborn and child health clinics in Lesotho. An implementation flow chart has been developed to guide the providers in the step by step process of diagnosing TB among women clients in the antenatal care clinics. A total of 800 women from the two clinics were engaged, out of which 160 women were HIV infected. All the women were screened using the WHO TB symptoms,  and direct sputum smear microscopy. Only one smear turned out to be TB positive. IPT was initiated in eligible women with TB symptoms, thereby eliminating their potential of infecting others, especially household members, and preventing potential maternal problems in case TB infection progressed.

According to the Centres for Disease Control and Prevention (CDC) in Atlanta USA, there is a great need to  start integrating TB and HIV services in maternal health settings. Why is this so? Courtney Emerson of the TB-HIV Team at CDC said that UK studies have shown that TB incidence is increased during pregnancy and postpartum period and has been resulting in TB related deaths making 10 million orphans worldwide. More research needs to be done in order to get answers in data gaps. For instance, national surveillance systems are not designed to capture data on pregnancy status of women and neither TB nor antenatal/ PMTCT monitoring and evaluation tools are able to capture data on TB burden in women during pregnancy, and during postpartum and breastfeeding period. She also added that surveillance systems are not designed to capture contact tracing information, family based HIV testing or screening for TB.

There was a roaring consensus from the delegates attending the 45th Union World Conference on Lung Health to 'create a working group that will deal with maternal newborn and child health and TB-HIV' and to develop a clear roadmap for integrated  health systems where all healthcare providers are engaged, especially at the community level. For further prevention of TB among women, professional practising midwives are being eyed as strong frontline providers of TB information and referral to a diagnostic and treatment facility.

Nenet L Ortega, Citizen News Service -CNS
10 November 2014
(WHO Global Tuberculosis Programme is supporting CNS for providing coverage on TB-HIV and community engagement related issues from the 45th Union World Conference on Lung Health in Barcelona, Spain. Email: nenet@citizen-news.org)

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