Operational research on implementation of tuberculosis guidelines in Mozambique Brouwer, Miranda

Transcription

1 UvA-DARE (Digital Academic Repository) Operational research on implementation of tuberculosis guidelines in Mozambique Brouwer, Miranda Link to publication Citation for published version (APA): Brouwer, M. A. (2015). Operational research on implementation of tuberculosis guidelines in Mozambique General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 18 Dec 2017

2 3. Are' routine' tuberculosis' programme' data' suitable'to'report'on'antiretroviral'therapy'use' of'hivainfected'tuberculosis'patients?' MirandaBrouwer 1,PaulaSamuGudo 2,ChaliceMageSimbe 3,PaulaPerdigão 4,FrankvanLeth 5,6 1 HealthAllianceInternational,TechnicalAssistanceUnit,Maputo,Mozambique 2 MinistryofHealth,Maputo,Mozambique 3 MinistryofHealth,ProvincialDirectorate,Manica,Mozambique 4 Independentchestphysician,Maputo,Mozambique 5 Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands 6 KNCVTuberculosisFoundation,DenHaag,TheNetherlands BMCResearchNotes2013;6:23. 21

3 Abstract'' Background:Antiretroviraltherapy(ART)islifesavingforHIV<infectedtuberculosis(TB)patients.ART<use by these patients lag behind compared to HIV<testing and co<trimoxazole preventive therapy. TB programmes provide the data on ART<use by HIV<infected TB patients, however often the HIV services providetheart.weevaluatedwhetherthedataonart<useinthetbregisterwerecompleteandcorrect. ThetimingofARTinitiationwasevaluatedtoassesswhetherreportingonART<usecouldhavehappened withthetbcasefindingreporting.wecollecteddataontbtreatment,hivtestingandartforadulttb casesin2007fromthreetbclinicsinmanicaprovince,mozambique.thesedataonuseofartfromtb registerswerecomparedwiththosefromthehivservices. Findings:Of624patientsincluded,504(81%)weretestedandofthese356(71%)wereHIV<infected.Ofthe co<infectedpatients,81%registeredwiththehivservicesinthesamefacility.thetbregisterwascorrect onart<usein73%ofco<infectedcasesandcompletein74%. InformationonART<usecouldhavebeenreportedwiththeTBcasefindingreportsin56%ofco<infected patients. Conclusion: The TB register is reasonably correct and complete on ART<use. However, the HIV patient recordseemsamuchbettersourcetoprovidethisinformation.reportingonart<useattheendofthe quarterinwhichtbtreatmentstartsprovidestheprogrammewithtimelybutincompleteinformation.a morecompletebutlesstimelypictureisavailableafterayear. 22

4 Background' Theuseofthepotentiallylifesavingantiretroviraltherapy(ART)fortuberculosis(TB)patientsco<infected with the Human Immunodeficiency Virus (HIV) did not progress as much as would be necessary in addressingthedualtbandhivepidemic.globally,thehivprevalenceamongnewtbpatientsis13%.in Mozambique this figure is 61%. 1 Worldwide, 29% of co<infected patients used ART in 2005, which had increased to 46% in In the same period, the percentage of TB patients knowing their HIV<status increasedfourfoldandprovisionofco<trimoxazolepreventivetherapy(cpt)reached75%ofhiv<infected TBpatients. TheWorldHealthOrganization(WHO)reportsthesefiguresyearlyinitsglobalTB<controlreport.Although in many countries the HIV services provide ART, also to TB patients, national tuberculosis programmes (NTPs)providethedataforthisreport.However,itisnotknownhowcompleteandcorrectthedataon ART<use are within NTPs. This is relevant as access to ART is one of the main indicators of TB<HIV collaborativeactivities. 2 To use routine programme data to monitor progress on implementation, ideally the data are correct, completeandtimelyavailable. 3 WHOrecommendsreportingofHIV<testingforTBpatientswiththeTBcase finding data at the end of the quarter. 4 Data are thus available shortly after the end of the quarter. However, for CPT and ART<use the recommendation is to report with the treatment outcome data 12 monthsafterthestartoftbtreatment.thisisnottimelyreportingandprecludesatimelyresponsefrom theprogrammeincaseofunder<utilization. In Mozambique TB treatment staff offer HIV<testing to all TB patients and CPT to the co<infected since 2006.ForfurthercareandtreatmentincludingART,theyrefertheco<infectedpatientstotheHIVservices. TBstaffreportbothHIVtestingofTBpatients,andCPTandART<usebytheco<infectedtogetherwiththe TBcasefindingdataattheendofthequarter.ThereforethedataonCPTandART<useareearlieravailable totheprogrammeincomparisontothewhorecommendedreportingtimeline.thisearlyavailabilitycan beusefulforprogrammemanagementpurposesifthedataarecorrectandcomplete. ThisstudythereforeevaluatedthecorrectnessandcompletenessoftheroutineTBregistersonART<use amonghiv<infectedtbpatients.weaddressedthefollowingquestions:1)howcorrectandcompleteare thedatainthetbregisteronart<use?2)howcompletecouldthedataonart<usebeforreportingatthe endofthecasefindingquarter? Methods' ' Studydesignandsetting We selected purposefully three health facilities in Manica province, Mozambique. Criteria for selection includedatleast150tbpatientsnotifiedin2007andthepresenceofbothtbandhivtreatmentservices inthesamefacility.theparticipatinghealthfacilitieswereanurbanfacilityintheprovincialcapitalandtwo ruralfacilitiesabout20and80kilometresfromtheprovincialcapital. In the TB recording and reporting system of Mozambique all TB cases receive a unique number in the notifyingfacility stbregister.patientshavetheirhivtestresultandthestartdateofartrecordedinthis register.allpatientsregisteredatthehivclinichaveapatientrecord,whichcontainsclinicalinformation, andauniquenumberforidentificationpurposes.alinkbetweenthetbregisterandhivpatientrecord doesnotexist.theuniquehivpatientnumberisnotsystematicallyrecordedinthetbregister,thoughtb 23

5 staff is encouraged to do so. The three selected health facilities have, in addition to the government s paperrecordingsystem,anelectronichivpatientdatabaseinstalledbyaninternationalnon<governmental organisation. Datacollection WeincludedallnotifiedTBcasesaged15yearsandolderfromJanuary1 st untildecember31 st,2007from theparticipatingfacilities.thefacility stbsupervisorcollectedthedatausingstandardizedforms.firstly, datafromthetbregisterwerecollected.theseincluded:thestartdateoftbtreatment,thehivtestresult andinitiationdateofartifthepatientusedart. Next,weusedtheuniqueHIVpatientnumber,ifavailableintheTBregister,toidentifytheHIVrecordsof thehiv<positivetbpatients.inaddition,localstafffamiliarwiththepatientsidentifiedsomerecords.if these methods did not lead to identification of the HIV patient record, we performed a search in the electronichiv<databaseusingthepatient snameandagetakenfromthetbregister.wetooktheunique HIVpatientnumberfromtheelectronicdatabaseandusedittolocatetheHIVpatientrecordforpositive matches.welimitedtheidentificationofthehivpatientrecordtothosehiv<positivetbpatientsreferred tothehivservicesinthesamehealthfacility. WecollectedCD4+cellcountresultsanddatesfrom12weeksbeforeandduringTBtreatment,ART<use, andthestartdateforartfromthehivpatientrecord. ToevaluatewhethertheTBregisterwascorrectandcompleteonART<use,wecomparedthedataonART< usefromthetbregisterwiththoseofthehivpatientrecord.incaseofdiscrepancyonart<use,wetook the data from the HIV patient record as correct for assessing ART<use because the HIV services provide ART.WealsoverifiedifthepatientshouldhavestartedARTaccordingtothenationalguidelinesforthose co<infectedpatientnotonart.atthetimeofthestudy,co<infectedpatientswereeligibleforartwhen theircd4+countequalledorwasbelow350cells/mm 3. 5 Welimitedouranalysistothepatientsforwhom boththetbregisterinformationandthehivpatientrecordwereavailable. WeevaluatedwhetherthepatientstartedARTbeforeorinthesamequarterasTBwasdiagnosedtoassess howcompletethedatacouldbeattheendofthetbcasefindingquarter. WeusedstandardWHOtreatmentoutcomestodefinetheendofTBtreatment. 6 Thiswasnecessaryto determinewhetherthepatientinitiatedartduringthecourseoftbtreatment. Statisticalanalysis We used EpiData version 3.1 for data entry and performed descriptive analysis with EpiData Analysis V Ethics The study protocol was approved by the National Bio<ethic Committee of the Ministry of Health of Mozambique and by the Institutional Review Board of the University of Washington in Seattle, USA. Becauseweusedroutinelyavailabledata,wedidnotobtaininformedconsent. Findings' Between January 1 st and December 31 st, 2007, the three health facilities notified 628 TB patients of 15 yearsandolder.figure4showsabreakdownofthetbnotificationsforwhichweidentifiedthehivpatient records(n=267).table2showsthetb<hivdatafortheindividualhealthfacilities. 24

6 Figure&4&Breakdown&of&notified&TB&patients&and&their&linkage&to&the&HIV&patient&record& HIV<testresultinTB register HIV<positive(ofthosewith HIVtestresult) ART<useregisteredinTB register(ofthehiv< infected) FacilityA(Urban,in provincialcapital, n=153) FacilityB(Rural,20 kmfromprovincial capital,n=245) FacilityC(Rural,80 kmfromprovincial capital,n=226) Total (n=624) N(%) N(%) N(%) N(%) RegistrationwithHIV servicesinthesamehealth facility(ofthehiv<infected) 147(96) 170(69) 187(83) 504(81) 107(71) 118(69) 133(71) 356(71) 16(15) 59(50) 86(65) 161(45) 81(77) 94(80) 112(84) 287(81) HIVPatientrecordavailable 74(91) 83(88) 110(98) 267(93) ART<useinHIVpatient record(ofthehiv<infected) 47(45) 59(50) 70(53) 176(49) Table&2&Results&of&HIV&testing,&registration&with&HIV&services&and&ART9use&in&the&three&health&facilities& 25

7 Of 157 co<infected patients recorded in the TB<register as using ART, 130 (83) were confirmed when crosscheckingthehivpatientrecord.ofthe110co<infectedpatientsrecordedinthetbregisternottobe usingart,64(58%)wereconfirmed.intotal,194(73%)entriesofart<useinthetb<registerwerecorrect. TheHIVpatientrecordshad176patientsrecordedasonART.Ofthose,130patientshadART<userecorded inthetbregister,acompletenessof74%. Inadditiontothe176patientsonARTintheHIVpatientrecord,23patientsnotonARTshouldhavebeen on ART according to the national guidelines because they had CD4+ cell counts equal to or below 350 cells/mm 3 during or before TB treatment. In total, 199 co<infected patients should have started or continuedonartwhilstontbtreatment.ofthese199patients,150(75%)couldhavebeenreportedat theendofthequarterwiththetbnotifications.potentially,theinformationinthetbregistercouldhave beencompletefor150/267(56%)attheendofthetbcasefindingquarter.whenreportedwiththetb treatmentoutcomes,thetbregisterwouldhavebeencompleteonart<usefor199ofthe267(75%)co< infectedpatients. Discussion' ThedataonART<useintheTBregisterwerecorrectin73%andcompletein74%.Thereportingattheend ofthecasefindingquartercouldhavebeen56%complete,ifdataonart<usefromthehivpatientrecords wereoptimallytranscribedinthetbregisters. The Global Fund to fight AIDS, Tuberculosis and Malaria assesses performance of grants on their programmaticachievements.theglobalfundconsidersaprogressagainsttargetachievementbetween60 and89%asadequate. 7 Usingthisperformanceassessment,ourstudyshowedthattheinformationofthe TBregisteronART<usehadanadequatelevel. However,thereismuchthatcanbeimprovedinreportingonART<useinco<infectedpatients.Areduction oftheincorrectrecordingofpatientsinthetbregisterasusingartofwhomart<usewasnotconfirmed bythehivpatientrecordwouldimprovedataquality.inourstudywefoundthisincorrectrecordingon ART<use in 17% of co<infected patients. We did not evaluate the reasons for this. Anecdotal evidence informedusthatpatientsattimesstatetheyalreadyuseart,whereasinfacttheydonot.reasonswhy patientsdonotstatetheirart<usecorrectlymightbeevenmorecomplexthanthereasonswhypatients do not start ART. A recent qualitative study in Malawi found that not starting ART was related to both healthsystemandpatientreasons. 8 ReasonsintheformercategoryincludedARTnotbeingofferedand non<availabilityofartdrugs.fearofdrugtoxicitywasthemainpatientrelatedreason.thestudyshowed thattoimplementtherecommendationtostartallco<infectedpatientsonartirrespectiveofthecd4+cell countrequiressubstantialeffortsfromthehealthsystem. 9 AstudyinCameroonexplainedatestrateof 95% partly because patients usually follow health care providers recommendations. 10 This shows the importanceofthehealthcareproviderofferingart. Inaddition,moreimprovementcouldcomefrommorecompleterecordingofART<useintheTBregister. Thisstudyshowedthat26%ofco<infectedpatientswererecordedintheTBregisterasnotonARTbutthe HIVpatientrecordedshowedtheywereinfactusingART. TheNTPinMozambiquereportedanART<useof33%forthewholecountryin Thiswaslowerthan the73%correctlyrecordedco<infectedpatientsinthetbregisteronartthatwefound.wecollectedthe datamorethan12monthsaftertbtreatmentstarted,whereasthentpdatawerereportedattheendof thequarterinwhichtbtreatmentstarted.thispartlyexplainsthedifference.anotherreasoncouldbethat 26

8 the HIV services provide ART and little collaboration or integration between the TB and HIV services existed.however,thehealthfacilitieshaveanartcommitteeofwhichthetbsupervisorisamember.the committeediscussespatientsthatareabouttostartartandassuchthetbsupervisorpotentiallyisaware oftheartstatusofthepatient. WefoundquiteadifferencebetweentheindividualhealthfacilitiesonHIVtestingandonART<use.Itisnot clearwherethesedifferencescomefrom.forhiv<testing,stockoutsofhiv<testkitscouldbeaproblem. Theurbanhealthfacilityisclosetotheprovincialdistributioncentreandmaybesufferslessfromstockouts orforashorterperiodoftime.thedifferenceinart<useseemedmuchmorerelatedtothedataexchange between the two services. According to the TB register in facility A, only 15% used ART, while the HIV< recordsshowedauseof45%. ThereportingonART<useattheendofthecasefindingquarterwasestimatedtobecompleteinonly56%. ReportingofART<usewiththeTBtreatmentoutcomes12monthsafterthestartofTBtreatmentincreased completenessto75%,butreducesthetimelyavailabilityofinformation.furthermore,inmanycountries thereportingontreatmentoutcomesislimitedtosputumsmear<positivecaseswhereasreportingonart< usewouldneedtobeforallhiv<infectedtbcases.thisdiscrepancymayinfluencethequalityofreporting on ART<use. Electronic data systems could facilitate data collection but also provide prompts to remind healthcareproviderstotakecertainaction,forexampletocollectabloodsampleforacd4+cellcountor tostartart. 12 Inourstudy12%oftheco<infectedpatientsdidnothaveasingleCD4+cellcountavailable duringtbtreatment.potentiallymorepatientwouldhavebeeneligibletostartart. Even though the data in the TB register on ART<use were adequately correct and complete, this study showed that services provided by one programme and reported data on these services by another programmeleadtoinconsistencies.datareportingisnotagoalonitsown,butprovidesprogrammeswith essential information on their performance. Ultimately, we want to improve patient outcome and integrationoftbandhivservicesmaybetheanswertothat.arecentpublishedsystematicreviewshowed thatintegrationofartprovisionintotbcareseemstoimprovepatientsoutcomes,however,theevidence isnotyetsufficient. 13 Limitations Thiswasaretrospectivestudybasedonroutinedata.Selectionbiasmayhaveoccurredbyincludingonly facilitieswherebothtbandhivserviceswerepresentinoneprovinceinmozambique.potentially,art< usemaybehigherinfacilitieswithbothservicesavailablethaninfacilitieswithonlytbtreatmentandthis mayhaveledtoapotentialoverestimationoftheart<use. AnothersourceofselectionbiasmightbethatnotallHIVpatientrecordscouldbetraced.However,we havenoevidencetoassumethatthepresenceofanhiv<recordisassociatedwithadequatereportingof data.furthermore,wemayhaveunderestimatedthecompletenessofdatabecausewedidnotverifyart statusofpatientsreceivingartinotherhealthfacilitiesthantheonewheretheyweretreatedfortb. We considered the information on ART<use from the HIV patient record, partially from an electronic database,ascorrect.potentiallythehivpatientrecordcontainsincorrectdata.however,arecentstudy from the same study area validated the electronic database used in our study. 14 That study found high levelsofmorethan95%agreementforthecd4+cellcount,thedateofthecd4+cellcountandthestart dateofart. Wecollectedthedata18to30monthsafterthestartofTBtreatment.TheWHOrecommendedreporting onart<use,is12monthsafterthestartoftbtreatment.ourfindingsmaypresentanoverestimationof 27

9 completeness though we think that little incentive exists for TB staff to update their registers after reportingthetreatmentoutcomes. Conclusion' ThedataonART<useinTBregisterarereasonablycorrectandcomplete.However,theTBregistermaynot bethebestsourcetoreportonart<useduringtbtreatmentbecausetheinformationinthehivpatient recordismuchmoreaccurate.reportingonart<useattheendofthequarterinwhichtbtreatmentstarts providestheprogrammewithtimelybutincompleteinformation.amorecompletebutlesstimelypicture isavailableafterayear. Futureresearchshouldfocusonhowtouseoptimallytheavailabledatainawaythatdoesnotaddan extraburdentohealthcareworkers. 28

10 References. 1. WorldHealthOrganization.GlobalTuberculosisControl2011.WHO/HTM/TB/ [Internet].2011.Available from: 2. World Health Organization. A guide to monitoring and evaluation for collaborative TB/HIV activities. WHO/HTM/TB/ WorldHealthOrganization.ManualonuseofRoutineDataQualityAudit(RDQA)toolforTBmonitoring WorldHealthOrganization.RevisedTBrecordingandreportingformsandregisters version Ministério da Saúde, Direcção Nacional de Assistência Médica. Tratamento antiretroviral e infecções oportunistasadultoeadolescente World Health Organization. Treatment of Tuberculosis: Guidelines for national programmes. Third edition. WHO/CDS/TB;2003: GlobalFundToFightAIDS,TuberculosisandMalaria.GrantPerformanceAssessmentMethodology.[Internet]. Availablefrom:7... (accessed28thnovember2012). 8. Kumwenda M, Tom S, Chan AK, Mwinjiwa E, Sodhi S, Joshua M, et al. Reasons for accepting or refusing HIV servicesamongtuberculosispatientsatatb<hivintegrationclinicinmalawi.intjtuberclungdisoffjintunion TubercLungDis.2011Dec;15(12): World Health Organization. Rapid Advice. Antiretroviral therapy for HIV infection in adults and adolescents NjozingNB,MiguelSS,TihPM,HurtigA<K.AssessingtheaccessibilityofHIVcarepackagesamongtuberculosis patientsinthenorthwestregion,cameroon.bmcpublichealth.2010;10: MinistériodeSaúde.ProgramaNacionaldoControlodaTuberculose.Relatóriodatuberculose2007.[Internet] Available from: relatorio_da_tuberculose_2007. Accessed29thMay PhiriS,KhanPY,GrantAD,GaretaD,TweyaH,KaluluM,etal.IntegratedtuberculosisandHIVcareinaresource< limited setting: experience from the Martin Preuss centre, Malawi. Trop Med Int Health TM IH Nov;16(11): UyeiJ,CoetzeeD,MacinkoJ,GuttmacherS.IntegrateddeliveryofHIVandtuberculosisservicesinsub<Saharan Africa:asystematicreview.LancetInfectDis.2011Nov;11(11): Lambdin BH, Micek MA, Koepsell TD, Hughes JP, Sherr K, Pfeiffer J, et al. An assessment of the accuracy and availability of data in electronic patient tracking systems for patients receiving HIV treatment in central Mozambique.BMCHealthServRes.2012;12:30. ' 29