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

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

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Pilot study

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completed

Database

rolled out

National office

Programme Review

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

Recommendation:

Overall, IPT is feasible and should be implemented.

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

Completed

n=25,075

(33%)

Non-completers

n=43,313

(59%)

Unknown

reason

(70%)

Eligible and started IPT

n= 71,541

Other

exclusions

(7%)

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

Actual in

2006

TOTs trained 96 +151 (157%)

Health care

workers trained

6619 4000 (60%)

Enrolment 50 000 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 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