Mean Chhi Vun, MD, MPH
NCHADS Director
Cambodia’s Experience on the Scale-Up
of Collaborative TB/HIV Activities
The 15th Core Group Meeting of the TB/HIV Working Group,
November 3-4, 2009, Geneva
Demography and Health Status in Cambodia
Total pop. In 2008 = 13,69 million*
Male to Female sex ratio is 93.5*
Age group 15-49 is 47.9%** (estimated total female pop. = 2,98
million)
Rural pop. (85%) and Urban pop. (15%)*
Annual Growth rate = 1.81%* (estimated No. of baby born per
year = 540,000)
IMR in 2005 = 66 per 1,000 LB and U5MR = 83 per 1,000LB**
MMR in 2005 is 472 deaths per 100,000 LB**
Sources: * 2008 census (MOP)
** CDHS, 2005
HIV/AIDS Situation in Cambodia
First HIV detected in 1991 and first AIDS case diagnosed in 1993
Main route of HIV transmission: heterosexual intercourse (95%)
MARP Group: EW, MSM, DU including IDU, Mobile people
In 2006: HSS’06, SSS’05 and BSS’05
- Estimated HIV prevalence among adult pop. age 15-49 is 0.9% and
among pregnant women at ANC is 1%
- Estimated number of PLHAs among adult population: 67,100 (women
57,500) and AIDS patients: ~ 30,000
- No official data on HIV infected children (estimated number was 9,000
HIV infected children including 3,000 AIDS patients)
Situation of TB in Cambodia
• Cambodia is one of the 22 high-burden countries of TB in the world
• 64% of the total population has been infected with TB
• Incidence Rate of TB all forms: 495/100,000
• Incidence Rate of TB SS +: 219/100,000
• Prevalence of TB all forms: 664/100,000
• Mortality due to TB: 89/100,000
5
HIV Prevalence Among Adult pop. 15-49, between 1995 and 2006
1.8
2.3
2.52.6
2.4
2.12.0
1.8
1.6
1.4
1.2
1.1
1.1
1.5
1.7
1.9
1.7
1.5 1.5
1.3
1.21.1
0.90.8
1.2
1.7
1.92.0 1.9
1.6
1.5
1.4
1.21.1
1.00.9
0
0.5
1
1.5
2
2.5
3
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Urban Rural Total
AEM-projected prevalence of HIV among the general population aged 15 – 49 years from 2006 – 2012 (with ART available)
0.9
0.8
0.7 0.7 0.7
0.6 0.6
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
2006 2007 2008 2009 2010 2011 2012
HIV incidence* among ANC by survey year
Actual number of AIDS Patients Receiving ART
as of September 2009
36,08432,586
3,498
1,716
914
802
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
Total Adult ChildrenEs
tim
ate
d n
um
be
r o
f p
eo
ple
in
ne
ed
of
AR
T
on ART not yet on ART
(81%)
(95%) (97%)
2009 Target:
Adult: 33,500
Children: 4,300
Total: 37,800
OI&ART: 52 sites
PAC: 29 sites
9
2.50%
3.90%
5.20%
7.90%
6.70%
11.80%
10%
7.80%
0%
2%
4%
6%
8%
10%
12%
14%
1995 1996 1997 1999 2000 2003 2005 2007
HIV sero-prevalence trend among TB cases
10
TB/HIV Collaborative Activities (1)
1999 : TB/HIV Sub-Committee was set up
2001 : First TB/HIV Clinic (CENAT/JICA) at Capital City
2002 : TB/HIV Framework has been endorsed by MoH
2003 : TB/HIV Pilot Projects at 4 sites: TB screening at OI and ART service
2003: CoC including TB screening and TB diagnosed for suspected case among PLHA before to start ART
2005: Joint statement between TB and HIV Program:
- Clearly defined role and responsibility of each Program: LSM
- Joint training activities
2005: SOP for HIV testing among TB patients (HPITC)
- Option 1: Refer TB –DOT to the nearest VCCT
- Option 2 : Transport blood sample of TB to the nearest VCCT by HC
- Option 3 : Taken blood sample of TB by HC staff through outreach
and send it to the nearest VCCT
11
TB/HIV Collaborative Activities (2)
2008 : Standardized TB/HIV Monitoring tools (TB Register, Reporting,...)
2008 : TB/HIV training curriculum and Clinical manual have been developed and endorsed by MoH
2009 : Revised TB/HIV Framework has been submitted to MoH
2009 : Reviewed TB/HIV Monitoring and Reporting System assisted by WHO
2009 : 3 Is Concept have been translated into action
- TB screening among all PLHA newly diagnosed (interviewed by HIV Counselors and OI and ART team)
- TB Infection Control at CoC services
- IPT (3 sites have been piloted since 2004), but No Expansion
As a Result of the Combined Efforts
For Over the Last 10 Year, 1999-2009
13
Result of TB/HIV Training Activities
By 2008 : Health workers in 68 of 77 ODs trained on TB/HIV collaborative activities
By April 2009 : 6 batches of 5 days training program on clinical management were completed:
- Trainees: Clinicians working at TB Ward of National Hospital,
RH at Provincial and OD level, NGOs,...
- Training Site: 11 provinces, 1 NGO, 3 National hospitals
14
HIV testing and ART in TB
2007
(all ODs)
2008
( all ODs)
Total TB cases registered 36,421 39,820
Unknown HIV status after TB registered
31,136 36,942
Referred to VCCT 13,535
(43%)
19,963
(54%) HIV tested 11,820 18,645
HIV positive 497 (4.2%) 431(2.3%)
TB/HIV under CPT 1,101 1,279
TB/HIV under ART 610 733
15
Intensified TB case finding and IPT
2007 2008
HIV+ Registered at VCCT 11,641 9,511
HIV+ clients screened for TB 5,318 (46%) 5,980 (63%)
TB diagnosed 1,974 2,159
Sputum smear+ 501(25%) 522(24%)
Sputum smear- 787 (40%) 826(38%)
EPTB 686 (35%) 811(38%)
IPT (3 sites only) 77 66
Main Challenge: Human Resource
VCCT ANC
FP/BS
MNCH
PMTCT
STI
Health Staff
EPI
OI and ART
PAC
TB
CPA and MPA
Challenges
Work load of existing health staff at NCHADS, CENAT and
PHD/OD
Creating conflict of interest and benefit (competition for resources)
Limited capacity for program management including finance and
budgeting, reporting at peripheral level
Limited Capacity to own the TB/HIV collaborative activities at OD
level
Limited Understanding of the issues at all levels
Unclear about Vertical and Integrated Programming ?
Limited Capacity in strategic thinking for having new approaches or
models and Acceptance of Change.
Harmonization among partners – needs strengthening
18
Increase access to IPT through Linked Response package activity at OD level (Linked response between HIV/AIDS /STI/RH/TB):
- 2010: If enabling environment will be good and supportive ,
in 15 OD providing one stop service (increasing access to IPT from 66 to 1320 PLHA)
- Develop SOP for implementing IPT at OD level
- Standardize monitoring tools for IPT including community base support activity
- Strengthen the referral and follow up TB/HIV co-infection who are receiving IPT through LR network (HIV services and TB service and linking them with community base support activity)
- Build ownership of the OD/HC Management Team to incorporate IPT into LR package
Next steps
NCHADS
HIV/AIDS/STI
Prev., Care and treat NCMCH
(RH, FP, MNH)
MOH
Package of Services:
- Policy, strategy ...
- Planning and monitoring
- Capacity building
- Technical support
- Logistic management
- Data management
PAO
HIV/AIDS/STI
Coordinator
HIV/AIDS/STI
PMCH
(RH, FP, MNH)
Coordinator
MCH
HIV/AIDS/STI and RH: Program Management
After 2002
Good collaboration
Good collaboration
TB +TB
+IPT
+TB screening
Thank you
