gms | German Medical Science

Introduction: HIV and TB services currently exist as parallel and independently operating structures in the Ukraine with the consequence of suboptimal care of co-infected patients. TB care is working along the historical centralized structures facing the problem of rising numbers of multiresistant TB (MDR-TB). In 2007 16% of new cases were MDR-TB cases (WHO. TB country profile Ukraine. 2007). HIV is a growing problem in the Ukraine with an estimated prevalence of 1,6% (UNAIDS/WHO Working Group on Global HIV/AIDS. Epidemiological fact sheet 2008), the most important risk factor still being intravenous drug use. With the help of interational donors HIV centers have been established in every Oblast in the recent years. This project aims to improve the cooperation between HIV and TB services and is realized by the non-governmental organisation (NGO) Connect plus e.v. with the support of the Gesellschaft für Technische Zusammenarbeit (GTZ) and the German Ministery of Health (BMG).

Methods: In September 2009 a workshop was held in Chernivtsi, Western Ukraine, with the aim of defining problems and discussing possible solutions to improve the situation. Participants were the medical directors of the TB and HIV services of 4 Oblasts (Chernivtsi, Vinitsa, Ternopil, Chmelnitzki), 2 representatives of the German NGO Connect plus e.V. as well as a German HIV and a TB specialist. At first, routine procedures were described by the Ukrainian Medical Directors. As next problems arising in the daily work with co-infected patients were presented and analyzed. Workshop results and future strategies were discussed thereafter with representatives of WHO Ukraine. The following workshops in November 2009 and February 2010 focused on a selection of problems and practical solutions.

Results:

Following main problem areas regarding the care of co-infected patients were identified:

Case finding:

• HIV patients have to be sent to TB-facilities for TB-testing, which leads to a loss of patients beacuse of fear and stigma regarding TB infection.
• Reporting about patients is lacking when patients are transferred from one to the other center.

Diagnostic:

• Diagnostic means like modern culture methods and rapid drug susceptibility testing are missing.
• Diagnostics based on PCR technics can only be performed in Kiew.
• X-Ray equipment is often of low quality and maintanance is not assured.

Treatment:

• TB medication can exclusivly be prescribed by TB specialists.
• The delivery of second line drugs and sometimes even first line treatment drugs is inconsistent.
• The quality of drugs was questioned.
• A surveillance system for co-infected patients does not exist in both facilities. - Psychosocial support for co-infected patients is not offered, because of financial issues and stigma.

Prevention:

• There is no supply of face masks neither for personell nor for patients.
• Isolation of patients with open TB can often not be realized. MDR patients are often isololated in groups.
• Instructions for postexposure prophylaxis are missing in both centers.

Discussion and future perspective:

The participants of the workshop agreed that cooperation between the different services should be improved. The workshop discussion gave sufficient information to the foreign experts to develop an initial strategy which could improve the existing structure, despite of limited financial resources in the Ukraine.

The following solution strategies were agreed on and are currently implemented:

• A medical doctor in every TB clinic at Oblast level will take responsibility for co-infected patients. The so-called “co-infectionist” will be set into place at every TB clinic at Oblast level with the task to help identifying co-infected patients, to integrate them into HIV care and to develop appropriate treatment strategies.
• A regional HIV/TB co-ordinator will supervise the project progress on site.
• The outpatient long-term care of co-infected patients will be standardized and take place in the AIDS-centres. HIV-clinicians will have to receive a permission to prescribe TB drugs.
• Additional training of clinicians will be organised locally and supported by German experts.
• A local surveillance system will be set up with additional electronic data collection according to recommendations of the International Union Against Tuberculosis and Lung Disease [1].
• Specific indicators will be monitored according to WHO guidelines in order to facilitate communication and evaluate the collaborative HIV/TB activities in future.