IPT BOTSWANA EXPERIENCE

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1 IPT BOTSWANA EXPERIENCE Oaitse I Motsamai RN, MW, B Ed, MPH Ministry of Health Botswana 11 th November 2008 Addis Ababa, Ethiopia

2 OUTLINE Botswana context Rationale for IPT in Botswana Pilot Current Programme Administration IPT Programme Evaluation

3 Background of Botswana 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%

4 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

5 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

6 TB Case Rate (per 100,000) HIV seroprevalence (%) Rationale For IPT In Botswana Year

7 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 : National roll out commenced 2003: IPT office established (3 officers) 2004: Complete roll out

8 Cases Progress of enrolment: Database rolled out Counseled Enrolled Completed Pilot study Coag signed National office Years Roll out completed Programme Review

9 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

10 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

11 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

12 Eligibility Criteria 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

13 Enrolment History and physical examination Exclusion of persons with cough and fever Client counseling Monthly review Side effects assessment TB screen Drug re-supply

14 Enrollment * 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%)

15 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)

16 IPT Programme Administration

17 IPT Staffing National Level: MOH National Coordinator Regional Coordinators (2) Data officers (3) IEC officer Implementation at the district level Doctors and nurses (MOLG, MOH) Complementary staff

18 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

19 Reporting and Recording Patient out-patient card (pink/blue) Register and Compliance record Dispensary Tally Sheet Patient Transfer form Monthly Report Form

20 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

21 Programme Funding Second-Five year cooperative agreement between CDC and MOH; ( , ) 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; : Over $2 million + technical support

22 IPT Programme Evaluation Conducted in May 2008 (external) Await final report Reviewed key functions Referral systems Medical screening Adherence Reporting/recording for M&E HCW training Patient counseling Assessed programmatic implications

23 Acknowledgements Botswana National TB Program Staff CDC Division of TB Elimination CDC Global AIDS Program/BOTUSA

24 Thank You

25 Backup Slides

26 2006 Programme Targets Target by 2006 Actual in 2006 TOTs trained (157%) Health care workers trained (60%) Enrolment ,186 (84%)

27 Caliber Trained Health professionals: Doctors Nurses Pharmacy Technicians Health Educators Social Workers Non-professionals - Family Welfare Educators - Lay Counselors - Health auxiliary

28 Challenges Encountered Overstretched national staff Inadequate counseling of some clients Loss of clients who are still on treatment Lack of clients follow up (defaulters) Transport problems particularly in the districts High mobility of clients Wrong addresses given by clients

29 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

30 Botswana Drug Resistance Surveys Since 1995, 3 resistance surveys done Fourth resistance survey in progress Results expected by 4 th quarter 2008.

31 Isoniazid Mono-Resistance Year New Retreatment % 9.9% % 16.6% % 14.2%

32 Multi Drug Resistance Year New Retreatment % 5.8% % 9% % 10.4%

33 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

34 Integration of TB & HIV Care

35 IPT as Part of HIV Care and Treatment Implementation of routine HIV testing from January 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

36 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

37 Reason for non-completion: 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%)

38 Achievements & Challenges

39 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

40 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

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