Healthcare delivery for HIV‐positive people with tuberculosis in Europe

Abstract

Background In a 2013 survey, we reported distinct discrepancies in delivery of tuberculosis (TB) and HIV services in eastern Europe (EE) vs. western Europe (WE). Objectives To verify the differences in TB and HIV services in EE vs. WE. Methods Twenty‐three sites completed a survey in 2018 (EE, 14; WE, nine; 88% response rate). Results were compared across as well as within the two regions. When possible, results were compared with the 2013 survey. Results Delivery of healthcare was significantly less integrated in EE: provision of TB and HIV services at one site (36% in EE vs. 89% in WE; P = 0.034), and continued TB follow‐up in one location (42% vs. 100%; P = 0.007). Although access to TB diagnostics, standard TB and HIV drugs was generally good, fewer sites in EE reported unlimited access to rifabutin/multi‐drug‐resistant TB (MDR‐TB) drugs, HIV integrase inhibitors and opioid substitution therapy (OST). Compared with 2013, routine usage of GeneXpert was more common in EE in 2018 (54% vs. 92%; P = 0.073), as was access to moxifloxacin (46% vs. 91%; P = 0.033), linezolid (31% vs. 64%; P = 0.217), and bedaquiline (0% vs. 25%; P = 0.217). Integration of TB and HIV services (46% vs. 39%; P = 1.000) and provision of OST to patients with opioid dependency (54% vs. 46%; P = 0.695) remained unchanged. Conclusion Delivery of TB and HIV healthcare, including integration of TB and HIV care and access to MDR‐TB drugs, still differs between WE and EE, as well as between individual EE sites.

Delayed diagnosis of tuberculosis in persons living with HIV in Eastern Europe: associated factors and effect on mortality—a multicentre prospective cohort study

“…It is very likely that better integration of clinical services and diagnostic capacity can decrease delays in diagnosing TB in PLWH. HIV and TB services in Eastern Europe are only provided in one place at about 36% of health care centers [ 32 ]. While evidence of the effect of integrated health care on delayed diagnosis is not available, studies in Sub-Saharan Africa have shown improved HIV and TB treatment outcomes when integrating HIV and TB care [ 33 , 34 ].…”

“…In Rwanda, expanded access to systematic Xpert testing and standardized treatment of Rifampicin-resistant TB in both HIV-seronegative and PLWH led to the reduction of diagnostic and treatment delays resulting in reduced mortality [ 35 ]. In Eastern Europe, Xpert was used as part of routine work-up at almost all (92%) clinics in 2018, which is a major improvement compared to 2013 (54%) when the present study was conducted, so we cannot rule out improvements to delayed diagnosis in the meantime [ 32 ]. A promising additional tool for rapid diagnosis and treatment initiation at the point of care for PLWH regardless of site of TB infection is the urine-based lipoarabinomannan (LAM) test [ 36 ].…”

“…Therefore, our results likely underestimate the effect of delayed diagnoses on mortality in the population. Secondly, Eastern Europe is heterogeneous, delay of diagnosis may vary within the region and in some countries, health care has improved since the period of data collection in 2013 [ 32 ]. As drug susceptibility testing was not widely available in Eastern Europe at the time of the study and those without testing results were assumed susceptible our study very likely underestimated MDR-TB and has led to increased mortality.…”

Improving healthcare for patients with HIV, tuberculosis and hepatitis C in eastern Europe: a review of current challenges and important next steps

“…Patients were even less likely to be treated for TB and HIV by the same physician and no improvement in the availability of OST was found [39,72]. A slightly positive trend is found for HIV treatment strategies, where earlier initiation of ART regardless of CD4 count is the standard of care in 62% compared with 46% of clinics in 2013 [39,72]. Officially, all countries in Europe now have the treat-all policy [44].…”

Tuberculosis Drug Susceptibility, Treatment, and Outcomes for Belarusian HIV-Positive Patients with Tuberculosis: Results from a National and International Laboratory

“…Another important observation is that despite of DST patterns becoming available during treatment, patients were not switched to a more effec-tive regimen. This could reflect reduced drug availability at the time of study and may have subsequently improved [16,17]. Bedaquiline, for example, was not available at the time of the study, but it is now.…”