1

TBHIV Dead Case Reviewชวยอะไรไดบางในงานพฒนาคณภาพ

พญพชร ขนตพงษTHE 2ND NATIONAL QI FORUMFOR HIV TB AND STIS1 สค 2559

2

High Burden Country Lists of 30 countries Will be used by WHO 2016-2020

ALL TB CASE by HIV statusin Chiang Rai Province1987 - 2008

TBHIV Research Project (RIT-JATA)

year

1st AIDS in THAI NAPHA CAT team

Extensive closed contact screening

2

TB treatment outcome in all HIV positiveIn Chiang Rai Province2000-2008

(Adjusted transfer cases)

Still high mortality rate for TBHIV co-infection during TB treatment in Chiang Rai province

3TBHIV Research Project (RIT-JATA)

TB treatment outcome in all HIV positive TB in Chiangrai Prachanukroh hospital 2000-2008

142

141

92

72

76

78

64

73

94

483

470

420

440

386

381

227

207

237

73

70

108

77

109

104

133

76

83

280

302

322

355

366

384

500

545

504 33

04

07

07

18

00

10

11

18

0 20 40 60 80 100

2551

2550

2549

2548

2547

2546

2545

2544

2543

Cure Complete Default Died Failure Transfer out

4TBHIV Research Project (RIT-JATA)

Information

Quality Improvement

Health System Technology

TB screening for HIV people and IPTsince 2004

TB screening before providing ARTsince 2004

HIV counseling and testing for all TBsince 2005

ARV for all PLHIV who have CD4 count helliphellipaccording to guideline

7

Implemented Program in Chiangrai Prachanukroh Hospital

However the mortality rate is still high

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

2

High Burden Country Lists of 30 countries Will be used by WHO 2016-2020

ALL TB CASE by HIV statusin Chiang Rai Province1987 - 2008

TBHIV Research Project (RIT-JATA)

year

1st AIDS in THAI NAPHA CAT team

Extensive closed contact screening

2

TB treatment outcome in all HIV positiveIn Chiang Rai Province2000-2008

(Adjusted transfer cases)

Still high mortality rate for TBHIV co-infection during TB treatment in Chiang Rai province

3TBHIV Research Project (RIT-JATA)

TB treatment outcome in all HIV positive TB in Chiangrai Prachanukroh hospital 2000-2008

142

141

92

72

76

78

64

73

94

483

470

420

440

386

381

227

207

237

73

70

108

77

109

104

133

76

83

280

302

322

355

366

384

500

545

504 33

04

07

07

18

00

10

11

18

0 20 40 60 80 100

2551

2550

2549

2548

2547

2546

2545

2544

2543

Cure Complete Default Died Failure Transfer out

4TBHIV Research Project (RIT-JATA)

Information

Quality Improvement

Health System Technology

TB screening for HIV people and IPTsince 2004

TB screening before providing ARTsince 2004

HIV counseling and testing for all TBsince 2005

ARV for all PLHIV who have CD4 count helliphellipaccording to guideline

7

Implemented Program in Chiangrai Prachanukroh Hospital

However the mortality rate is still high

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

ALL TB CASE by HIV statusin Chiang Rai Province1987 - 2008

TBHIV Research Project (RIT-JATA)

year

1st AIDS in THAI NAPHA CAT team

Extensive closed contact screening

2

TB treatment outcome in all HIV positiveIn Chiang Rai Province2000-2008

(Adjusted transfer cases)

Still high mortality rate for TBHIV co-infection during TB treatment in Chiang Rai province

3TBHIV Research Project (RIT-JATA)

TB treatment outcome in all HIV positive TB in Chiangrai Prachanukroh hospital 2000-2008

142

141

92

72

76

78

64

73

94

483

470

420

440

386

381

227

207

237

73

70

108

77

109

104

133

76

83

280

302

322

355

366

384

500

545

504 33

04

07

07

18

00

10

11

18

0 20 40 60 80 100

2551

2550

2549

2548

2547

2546

2545

2544

2543

Cure Complete Default Died Failure Transfer out

4TBHIV Research Project (RIT-JATA)

Information

Quality Improvement

Health System Technology

TB screening for HIV people and IPTsince 2004

TB screening before providing ARTsince 2004

HIV counseling and testing for all TBsince 2005

ARV for all PLHIV who have CD4 count helliphellipaccording to guideline

7

Implemented Program in Chiangrai Prachanukroh Hospital

However the mortality rate is still high

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

TB treatment outcome in all HIV positiveIn Chiang Rai Province2000-2008

(Adjusted transfer cases)

Still high mortality rate for TBHIV co-infection during TB treatment in Chiang Rai province

3TBHIV Research Project (RIT-JATA)

TB treatment outcome in all HIV positive TB in Chiangrai Prachanukroh hospital 2000-2008

142

141

92

72

76

78

64

73

94

483

470

420

440

386

381

227

207

237

73

70

108

77

109

104

133

76

83

280

302

322

355

366

384

500

545

504 33

04

07

07

18

00

10

11

18

0 20 40 60 80 100

2551

2550

2549

2548

2547

2546

2545

2544

2543

Cure Complete Default Died Failure Transfer out

4TBHIV Research Project (RIT-JATA)

Information

Quality Improvement

Health System Technology

TB screening for HIV people and IPTsince 2004

TB screening before providing ARTsince 2004

HIV counseling and testing for all TBsince 2005

ARV for all PLHIV who have CD4 count helliphellipaccording to guideline

7

Implemented Program in Chiangrai Prachanukroh Hospital

However the mortality rate is still high

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

TB treatment outcome in all HIV positive TB in Chiangrai Prachanukroh hospital 2000-2008

142

141

92

72

76

78

64

73

94

483

470

420

440

386

381

227

207

237

73

70

108

77

109

104

133

76

83

280

302

322

355

366

384

500

545

504 33

04

07

07

18

00

10

11

18

0 20 40 60 80 100

2551

2550

2549

2548

2547

2546

2545

2544

2543

Cure Complete Default Died Failure Transfer out

4TBHIV Research Project (RIT-JATA)

Information

Quality Improvement

Health System Technology

TB screening for HIV people and IPTsince 2004

TB screening before providing ARTsince 2004

HIV counseling and testing for all TBsince 2005

ARV for all PLHIV who have CD4 count helliphellipaccording to guideline

7

Implemented Program in Chiangrai Prachanukroh Hospital

However the mortality rate is still high

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

Information

Quality Improvement

Health System Technology

TB screening for HIV people and IPTsince 2004

TB screening before providing ARTsince 2004

HIV counseling and testing for all TBsince 2005

ARV for all PLHIV who have CD4 count helliphellipaccording to guideline

7

Implemented Program in Chiangrai Prachanukroh Hospital

However the mortality rate is still high

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

TB screening for HIV people and IPTsince 2004

TB screening before providing ARTsince 2004

HIV counseling and testing for all TBsince 2005

ARV for all PLHIV who have CD4 count helliphellipaccording to guideline

7

Implemented Program in Chiangrai Prachanukroh Hospital

However the mortality rate is still high

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

Cause of death Number

TB 38 27

HIV associated condition 50 35

TB or HIV equally likely 32 23

Non TBHIV associated 22 15

Total 142 100

In HIV tertiary care in Bangkok Thailand

TB itself is not main cause of death among TBHIV co-infection

8

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai Northern Thailand

Pacharee Kantipong1 Kuniko Murakami2 Saiyud Moolphate3 Myo Nyein Aung45 and Norio Yamada2

Cause of death Number

TB 130 393

AIDS related OIs 94 284

Non TBnonAOI systemic diseases ( renal or liver disease)

54 163

Ambiguous causes 53 16

Total 331 100

2005-2008

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (1)

N

Total number 331 100

Male 219 662

Female 112 338

Age

lt45 263 795

ge45 68 205

Median 35

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (2)

N

Ethnicity

Thai 297 897

Non-Thai 34 103

Marital status

Married 146 445

Single 87 265

Widoweddivorce 95 290

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (3)

N

Occupation

Laborer 140 438

Farmer 84 263

Household worker 36 113

Prisoner 16 50

Business owner 13 41

Government employee 6 19

Other 25 78

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (4)

N

Site of TB

Pulm TB 134 405

Extra with Pulm TB 64 193

Extrapulmonary TB 133 402

Extrapulmonary TB

Meningeal 60 305

Lymphatic 41 208

Intestinal 38 193

Disseminated 36 183

Pleural 12 61

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (5)

N

TB Diagnosis reconfirmation

Definitive 102 308

Probable 46 139

Presumptive 165 499

NTM 18 54

MDR TB

Yes 7 21

No 324 979

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (6)

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

CD4

lt200 205 6193

gt200 23 695

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (7)

N

ART

Before TB Dx 73 221

After TB Dx 35 106

Not received 223 674

Time of death after start TB Rx

Within 30 days 121 3656

Later than 30 days 210 6344

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (2)

N

Ethnicity

Thai 297 897

Non-Thai 34 103

Marital status

Married 146 445

Single 87 265

Widoweddivorce 95 290

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (3)

N

Occupation

Laborer 140 438

Farmer 84 263

Household worker 36 113

Prisoner 16 50

Business owner 13 41

Government employee 6 19

Other 25 78

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (4)

N

Site of TB

Pulm TB 134 405

Extra with Pulm TB 64 193

Extrapulmonary TB 133 402

Extrapulmonary TB

Meningeal 60 305

Lymphatic 41 208

Intestinal 38 193

Disseminated 36 183

Pleural 12 61

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (5)

N

TB Diagnosis reconfirmation

Definitive 102 308

Probable 46 139

Presumptive 165 499

NTM 18 54

MDR TB

Yes 7 21

No 324 979

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (6)

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

CD4

lt200 205 6193

gt200 23 695

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (7)

N

ART

Before TB Dx 73 221

After TB Dx 35 106

Not received 223 674

Time of death after start TB Rx

Within 30 days 121 3656

Later than 30 days 210 6344

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (3)

N

Occupation

Laborer 140 438

Farmer 84 263

Household worker 36 113

Prisoner 16 50

Business owner 13 41

Government employee 6 19

Other 25 78

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (4)

N

Site of TB

Pulm TB 134 405

Extra with Pulm TB 64 193

Extrapulmonary TB 133 402

Extrapulmonary TB

Meningeal 60 305

Lymphatic 41 208

Intestinal 38 193

Disseminated 36 183

Pleural 12 61

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (5)

N

TB Diagnosis reconfirmation

Definitive 102 308

Probable 46 139

Presumptive 165 499

NTM 18 54

MDR TB

Yes 7 21

No 324 979

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (6)

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

CD4

lt200 205 6193

gt200 23 695

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (7)

N

ART

Before TB Dx 73 221

After TB Dx 35 106

Not received 223 674

Time of death after start TB Rx

Within 30 days 121 3656

Later than 30 days 210 6344

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (4)

N

Site of TB

Pulm TB 134 405

Extra with Pulm TB 64 193

Extrapulmonary TB 133 402

Extrapulmonary TB

Meningeal 60 305

Lymphatic 41 208

Intestinal 38 193

Disseminated 36 183

Pleural 12 61

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (5)

N

TB Diagnosis reconfirmation

Definitive 102 308

Probable 46 139

Presumptive 165 499

NTM 18 54

MDR TB

Yes 7 21

No 324 979

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (6)

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

CD4

lt200 205 6193

gt200 23 695

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (7)

N

ART

Before TB Dx 73 221

After TB Dx 35 106

Not received 223 674

Time of death after start TB Rx

Within 30 days 121 3656

Later than 30 days 210 6344

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (5)

N

TB Diagnosis reconfirmation

Definitive 102 308

Probable 46 139

Presumptive 165 499

NTM 18 54

MDR TB

Yes 7 21

No 324 979

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (6)

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

CD4

lt200 205 6193

gt200 23 695

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (7)

N

ART

Before TB Dx 73 221

After TB Dx 35 106

Not received 223 674

Time of death after start TB Rx

Within 30 days 121 3656

Later than 30 days 210 6344

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (6)

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

CD4

lt200 205 6193

gt200 23 695

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (7)

N

ART

Before TB Dx 73 221

After TB Dx 35 106

Not received 223 674

Time of death after start TB Rx

Within 30 days 121 3656

Later than 30 days 210 6344

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Characteristic of TBHIV death in Chiangrai Prachanukroh hospital during

2005-2008 (7)

N

ART

Before TB Dx 73 221

After TB Dx 35 106

Not received 223 674

Time of death after start TB Rx

Within 30 days 121 3656

Later than 30 days 210 6344

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Causes of death shown by proportion of deathsin each month of TB treatment

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

bull 3927 of TBHIV death was caused by TB and 2840 by AIDS-related OIs

bull 674 of TBHIV death didnt receive ART

bull Most case had extra-pulmonary TB 595

bull Dx HIV before TB 662

bull CD4 lt 200 6193 unknown CD4 3112

18

Summary

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

bull All TBHIV dead within 1 mo after Dx 367

2nd mo 187

bull 669 of death in 1st mo due to TB

bull Death from AOI occurred throughout the timeline of TB Rx peak at 4th mo

bull Systemic diseases deaths in the later mo

19

Summary

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

HIV Care

N

HIV testing

Known before TB Rx 219 662

Not known before TB Rx 112 338

ART

Not received 223 674

CD4

Unknown 103 3112

Median CD4 37

Thai HIVTB Guideline 2008

CD4 counts (cellsmm3)

Recommendation according to the

Thai AIDS Society Guideline 2008

lt 100Start as soon as possible after patients can

tolerate anti-TB treatment

100 - 200Start ART at 2 months after initiation of TB

treatment

200 ndash 350Defer ART and follow-up clinical status AND

monitor CD4 cell count every 3 months

gt 350Defer ART and follow-up clinical status AND

monitor CD4 cell count every 6 months

Some Thai HIV experts may commence ART 2 months after the start of TB treatment especially if the patients cannot be tested for CD4 counts at 3 months after initiation of TB treatment

TAS J Med Assoc Thai 2008911925-36

33

Thai HIVTB Guideline 2016 (draft)

CD4 counts (cellsmm3)

Recommendation according to the

Thai AIDS Society Guideline 2008

lt 50 เรมภายใน 2 สปดาห อยางชาไมเกน 4 สปดาห

50-350

-ถาอาการวณโรครนแรงเรมภายใน 2 สปดาห อยางชาไมเกน 4 สปดาห

-ถาอาการวณโรคไมรนแรง เรมระหวาง 2 สปดาห อยางชาไมเกน 8 สปดาห

gt350 เรมระหวาง 2 สปดาห ndash 6 เดอน

อาการวณโรครนแรง ไดแก วณโรคแพรกระจาย น าหนกตวนอย อลบมนในเลอดต า ซด

33

TB Care

bull Dx of TB is difficult in HIV-infected patients

bull Definitive Dx is only 13

bull Routine microscopic and culture are not sensitive enough to detect active TB in PLWH

bull 595 had extrapulm TB

bull 305 of extrapulm Tb is TB meningitis

bull The importance of earlier detection of TB and improvement of immune status

Thai HIVTB Guideline 2016 (draft)

CD4 counts (cellsmm3)

Recommendation according to the

Thai AIDS Society Guideline 2008

lt 50 เรมภายใน 2 สปดาห อยางชาไมเกน 4 สปดาห

50-350

-ถาอาการวณโรครนแรงเรมภายใน 2 สปดาห อยางชาไมเกน 4 สปดาห

-ถาอาการวณโรคไมรนแรง เรมระหวาง 2 สปดาห อยางชาไมเกน 8 สปดาห

gt350 เรมระหวาง 2 สปดาห ndash 6 เดอน

อาการวณโรครนแรง ไดแก วณโรคแพรกระจาย น าหนกตวนอย อลบมนในเลอดต า ซด

33

TB Care

bull Dx of TB is difficult in HIV-infected patients

bull Definitive Dx is only 13

bull Routine microscopic and culture are not sensitive enough to detect active TB in PLWH

bull 595 had extrapulm TB

bull 305 of extrapulm Tb is TB meningitis

bull The importance of earlier detection of TB and improvement of immune status

TB Care

bull Dx of TB is difficult in HIV-infected patients

bull Definitive Dx is only 13

bull Routine microscopic and culture are not sensitive enough to detect active TB in PLWH

bull 595 had extrapulm TB

bull 305 of extrapulm Tb is TB meningitis

bull The importance of earlier detection of TB and improvement of immune status

TB Care

QI Projects

bull Increase coverage HIV testing in TB patients

bull Early Dx and Rx TBHIV

bull Collaboration Tb and HIV care

409 397 367 373 358 338 312 297 270 251 253 225 195 177 180 150

375 376394 382 415

525 602 627 658 706 697697

663 676747

768

216 227 239 245 228

13786 76 72 43 50 78

142 14773 83

0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Positive Negative Unknown

Database update 30 Sep 2015

Total (N) 1946 1994 1893 2050 2162 2250 1923 1923 1822 1828 1881 1829 1562 1597 1629 1575

Year

226

246

188

120

143

165

120

0

50

100

150

200

250

300

2009 2010 2011 2012 2013 2014 2015

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

577552

469 468 464

414

319 317295

281267 264

215

244230

170

0

100

200

300

400

500

600

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Database update 30 Sep 2015

Data sources fiscal year 2000-2011 RITJATA and THRF2012-2015 CR-PHO

707

688

728

707

690

687

651

660

639

607

596

568

548

514

506

72

70

59

75

95

106

115

113

113

140

119

122

134

126

119

153

165

149

161

156

163

171

170

172

191

221

236

252

285

303

07

07

17

18

18

16

20

13

20

20

21

31

17

17

24

61

70

48

38

41

29

43

44

55

42

43

43

49

59

48

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(1906)

(1940)

(1864)

(1987)

(2103)

(2164)

(1852)

(1866)

(1729)

(1728)

(1712)

(1641)

(1447)

(1490)

(1521)

Year (N)

747

709

762

718

701

694

662

689

674

638

624

600

568

564

510

51

54

47

55

95

89

93

95

93

153

121

117

143

114

120

149

178

146

157

135

154

169

145

151

151

175

203

219

247

292

07

09

18

31

32

27

33

20

34

26

32

39

24

30

30

46

50

28

39

37

36

42

50

48

32

48

41

47

45

47

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(866)

(764)

(807)

(822)

(846)

(809)

(755)

(733)

(687)

(671)

(652)

(649)

(685)

(664)

(570)

Year (N)

606

587

646

652

671

616

647

631

577

541

506

461

374

334

328

99

91

67

53

76

92

82

80

89

89

73

84

101

79

74

241

248

214

242

218

253

236

258

274

322

369

398

466

516

533

04

00

11

14

07

18

13

05

14

15

09

20

10

13

22

51

75

63

39

28

21

22

25

45

33

42

37

48

58

42

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

Year (N)

(780)

(773)

(684)

(739)

(753)

(730)

(572)

(550)

(462)

(435)

(422)

(359)

(285)

(254)

(274)

520

484

512

561

544

612

530

30

71

70

79

76

54

60

160

284

310

246

298

237

258

18

12

18

290

161

109

96

70

80

152

0 10 20 30 40 50 60 70 80 90 100

2015

2014

2013

2012

2011

2010

2009

Success DEFA DIED FAIL TOUT

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

226

246

188

120

143

165

120

0

50

100

150

200

250

300

2009 2010 2011 2012 2013 2014 2015

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

577552

469 468 464

414

319 317295

281267 264

215

244230

170

0

100

200

300

400

500

600

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Database update 30 Sep 2015

Data sources fiscal year 2000-2011 RITJATA and THRF2012-2015 CR-PHO

707

688

728

707

690

687

651

660

639

607

596

568

548

514

506

72

70

59

75

95

106

115

113

113

140

119

122

134

126

119

153

165

149

161

156

163

171

170

172

191

221

236

252

285

303

07

07

17

18

18

16

20

13

20

20

21

31

17

17

24

61

70

48

38

41

29

43

44

55

42

43

43

49

59

48

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(1906)

(1940)

(1864)

(1987)

(2103)

(2164)

(1852)

(1866)

(1729)

(1728)

(1712)

(1641)

(1447)

(1490)

(1521)

Year (N)

747

709

762

718

701

694

662

689

674

638

624

600

568

564

510

51

54

47

55

95

89

93

95

93

153

121

117

143

114

120

149

178

146

157

135

154

169

145

151

151

175

203

219

247

292

07

09

18

31

32

27

33

20

34

26

32

39

24

30

30

46

50

28

39

37

36

42

50

48

32

48

41

47

45

47

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(866)

(764)

(807)

(822)

(846)

(809)

(755)

(733)

(687)

(671)

(652)

(649)

(685)

(664)

(570)

Year (N)

606

587

646

652

671

616

647

631

577

541

506

461

374

334

328

99

91

67

53

76

92

82

80

89

89

73

84

101

79

74

241

248

214

242

218

253

236

258

274

322

369

398

466

516

533

04

00

11

14

07

18

13

05

14

15

09

20

10

13

22

51

75

63

39

28

21

22

25

45

33

42

37

48

58

42

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

Year (N)

(780)

(773)

(684)

(739)

(753)

(730)

(572)

(550)

(462)

(435)

(422)

(359)

(285)

(254)

(274)

520

484

512

561

544

612

530

30

71

70

79

76

54

60

160

284

310

246

298

237

258

18

12

18

290

161

109

96

70

80

152

0 10 20 30 40 50 60 70 80 90 100

2015

2014

2013

2012

2011

2010

2009

Success DEFA DIED FAIL TOUT

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

577552

469 468 464

414

319 317295

281267 264

215

244230

170

0

100

200

300

400

500

600

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Database update 30 Sep 2015

Data sources fiscal year 2000-2011 RITJATA and THRF2012-2015 CR-PHO

707

688

728

707

690

687

651

660

639

607

596

568

548

514

506

72

70

59

75

95

106

115

113

113

140

119

122

134

126

119

153

165

149

161

156

163

171

170

172

191

221

236

252

285

303

07

07

17

18

18

16

20

13

20

20

21

31

17

17

24

61

70

48

38

41

29

43

44

55

42

43

43

49

59

48

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(1906)

(1940)

(1864)

(1987)

(2103)

(2164)

(1852)

(1866)

(1729)

(1728)

(1712)

(1641)

(1447)

(1490)

(1521)

Year (N)

747

709

762

718

701

694

662

689

674

638

624

600

568

564

510

51

54

47

55

95

89

93

95

93

153

121

117

143

114

120

149

178

146

157

135

154

169

145

151

151

175

203

219

247

292

07

09

18

31

32

27

33

20

34

26

32

39

24

30

30

46

50

28

39

37

36

42

50

48

32

48

41

47

45

47

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(866)

(764)

(807)

(822)

(846)

(809)

(755)

(733)

(687)

(671)

(652)

(649)

(685)

(664)

(570)

Year (N)

606

587

646

652

671

616

647

631

577

541

506

461

374

334

328

99

91

67

53

76

92

82

80

89

89

73

84

101

79

74

241

248

214

242

218

253

236

258

274

322

369

398

466

516

533

04

00

11

14

07

18

13

05

14

15

09

20

10

13

22

51

75

63

39

28

21

22

25

45

33

42

37

48

58

42

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

Year (N)

(780)

(773)

(684)

(739)

(753)

(730)

(572)

(550)

(462)

(435)

(422)

(359)

(285)

(254)

(274)

520

484

512

561

544

612

530

30

71

70

79

76

54

60

160

284

310

246

298

237

258

18

12

18

290

161

109

96

70

80

152

0 10 20 30 40 50 60 70 80 90 100

2015

2014

2013

2012

2011

2010

2009

Success DEFA DIED FAIL TOUT

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

707

688

728

707

690

687

651

660

639

607

596

568

548

514

506

72

70

59

75

95

106

115

113

113

140

119

122

134

126

119

153

165

149

161

156

163

171

170

172

191

221

236

252

285

303

07

07

17

18

18

16

20

13

20

20

21

31

17

17

24

61

70

48

38

41

29

43

44

55

42

43

43

49

59

48

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(1906)

(1940)

(1864)

(1987)

(2103)

(2164)

(1852)

(1866)

(1729)

(1728)

(1712)

(1641)

(1447)

(1490)

(1521)

Year (N)

747

709

762

718

701

694

662

689

674

638

624

600

568

564

510

51

54

47

55

95

89

93

95

93

153

121

117

143

114

120

149

178

146

157

135

154

169

145

151

151

175

203

219

247

292

07

09

18

31

32

27

33

20

34

26

32

39

24

30

30

46

50

28

39

37

36

42

50

48

32

48

41

47

45

47

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(866)

(764)

(807)

(822)

(846)

(809)

(755)

(733)

(687)

(671)

(652)

(649)

(685)

(664)

(570)

Year (N)

606

587

646

652

671

616

647

631

577

541

506

461

374

334

328

99

91

67

53

76

92

82

80

89

89

73

84

101

79

74

241

248

214

242

218

253

236

258

274

322

369

398

466

516

533

04

00

11

14

07

18

13

05

14

15

09

20

10

13

22

51

75

63

39

28

21

22

25

45

33

42

37

48

58

42

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

Year (N)

(780)

(773)

(684)

(739)

(753)

(730)

(572)

(550)

(462)

(435)

(422)

(359)

(285)

(254)

(274)

520

484

512

561

544

612

530

30

71

70

79

76

54

60

160

284

310

246

298

237

258

18

12

18

290

161

109

96

70

80

152

0 10 20 30 40 50 60 70 80 90 100

2015

2014

2013

2012

2011

2010

2009

Success DEFA DIED FAIL TOUT

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

747

709

762

718

701

694

662

689

674

638

624

600

568

564

510

51

54

47

55

95

89

93

95

93

153

121

117

143

114

120

149

178

146

157

135

154

169

145

151

151

175

203

219

247

292

07

09

18

31

32

27

33

20

34

26

32

39

24

30

30

46

50

28

39

37

36

42

50

48

32

48

41

47

45

47

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

(866)

(764)

(807)

(822)

(846)

(809)

(755)

(733)

(687)

(671)

(652)

(649)

(685)

(664)

(570)

Year (N)

606

587

646

652

671

616

647

631

577

541

506

461

374

334

328

99

91

67

53

76

92

82

80

89

89

73

84

101

79

74

241

248

214

242

218

253

236

258

274

322

369

398

466

516

533

04

00

11

14

07

18

13

05

14

15

09

20

10

13

22

51

75

63

39

28

21

22

25

45

33

42

37

48

58

42

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

Year (N)

(780)

(773)

(684)

(739)

(753)

(730)

(572)

(550)

(462)

(435)

(422)

(359)

(285)

(254)

(274)

520

484

512

561

544

612

530

30

71

70

79

76

54

60

160

284

310

246

298

237

258

18

12

18

290

161

109

96

70

80

152

0 10 20 30 40 50 60 70 80 90 100

2015

2014

2013

2012

2011

2010

2009

Success DEFA DIED FAIL TOUT

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

606

587

646

652

671

616

647

631

577

541

506

461

374

334

328

99

91

67

53

76

92

82

80

89

89

73

84

101

79

74

241

248

214

242

218

253

236

258

274

322

369

398

466

516

533

04

00

11

14

07

18

13

05

14

15

09

20

10

13

22

51

75

63

39

28

21

22

25

45

33

42

37

48

58

42

0 10 20 30 40 50 60 70 80 90 100

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

Success Loss follow up Death Failure Transfer out

Database update 30 Sep 2015

Year (N)

(780)

(773)

(684)

(739)

(753)

(730)

(572)

(550)

(462)

(435)

(422)

(359)

(285)

(254)

(274)

520

484

512

561

544

612

530

30

71

70

79

76

54

60

160

284

310

246

298

237

258

18

12

18

290

161

109

96

70

80

152

0 10 20 30 40 50 60 70 80 90 100

2015

2014

2013

2012

2011

2010

2009

Success DEFA DIED FAIL TOUT

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

520

484

512

561

544

612

530

30

71

70

79

76

54

60

160

284

310

246

298

237

258

18

12

18

290

161

109

96

70

80

152

0 10 20 30 40 50 60 70 80 90 100

2015

2014

2013

2012

2011

2010

2009

Success DEFA DIED FAIL TOUT

Database update 30 Sep 2015copyCopy right (THRF_RIT-JATA)

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

Acknowledgements

33

-Dr Hutsaya Tantipong-Staffs members of RIT THRF-Staff members of TB clinic-Staff members of HIV clinic-Laboratory of Chiangrai PrachnukrohHospital

34

Thank you for your kind attention

34

Thank you for your kind attention