Integrated TB and HIV care for Mozambican children: temporal trends, site-level determinants of performance, and recommendations for improved TB preventive treatment

Mariana Siapka,Megan Gleason,Criménia Muthemba,Maria Inês De Deus,Benedita Jose,Peter Kerndt,W Chris Buck,Jessica Greenberg Cowan,Ferreira Ferreira,Beatriz Simione,Hanh Nguyen,Lopa Basu,Carla Xavier

doi:10.1186/s12981-020-00325-9

Abstract

BackgroundPediatric tuberculosis (TB), human immunodeficiency virus (HIV), and TB-HIV co-infection are health problems with evidence-based diagnostic and treatment algorithms that can reduce morbidity and mortality. Implementation and operational barriers affect adherence to guidelines in many resource-constrained settings, negatively affecting patient outcomes. This study aimed to assess performance in the pediatric HIV and TB care cascades in Mozambique.MethodsA retrospective analysis of routine PEPFAR site-level HIV and TB data from 2012 to 2016 was performed. Patients 0–14 years of age were included. Descriptive statistics were used to report trends in TB and HIV indicators. Linear regression was done to assess associations of site-level variables with performance in the pediatric TB and HIV care cascades using 2016 data.ResultsRoutine HIV testing and cotrimoxazole initiation for co-infected children in the TB program were nearly optimal at 99% and 96% in 2016, respectively. Antiretroviral therapy (ART) initiation was lower at 87%, but steadily improved from 2012 to 2016. From the HIV program, TB screening at the last consultation rose steadily over the study period, reaching 82% in 2016. The percentage of newly enrolled children who received either TB treatment or isoniazid preventive treatment (IPT) also steadily improved in all provinces, but in 2016 was only at 42% nationally. Larger volume sites were significantly more likely to complete the pediatric HIV and TB care cascades in 2016 (p value range 0.05 to < 0.001).ConclusionsMozambique has made significant strides in improving the pediatric care cascades for children with TB and HIV, but there were missed opportunities for TB diagnosis and prevention, with IPT utilization being particularly problematic. Strengthened TB/HIV programming that continues to focus on pediatric ART scale-up while improving delivery of TB preventive therapy, either with IPT or newer rifapentine-based regimens for age-eligible children, is needed.

Highlights

Pediatric tuberculosis (TB), human immunodeficiency virus (HIV), and TB-HIV co-infection are health problems with evidence-based diagnostic and treatment algorithms that can reduce morbidity and mortality
A total of 312 TB sites reporting 2350 co-infected children, and 718 HIV sites reporting 22,898 children newly enrolled in care, were included in the study
TB program trends Our descriptive analysis at a national level indicates that 99% of TB patients were tested for HIV in 2016, up from 90% in 2012

Summary

Introduction

Pediatric tuberculosis (TB), human immunodeficiency virus (HIV), and TB-HIV co-infection are health problems with evidence-based diagnostic and treatment algorithms that can reduce morbidity and mortality. Given the high rates of HIV-TB co-infection, well-integrated care programs for these diseases are critical to ensure that new cases are detected and that children receive the full package of available preventive and therapeutic evidence-based interventions [5,6,7]. This begins with routine screening, and both WHO and Mozambique national guidelines recommend active case-finding through provider-initiated testing and counseling (PITC) and/or routine optout testing for HIV in all children with TB, as well as routine symptom-based screening for TB during all pediatric HIV consultations [8,9,10,11,12]

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