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Title
How does integrating HIV and TB services affect health outcomes for HIV-TB coinfected patients in Ukraine? Results from an impact evaluation
Presenter
Sabrina Eagan
Authors
S. Agarwal1, S. Curtis1, S. Mullen2, M. Skiles1, Z. Charyeva3, K. Brugh4, C. Suchindran5, O. Zaliznyak6, T. Senik6, P. Brodish1, S. Eagan7
Institutions
1MEASURE Evaluation, University of North Carolina, Chapel Hill, United States, 2MEASURE Evaluation, John Snow, Inc., Virgina, United States, 3MEASURE Evaluation/University of North Carolina at Chapel Hill, Palladium, Chapel Hill, United States, 4MEASURE Evaluation, Palladium, Chapel Hill, United States, 5University of North Carolina, Department of Biostatistics, Chapel Hill, United States, 6IFAK Institut, Kyiv, Ukraine, 7JSI, Washington, United States

Background: Ukraine is one of the 10 countries with the highest incidence of multi-drug resistant TB, and about a quarter of all TB patients are also infected with HIV. The USAID-funded Strengthening Tuberculosis Control in Ukraine (STbCU) project aims to strengthen the integration of TB and HIV services to improve timeliness of care and enhance the life expectancy of patients with HIV-TB coinfections. This study evaluated the impact of the STbCU project on HIV and TB service utilization and mortality.
Methods: The study employed a mixed-methods approach, with a quasi-experimental quantitative evaluation design, complemented by qualitative interviews. Using data abstracted from HIV and TB health facility records at baseline in 2012 (N=2,491) and endline in 2015 (N=2,993), we employed a Cox-proportional hazards model with a difference-in-differences approach to assess the impact of integration on screening, diagnostic testing, and treatment for HIV and TB at each of the health facilities.
Results: The HIV-TB integration program was associated with a significant increase in timely initiation of antiretroviral therapy (ART) in HIV centers (HR=1.49, p< 0.05), and was significantly associated with the likelihood of patients in TB centers receiving a diagnostic HIV test (HR=1.28, p< 0.05) and starting ART (HR=2.91, p< 0.001) (Figure 1). Despite improvements in timely initiation of ART, we did not detect an impact on survival. The survival models did not control for disease severity, due to a large amount of missing data on important variables such as CD4 cell count and TB disease stage.

Figure 1: ART initiation among coinfected patients at TB dispensaries
[Figure 1: ART initiation among coinfected patients at TB dispensaries]


Conclusions: The study suggests that the STbCU program has a positive impact on integrating HIV and TB services and is associated with improvements in timely testing and treatment. At the individual level, having complete records is critical to clinical decision making. At the population level, it is not possible to understand how well interventions are working without complete data. To address this, facility-level measures to ensure data completeness and quality control should be instituted. Efforts to develop digital databases with protocols for sharing confidential patient information across facilities should be strengthened.

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