IPT BOTSWANA EXPERIENCE

Oaitse I Motsamai RN, MW, B Ed, MPH Ministry of Health Botswana

11th November 2008 Addis Ababa, Ethiopia

OUTLINE

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

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%

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

TB Case Rate (per 100,000)

100 200 300 400 500 600 700 0

Rationale For IPT In Botswana

HIV seroprevalence (%)

Year
0 5 10

19 75 19 77 19 79 19 81 19 83 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05

15

20

25

30

35

40

45

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

15000

Cases

Counseled

10000

Database rolled out Roll out completed

Enrolled Complet ed

5000

Programme Review

Coag signed

National office
Pilot study
0 2000 2001 2002 2003 Years 2004 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
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
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
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

Target by 2006 TOTs trained Health care workers trained Enrolment 96 6619 50 000 Actual in 2006 +151 (157%) 4000 (60%) 42,186 (84%)

Caliber Trained
Health professionals:
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
Lack of clients follow up (defaulters) Transport problems particularly in the districts High mobility of clients Wrong addresses given by clients

Challenges Contd
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 1996 New 1.6% Retreatment 9.9%

1999
2002

4.4%
4.5%

16.6%
14.2%

Multi Drug Resistance

Year 1996 1999 2002 New 0.2% 0.5% 0.8% Retreatment 5.8% 9% 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