IPT BOTSWANA EXPERIENCE

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

Botswana

11th November 2008Addis 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 IPT1999: Formation of an IPT Working Group2000: Pilot conducted in three districts in to assess feasibility of national

scale-up2001: Pilot completed in April; evaluated in October 20012001: National roll out commenced2003: IPT office established (3 officers)2004: Complete roll out

Progress of enrolment: 2001-2007

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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-completersn=43,313

(59%)

Unknown reason (70%)

Eligible and started IPTn= 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 & DatabaseOther 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