The document summarizes efforts to integrate TB and HIV services in Ukraine. It describes challenges including a highly vertical healthcare system, lack of cooperation between AIDS and TB services, and ensuring access to quality second-line drugs for drug-resistant TB. Methods used to address this include establishing a TB/HIV working group, training health workers, and integrating prevention and treatment services. Outcomes include signing collaboration agreements and expanding integrated care services to over 1,000 clients. Further reforms are needed to fully integrate services and ensure long-term sustainability.

1. 42nd Union World Conference on
Lung Health
26-30 October 2011 Lille, France
Scaling up partnership for TB/HIV integration
in the vertical health care system of Ukraine
Zahedul Islam
International HIV/AIDS Alliance in Ukraine
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2. Outline
Issues
Background
Methods/Activities
Challenges
Outcomes
Conclusion/next steps
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3. Outline
Issues
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4. Epidemiology
Number of officially registered HIV-positive cases- 185 147 while its estimated
about 350 000 adult are infected
Number of officially registered TB cases -36 409
TB patients with known HIV status -34 621 (95%)
TB patients that are HIV-positive - 4 501(13%)
HIV-positive TB patients started on ART -50 %
Cases tested for MDR-TB-14 034
Confirmed cases of MDR-TB -5 336
MDR-TB patients started treatment -3 870
Ukrainian epidemics further fueled by injecting drug use
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Tuberculosis is the key reason of death in people living with HIV/AIDS
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5. TB and HIV incidence in Ukraine: 1995-2010
90 84,8
80,9 79,8
TB HIV/AIDS
80 75,6
77,5 83,2
77,9 74,4
70
68,6
68,4
60 55,3 60,2
54,4
per 100 000
50
41,7 49,1 44,7
45,8 38,0 40,9
40 34,4 43,2
30 26
29,2
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17 17 18
12 15
20 14
12 13
10
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Center of Medical Statistics of the Ministry of Health of Ukraine, 2010
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6. HIV-
HIV-TB dynamics: 1999-2009
1999-
8 7.4
6.3
5.5
6 4.9
5
per 100,000
4.3 3.9
4 3.3 3.4
2.5
1.99 2.4
2
2 0.61 0.85
1.4
0.44 0.53
0.22 0.1 0.25 0.42
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Incidence Mortality
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7. MoH HIV/TB Management Structure
Ministry of Health
State Servises
National AIDS Center National TB Center
Regional Healthcare Department
Regional AIDS Center Regional TB Dispensary and TB Hospital
Infections District Polyclinic Cabinets TB District Polyclinic
Disease hospitals s of trust laboratory hospitals s
Laborator 1-3 levels
y
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8. Outline
Background
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9. Alliance Ukraine activities
-Principal Recipient (PR) for GFATM Round 1 HIV (2004-2008) and
Co-PR for Round 6 HIV (2008-2012)
-Key Sub Recipient (SR) for GFATM Round 9 TB program 2011-2015
-Strengthen the collaboration Mechanism at National, Regional and Local
Levels
-Decrease the burden of TB in PLWHA
-Decrease the burden of HIV in TB patients
-Scaling up NGO activities aimed at HIV prevention to the area of TB
treatment
-Access to quality treatment (advocacy)
-Access to high quality integrated care (HIV, TB, HCV,OST,STI-
diagnostics and treatment) services to MARPS specially focusing on HIV 11
+ IDU’s
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10. Outline
Methods/Activities
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11. Strengthening collaboration
Cross-sectoral HIV/TB working group (WG)
Trilateral memorandum among Ukrainian AIDS Center, All-Ukrainian TB
Control Center and Alliance;
Biannual reporting meetings for TB and HIV program managers to
share experience and plan joint activities.
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12. Decrease the burden of TB in PLWHA
Revision and development of the national protocols for providing
medical support to HIV/TB patients.
Support in creation of diagnostics boxes in AIDS centers and in penal
institutions aimed at meeting infection control requirements
Trainings for NGOs and TB dispensaries and AIDS centers staff on the
main aspects of TB infection: the specific of HIV prevention services
provision for people with TB, M&E and data collection, management and
reporting on TB and HIV.
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13. Decrease the burden of HIV in TB patients
Technical support in creating proper terms and conditions for PITC
(group and individual) in TB control institutions
Development of the guidelines:
- on conducting VCT among the patients of TB control facilities;
- on preventive cotrimoxazol treatment for HIV/TB patients;
- of the mechanisms for passing ART and SMT medications to the
patients who are treated in in-patient units of TB control facilities.
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14. Civil Society response
Reaching TB population with HIV prevention and harm reduction
services by integrating these services to the TB treatment sphere
Integration and co-location of services under GF programs
Access to quality treatment
Access to high quality integrated care (HIV, TB, HCV,OST,STI-
diagnostics and treatment) services with NGO support
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15. Coordination
Develop a mechanism of cooperation between HIV and TB
services:
 Coordination of TB/HIV reference group
Participation in the development of the MOH order of the mechanism of
cooperation between HIV and TB services
New clinical protocols development and reviewing of the old ones
Strengthening the monitoring system on HIV + TB
TB/HIV monitoring system assessment
Development of National TB/HIV M&E plan with a list of TB/HIV indicators
Coordination of the unified electronic data collection tool development and
implementation in TB and HIV services
TB and AIDS Centers’ staff capacity building in the area of TB/HIV M&E
Conducting a number of special surveys
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16. Partnership
Stakeholder approach (NGO’s, MoH, PLHA network, WHO)
Working groups
Partnership through GFATM programs
Using sub-grant and voluntary MoU as partnership management tools
Building relationships between civil society and TB services ( well
developed in HIV but far behind on TB)
10 NGOs working on HIV/STI prevention among TB patients
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17. Integrated care models for HIV+ IDU’s
Organization of HIV, TB, HBC treatment in facilities of healthcare
institutions which provide MAT(such as narcological clinics).
Provision of MAT within healthcare facilities which provide
specialized treatment of HIV, TB, HCV (AIDS-centers, TB- clinics).
Provision of MAT, HIV/TB treatment at healthcare institutions of
primary care, general hospitals.
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18. Outline
Challenges
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19. Access to SLD’s in Ukraine
Information on registration of SLDs in Ukraine to be procured through the Green Light Committee
Round 9. Decrease the burden of TB in PLWHA
International name of Information on registration
No. drug Form of release Manufacturer
1 Kanamycin (Km) GDF eligible manufacturer not willing to register.
2 Capreomycin (Cm) GDF eligible manufacturer not willing to register.
Coated tablets, 500mg each,
3 Levofloxacin (Lev) MacLeods Pharmaceuticals Ltd., India: registered.
No.5, No.10
Coated tablets, 400mg each,
4 Moxifloxacin (Mfl) No eligible manufacturer with registered product.
No.5 in a blister
Capsules, 250mg No.100
5 Cycloserine (Cs) MacLeods Pharmaceuticals Ltd., India: registered.
(10×10)
Oral powder, 5,52g, № 25, №
6 PAS Olainpharm, Latvia: registered.
300
Coated tablets, 250mg each
7 Ethionamide (Et) MacLeods Pharmaceuticals Ltd., India: registered.
No.50 (10×5)
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20. Risks in supplies of SLDs
 Registration in Ukraine: only registered medicines can be used; not all
Round 9. Decrease the burden of TB in PLWHA
GDF eligible manufacturers wish to register. At that, registration is highly
bureaucratic process, which requires around 6 months.
 When manufacturers’ contracts with GDF and/or ERP validity run out
manufacturers lose their eligibility with GDF; this seems to happen often and
it looks unpredictable. Consequences may be as serious as treatment
interruption and failure of the program.
 Due to new WHO treatment recommendations, changes in PR’s plans and
other reasons final approval of the medicines list and quantities is
dramatically delayed, which delays procurement and treatment.
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21. Challenges
 Highly vertical heath care system of Ukraine is a major obstacle for HIV/TB
integration.
 Frequent changes of management in the government leadership
 Lack of cooperation between AIDS and TB services: information sharing,
joint planning, M&E performance measures and indicators.
 Access to quality-assured second-line drugs
 Lack of adequate financing
 Stigma and discrimination
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22. Outline
Outcomes
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23. Achievements
Signed a trilateral MoU among Ukrainian AIDS Center, Ukrainian TB Control
Center and Alliance Ukraine on partnership and collaboration
A broader MoU was signed by the R9 PR (The Foundation for Development
of Ukraine), Regional Healthcare Departments and all sub-recipients
Creation and coordination of TB/HIV reference group
TB/HIV protocols and orders review
During last 7 months, around 150 service providers were trained from TB
and HIV services
During last 7 months, more than 2832 TB patients were covered with HIV
prevention services.
1220 clients were covered with integrated care services (HIV/TB/SMT)
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24. Presentation outline
Conclusion/Next steps
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25. Conclusion
 Health care reform is needed in the area of HIV and TB and drug treatment.
 Integration of these services should be replicated throughout the country to
provide better access for MARPs.
 With the leadership from the Government a functional coordination
mechanism between all these services must be in place.
 Ensure quality-assured second-line drugs
 State financing is a cornerstone of sustainability
 Further develop and mobilize civil society to demand accountability and to
address stigma and discrimination
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26. Merci!
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