Department of Health’s Administrative Order (AO) 2014-0005 [21] mandated that PICT be offered to TB patients in TB DOTS facilities in Category A (high HIV prevalence) and Category B (medium to high HIV prevalence) as identified by the Priority Areas for HIV Intervention [22]. In other non-priority areas, TB patients are informed of the benefits of HIV testing and referred to Social Hygiene Clinics (primary health care facilities that specifically provide sexually transmitted diseases (STI) testing and treatment). AO 2017-0019 [23] limited the conduct of HIV testing to MTs who are certified as “HIV-test proficient”, and that reactive samples from patients be brought to the National Reference Laboratory / San Lazaro Hospital STD AIDS Cooperative Central Laboratory (NRL / SLH SACCL) for confirmatory testing. This AO also distinguished between ‘HIV screening’ and HIV ‘testing’, the former is considered as the first step in the diagnostic algorithm, while the latter is only considered as a risk-screening tool.
The themes that emerged from the thematic analysis are as follows: (1) Policy bottlenecks affecting implementation of current policies related to TB/HIV (or lack thereof); (2) Operational bottlenecks in the form of operationalization differences between the TB and HIV programs; (3) Human resource bottlenecks in the coordinated approach between HIV and TB focused programs resulting from manpower issues, and lastly, (4) Patient-related factors such as their perceptions and health seeking behavior contributing to the hurdles in TB/HIV collaboration in the Philippines.
Policy bottlenecks to integrated TB/HIV collaboration
That the Philippine health system is devolved, and therefore programmatic decision-making is in the hands of mayors, was identified as one of the health system variables that affected TB/HIV collaboration. Stakeholders lamented that in some cities, mayors do not consider TB and HIV co-infection as priority hence limit allocation of resources; upper-level program managers felt powerless as they can only advocate increasing TB/HIV activities to the local governments. Thus, most of the TB/HIV programs are dependent on donor-driven programs.
[Implementation] is highly dependent on how a city is run. The region cannot meddle as well, we can only augment the manpower, advocate the mayors so they invest in health. We also need to convince barangay officials to get on board… we need to have good partnerships with our local governments so that they believe TB/HIV activities are good for the community… ask them also to be part of activities because if you just hand them down from top to bottom, it will not happen. They will be insulted, they are devolved. (Regional Infectious Diseases Program Manager)
Stakeholders felt that the AO on TB/HIV collaboration limited HIV testing among TB patients to certain areas when there should be a need to implement it, especially in adjacent areas bordering Category A and B areas.
Operational bottlenecks to integrated TB/HIV collaboration
Differences in how the TB and HIV programs handle patient information were also identified as bottlenecks to integration. A program manager said that the epidemiology of HIV among TB patients in their area is not known because of privacy restrictions set by Republic Act 8504 (Philippine HIV/AIDS Act of 1994, the applicable law at the time of the study). Thus, it became difficult for upper-level managers to advocate the importance of TB/HIV collaboration in cities.
In a devolved system, the real bosses are the mayors and governors. When they ask us about the burden of TB and HIV, we are only able to provide a general picture. From a political person’s perspective, they would want to see the ‘real’ burden right, in terms of statistics? But we don’t have that now. There’s no study which shows how many TB patients have HIV, or what is the risk of acquiring TB among HIV patients and vice-versa. (Provincial Infectious Diseases Program Manager)
AO 2017-0019’s provision that blood samples of reactive patients in rapid diagnostic test kits be sent for confirmatory testing in NRL / SLH SACCL has been identified as one of the contributors to delays in linkage to care. Stakeholders reported issues in TB/HIV service delivery networks, in particular, when TB patients diagnosed in Category A cities return to their hometowns, which are not ‘priority’ areas.
There are patients who get diagnosed with TB in the National Capital Region, but they go back to the provinces and they continue their treatment there. But PICT is yet to be introduced in those areas. So, their condition gets worse, undetected. (PLHIV organization representative)
While staff are trained to provide PICT to TB patients, some health centers do not have resources to provide integrated TB/HIV care. Hence patients are referred to social hygiene clinics within service delivery networks. Stakeholders felt that these networks need institutionalization, as these are currently informal physician-to-physician referrals.
We are still struggling with the concept of service delivery networks. For small health centers, they struggle to look for social hygiene clinics or satellite treatment hubs for HIV. (Regional Infectious Disease Program Manager)
Stakeholders also mentioned the lack of communication between government and private healthcare institutions, between TB and HIV care providers, and TB and HIV NGOs; some even reported encountering resistance from local government units.
The way to go is to expand the network of available providers because the public sector is overburdened. The private sector is there, but we have not really formally engaged with them so each has its own pockets of population where they deliver services but it is not a concerted effort. (International HIV non-government organization (NGO) representative)
TB/HIV collaboration’s implementation also needs to be more operationally defined in the community. Stakeholders further attributed this discordance between the upper and lower levels of the health system is because those at the community may not be able to comprehend the technical language of AOs written in English. They also felt that mechanisms of knowledge transfer from program managers to grassroots needed to be more specific.
The reality is when you get down to the grassroots, you have one TB program manager, one for HIV and they don’t talk. So, each one runs their own program, separately. I think it’s the information, the way information is cascaded downwards, everything is discussed here at the program level with all partners, and then there’s this assumption this information will trickle down. But without a really clear process for the program to bring down information, make everybody at the grassroots understand this co-infection. And because all of our guidelines are written in English, of course not all at the grassroots can appreciate or are familiar with the technical language of the issuance. (International HIV NGO Representative)
Human resource bottlenecks to integrated TB/HIV collaboration
Not all MTs can provide HIV testing; they have to undergo HIV testing-proficiency certification (costing US$ 350 to US$ 400, either paid by local governments or themselves). The lack of certified MTs was perceived as the most significant impediment to delivering TB/HIV services at the grassroots.
A stakeholder shared that in one city, HIV testing is only conducted once a month because of the insufficient number of MTs. They are also overburdened; one MT caters to 3 to 4 primary healthcare centers, in addition to processing specimens from other health services. The release of patients’ test results also gets significantly delayed when MTs are asked to attend trainings, or to report to other official functions during work hours.
Even if the patient is available for PICT but the medical technologist isn’t? Our medical technologist was in a seminar for the whole week, that’s why we don’t have any results yet, our specimens are already piling up. (Midwives)
Most MTs also have insecure job positions with salaries ranging from US$ 200 to US$ 300 a month, contributing to fast turnover. To make PICT accessible, HIV screening was implemented to circumvent existing policies that limits HIV testing to certified MTs; providers who were trained by the Department of Health are allowed to do the former, while only HIV-proficient MTs can do the latter (only by the results of HIV testing will a patient be enrolled in HIV care).
They tell us ‘why do you allow a layperson to test’? We replied it’s ok because this is just pricking, not extraction. We trained these lay providers. It’s like we’re playing around the gray areas of the policies just so that we can implement. (Regional HIV Program Manager)
Stigmatization behaviors among health providers were also reported to hamper TB/HIV collaboration. A stakeholder shared his experience in a social hygiene clinic in a province north of Manila:
There are social hygiene clinics where the doctors are conservative and when you enter they will scold you and ask you ‘why do you want to be tested for HIV?!’ (PLHIV organization representative)
Some, however, felt that not offering PICT to at-risk populations was not a result of stigma but of being overburdened by other equally-important responsibilities and health programs.
Maybe it’s not really because of stigma, but it’s more of our commitment in providing PICT. For example, if you have so many things to do, will you still do PICT, or report it? This patient is already old, will I still offer PICT, maybe he doesn’t even have sex anymore. Health care workers have those kinds of biases. (Infection Control Coordinator)
Community health workers filling-up surveillance forms account for the highest workload burden, which in turn, limit the time they could spend monitoring the health of households under their responsibility.
With the number of forms they ask us to fill-up, we don’t even know the difference anymore, or what we will prioritize. They always change the forms, like now there’s going to be a new form, and it will change again after some time. (Community health worker leader)
Patient-related factors influencing integrated TB/HIV collaboration
Poor knowledge about the relationship between TB and HIV was also identified as a barrier to providing HIV testing among TB patients. Stakeholders were aware of the need to link these two diseases in information dissemination campaigns but were also wary that doing so may lead to “double stigmatization” among patients, as is the case for some now:
Even the physical identity, when other patients see a thin patient, they would say he has TB maybe even HIV. That’s how they perceive it, they come up with their own indicators. (Local HIV patient organization representative)
Program managers also felt that some patients might be more ‘conservative’, hence they felt ashamed to have themselves tested for HIV, especially when they already have TB.
There are so many reasons for the delay. Firstly, they would say, ‘I only have TB why do you need to test me for HIV?’ Because with HIV, it connotes something, a practice that they cannot accept. (Regional HIV program manager)
They also pointed to the health-seeking behavior among Filipinos of only going for check-up when there are already overt symptoms.