Transcript Motsamai IPT Ethiopia Nov 2008 []

IPT
BOTSWANA EXPERIENCE
Oaitse I Motsamai RN, MW, B Ed, MPH
Ministry of Health
Botswana
11th November 2008
Addis Ababa, Ethiopia
OUTLINE
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Botswana context
Rationale for IPT in Botswana
Pilot
Current Programme
Administration
IPT Programme Evaluation
Background of Botswana
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Population 1.7 million
HIV prevalence in general population 17% (2004)
HIV prevalence in antenatal women 33.4% (2005)
TB notification rate 514/100,000 (2006)
HIV seroprevalence among TB patients 60-86%
TB Services in Botswana
• National TB Program (Disease Control Unit, MOH)
• Tuberculosis treatment free and universally
available
• >600 health facilities provide TB and IPT services
• 24 Districts each with TB Coordinator
• TB surveillance through electronic TB register
HIV/TB
Program
Context
• Anti-retroviral therapy (ART) has been available
since 2001 and is free to all Batswana citizens
• Policy on Routine HIV Testing (RHT) introduced
2004
• Under national ART guidelines, TB patients
eligible for ART; initiation based on CD4 count
• There are 35 ART centers in Botswana
700
600
35
500
30
400
25
300
20
15
200
10
100
5
0
0
Year
HIV seroprevalence (%)
19
75
19
77
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79
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81
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83
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85
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87
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89
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91
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93
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95
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97
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99
20
01
20
03
20
05
TB Case Rate (per 100,000)
Rationale For IPT In Botswana
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IPT Timeline
1998: Joint WHO/UN Guidelines on HIV/AIDS
recommending 6 months of IPT
1999: Formation of an IPT Working Group
2000: Pilot conducted in three districts in
to assess feasibility of national scale-up
2001: Pilot completed in April; evaluated in
October 2001
2001: National roll out commenced
2003: IPT office established (3 officers)
2004: Complete roll out
Progress of enrolment: 2001-2007
25000
20000
Cases
15000
Counseled
Database
rolled out
10000
Enrolled
Completed
Roll out
completed
5000
Programme Review
Coag signed
National office
Pilot study
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2000
2001
2002
2003
2004
Years
2005
2006
2007
Pilot Study Goals
1. Assess motivation to undergo testing and
accept IPT;
2. Determine if IPT would increase HCW
workload; and
3. Determine whether HCWs could
successfully exclude clients with active
disease
Pilot Findings
• IPT well-integrated into general clinic
services
• Acceptable to clients; clients motivated to
test by knowledge that HIV interventions
(IPT/ART) available
• CXR should not be used for ASX patients
• Reporting and recoding methods too
cumbersome for HCWs
Current Programme
• Screen and enroll medically eligible
patients referred from VCT/RHT/PMTCT
• 6 months self-administered in 6-9 mos.
• Monthly follow-up visits
– Side effects counseling
– TB screening
– Compliance
– Prescription refill
Eligibility Criteria
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Confirmed HIV-infected
16 years and above
Not currently pregnant
No active TB
No terminal illness
No hepatitis
No history of INH intolerance
No History of TB in the past 3 years
Enrolment
• History and physical examination
– Exclusion of persons with cough and fever
• Client counseling
• Monthly review
– Side effects assessment
– TB screen
– Drug re-supply
Enrollment 2001-2007*
Registered
N=75,235
Eligible
n= 73,263
Eligible and started IPT
n= 71,541
Completed
n=25,075
(33%)
Other
exclusions
(7%)
Non-completers
n=43,313
(59%)
Unknown
reason
(70%)
Major Challenges
• Referral to IPT
– Difficult to estimate % eligible captured
• Medical Screening
– Eligibility
– Active TB (prior to and during treatment)
• Treatment adherence* (preliminary data, n= 71,541)
– Median- 4 follow-up visits
– Duration of therapy 98 days
• Monitoring and evaluation
– High levels of incomplete data
– Recording and data entry barriers
• Staff turn over: IT no data manager (national)
IPT Programme Administration
IPT Staffing
• National Level: MOH
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National Coordinator
Regional Coordinators (2)
Data officers (3)
IEC officer
• Implementation at the district level
– Doctors and nurses (MOLG, MOH)
– Complementary staff
Support & Supervision
• District-level TB Coordinators (DTBCs) placed at
District Health Teams
• TBCs are supervised by the District Health Teams
• District-level activities supervised by TBCs
• The national level monitors a sample of facilities on
quarterly basis
• DHTs are given feedback on their performance
• TBCs hold workshops (twice a year)
• Training for IPT, TB/HIV surveillance and TB case
management, Community TB care for HCWs
Reporting and Recording
• Patient out-patient card (pink/blue)
• Register and Compliance record
• Dispensary Tally Sheet
• Patient Transfer form
• Monthly Report Form
Other Documents & Database
Other IPT Documents:
• Training guides: Facilitators’ & Health workers’
• IEC materials: Brochures, video cassettes
Electronic Database:
• Developed and Funded with the assistance of CDC
(BOTUSA)
• Rolled out to all 24 districts in November 2005
• Built-in reporting and error functions
Programme Funding
• Second-Five year cooperative agreement between
CDC and MOH; (2002-2005, 2005-2010)
• Ministry of Health provides: infrastructure, drugs &
technical support
• Clinical staff supported thru Ministry of Local
Government O Ministry of Health
• CDC provides funds for salaries, training, purchase of
equipments; 2001-2007: Over $2 million + technical
support
IPT Programme Evaluation
• Conducted in May 2008 (external)
• Await final report
• Reviewed key functions
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Referral systems
Medical screening
Adherence
Reporting/recording for M&E
HCW training
Patient counseling
• Assessed programmatic implications
Acknowledgements
• Botswana National TB Program Staff
• CDC Division of TB Elimination
• CDC Global AIDS Program/BOTUSA
Thank You
Backup Slides
2006 Programme Targets
TOTs trained
Health care
workers trained
Enrolment
Target by
2006
Actual in
2006
96
+151 (157%)
6619
4000 (60%)
50 000
42,186 (84%)
Caliber Trained
• Health professionals:
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Doctors
Nurses
Pharmacy Technicians
Health Educators
Social Workers
• Non-professionals
- Family Welfare Educators
- Lay Counselors
- Health auxiliary
Challenges Encountered
– Overstretched national staff
– Inadequate counseling of some clients
– Loss of clients who are still on treatment
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Lack of clients’ follow up (defaulters)
Transport problems particularly in the districts
High mobility of clients
Wrong addresses given by clients
Challenges Cont’d
– Recording and Reporting problems
• Incomplete clients’ records
• Lack of timely reporting
– Personnel
• High turnover in districts including TBCs
• Weak supervision especially at district level
– Training: Continuous re-training of HCW
necessary
Botswana Drug
Resistance Surveys
– Since 1995, 3 resistance surveys done
– Fourth resistance survey in progress
– Results expected by 4th quarter 2008.
Isoniazid Mono-Resistance
Year
New
Retreatment
1996
1.6%
9.9%
1999
4.4%
16.6%
2002
4.5%
14.2%
Multi Drug Resistance
Year
New
Retreatment
1996
0.2%
5.8%
1999
0.5%
9%
2002
0.8%
10.4%
Plans To Prevent Drug Resistance
• Emphasis on constant & proper use of the algorithm
on screening of clients
• Screening of clients at each visit
• Thorough investigation of TB suspects
• Extensive adherence counseling of clients
Integration of TB & HIV Care
IPT as Part of HIV Care and Treatment
– Implementation of routine HIV testing from January
2004.
– HIV testing of TB patients is routine but so far at 68%
– IPT is prescribed in all health facilities by
doctors and nurses.
– IPT is given as (often first) package of HIV care
– Other sources of referral to IPT
• PMTCT
• VCTs
• NGOs
• ARV programmes
Integration of TB/HIV services
• IPT provides a systematic way to screen
PLWH for TB
• Policy to provide HAART to HIV-infected TB
patients
• TB/HIV integrated surveillance rolled out 2005
• TB/HIV advisory body established
• TB/HIV care issues in the new TB manual
Reason for non-completion:
2001-2007
Active TB (0.4% )
Terminal AIDS (0.2% )
Hepatitis Severe Side Effects (0.1% )
Loss to Follow-up/Default (18.3% )
Discontinued by HCW (2.3% )
Voluntary Withdrawal (4.4% )
Achievements
&
Challenges
Achievements
• TOTs in all 24 districts (average; 5 per district)
• Trained (65%) of all health workers
• IPT programme officers at national level
• IPT available in all 24 districts and all 636 facilities
• Public awareness & uptake has increased
• Improved paper based reporting from districts
• Computers purchased for all districts
Achievements Continued
• Database available in all districts
• Designated TB coordinators in almost all
districts
• Enabled linkage of IPT to TB and ARV
databases through the use of national ID
• Improved frequency & quality of support
visits