SOLUCION TBComorbidities:

A Partnership for Transformation

Final Report: October 1 2010 – December 31 , 2012Date Submitted: March 30th, 2013

Report Prepared by:Blanca Lomeli, Regional Director, US and México

Patricia M. Juárez-Carrillo, Monitoring and Evaluation Coordinator STB4Janine Schooley, Senior Vice President for ProgramsJessica Chen, Information Management Associate

PCI y Secretaría de Salud para el control de la Tuberculosis

A person affected by TB returns to a TB clinic in Tijuana to thank the nurse that provided him with care and support throughout his

six-month treatment schedule.

ACKNOWLEDGEMENTS

PCI would like to thank USAID for funding and supportingthe life-saving activities of the SOLUCION TB4 Comorbidities Program. We acknowledge the strategic support and advice provided by the USAID México program officers who partnered with PCI to carry

out this program and contribute to México's fight against TB.

PCI acknowledges and dedicates this report to all of the partner health service providers (leaders, managers, clinicians and administrators) who tirelessly work every day to make life better for those affected by TB, HIV/AIDS and diabetes and to prevent complications and death. Your dedication and

hard work are truly an inspiration.

PCI thanks all the people affected by TB, HIV/AIDS and diabetes across the country and especially in the participant jurisdictions, who provided their insight and recommendations to the design of the different phases of STB. Your example and participation will undoubtedly contribute to achieving

better services for others who will come after you.

“PCI represented a breakthrough for Tuberculosis (TB) control in México. A person-centered approach to service delivery, improved awareness of the

disease, and improved co-morbidity services for TB-HIV/AIDS and TB-diabetes are direct results of this partnership.”

Dr. Martín Castellanos JoyaDirector, National Tuberculosis Program Ministry of Health, México, November 2012

“Those of us who carried out this great project know that it has forever changed the way we work against TB in México and that it is now an example for other

countries. But above all, the best of it was the learning we all shared during the many opportunities we came together.”

Dr. Gonzalo CrespoDirector of Primary Health Care in Tamaulipas, November 2012

“I was pleasantly surprised by the quality of the care and services I received from the Ministry of Health. I was treated promptly, was given needed

information about the diseases, all the medications I needed, and fabulous support from the TB health workers. Their support also helped me overcome

the stigma and discrimination I was facing. I can only say thank you all for taking such great care of me.”

Person affected by TB and diabetes in Zapopan, Jalisco, June 2012

“We are really pleased with the achievements of this program which has focused on coordination and collaboration among the institutions that handle

HIV/AIDS, TB, and diabetes. The program has improved services provided to patients; systems of strategic information; and diagnosis and treatment.

We are satisfied that the program has exceeded its goals. I hope that Mexico considers the success of this truly Mexican program as an important

complement to all the efforts in the country fighting against TB.”

Sean JonesDeputy Director, USAID México

November 14th, 2012

TABLE OF CONTENTS

I. Executive Summary...............................................................................................II. Background..........................................................................................................III. Achievements.....................................................................................................

Strategic Objectives.......................................................................................... a) Proportion of clients newly diagnosed with a comorbidity who are referred for treatment........................................................................... b) Proportion of clients expressing satisfaction with comorbidities prevention or care services..................................................................................

IR1: Improved Communication, Collaboration and Coordination Between TB, HIV, and DM Programs.........................................................

IR2: Improved Quality of Services Provided to Target Populations................... a) Technical Trainings........................................................................................... b) People Outreached, Screened, and Diagnosed...............................................

IR3: Improved Systems for Strategic Information Management and Decision-Making................................................................................. a) Comorbidities Database................................................................................... b) Inter-programmatic Supervision and Monitoring............................................

IR4: Improved Care-Seeking and Care-Taking Behaviors.................................. a) Dissemination of Information to the Public......................................................... b) ACSM and Integrated Care Results......................................................................

IV. Challenges...........................................................................................................V. Lessons Learned and Recommendations............................................................ Key Lessons Learned............................................................................................. Recommendations................................................................................................VI. Close Out Strategy.............................................................................................. Sustainability........................................................................................................ Documentation and Dissemination of Results.....................................................

A. STB4 Results FrameworkB. STB4 Indicator Performance Tracking TableC. SOLUCION TB Tools, Products, and DocumentsD. SOLUCION TB Timeline

Annexes

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Advocacy, Communication and Social MobilizationBaja CaliforniaCentro Ambulatorio para la Prevención y Atención del Sida e Infecciones de Transmisión Sexual [Ambulatory Centers for Prevention and Care of AIDS and Sexually Transmitted Infections]National Center for Disease Prevention and ControlCentro Nacional para la Prevención y el Control del VIH/SIDA [National Center for the Prevention and Control of HIV/AIDS]Diabetes MellitusDirectly Observed Therapy, Short-courseFiscal YearGrupos de Ayuda Mutua (Support Groups)Greater Involvement of People AffectedHuman Immunodeficiency Virus / Acquired Immunodeficiency SyndromeIsoniazide Preventive TherapyIntermediate ResultsMinistry of Health National Tuberculosis ProgramNorma Oficial Mexicana (Mexican Official Norm)People affected by diabetesPeople affected by TuberculosisProject Concern InternationalPeople living with HIV/AIDSRed de Inteligencia Epidemiológica Mexicana [Mexican Epidemiological Intelligence Network]Strategic ObjectiveStrengthening Observed therapy Linking Up Community-based Integrated Outreach Networks for Tuberculosis controlSOLUCION TB Project Phase 4TuberculosisUnidad de Especialidades Médicas (Specialty Medical Unit)United States Agency for International Development

ACSM BC

CAPASITS

CENAPRECE CENSIDA

DM DOTS

FYGAM GIPA

HIV/AIDSIPT

IR MOH

NTPNOM

PADMPATB

PCIPLHIVRIEM

SOSOLUCION TB

STB4TB

UNEMEUSAID

ACRONYMS

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I. Executive Summary

The SOLUCION TB (Strengthening Observed therapy Linking Up Community-based Integrated Outreach Networks for TB control) Program Phase 4, also called STB4 Comorbidities or STB4, was implemented in close collaboration with the Mexican National Tuberculosis Program (NTP) in five jurisdictions including Tijuana in the state of Baja California, Ciudad Juárez in Chihuahua, Guadalupe in Nuevo León, Reynosa in Tamaulipas, and Zapopan in Jalisco. STB4 focused on tuberculosis (TB) and the comorbidities of TB-HIV/AIDS and TB-Diabetes Mellitus (DM). STB4 was funded by USAID México and implemented from October 1, 2010 to December 31, 2012. This final report summarizes the strategies, achievements, challenges, and lessons learned of STB4, as well as recommendations for future projects. Included as appendices are documents that provide greater detail about STB achievements and deliverables (all phases).

STB Phases 1 and 2 were implemented in Baja California and in 13 priority states of Mexico. Over the years, the STB approach has evolved, placing the person affected by TB at the center of a multi-faceted service delivery model. STB pioneered participatory approaches in mitigation of stigma and discrimination, including greater participation of people affected by TB and intensive outreach and awareness raising to address myths and misconceptions in TB transmission, and conducted the first national study on Knowledge, Attitudes and Practices. STB Phase 3, carried out from January to September 2010, served as the pilot phase for comorbidities with TB. The results of STB4 described in this report are, in essence, a culmination of all 4 phases.

The STB4 program's overall goal was to contribute to the reduction of morbidity and mortality related to TB-HIV and TB-DM in Mexico. The goal was achieved through the Strategic Objective (SO) of improved access to comorbidity prevention and care services for targeted persons in the five participating jurisdictions. Success in SO achievement was measured using two indicators: 1) Proportion of participating clients newly diagnosed with comorbidity who are referred for treatment; and 2) Proportion of participating clients expressing satisfaction with comorbidities prevention or care services via a User Satisfaction Study.

The SO was achieved through the following four interrelated intermediate results (IRs): 1. IR1: Improved communication, collaboration and coordination between

TB, HIV and DM programs 2. IR2: Improved quality of services provided to target populations 3. IR3: Improved systems for strategic information management and decision-making 4. IR4: Improved care-seeking and care-taking behaviors

STB4 was implemented collaboratively between PCI and the Mexican Ministry of Health's (MOH) NTP in collaboration with the National Center for the Prevention and Control of HIV/AIDS (CENSIDA) and the National DM Program. STB4 worked to promote an integrated person-centered approach to service delivery among two target populations: health providers and affected individuals. STB, including Phase 4, has been first and foremost a national systems strengthening program carried out through a transformative partnership approach. The transformational nature of the partnership was achieved through many years of collaboration that always respected local ownership and which recognized the need to collectively address the knowledge, systems and behaviors necessary for true transformation. PCI, together with the NTP as the natural leader of the comorbidity effort,

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worked to identify root causes and barriers to collaboration and to develop tools designed to support and enhance ongoing training and raise awareness. Although there were many challenges related to breaking down the inherent verticality in the public health system, PCI and the NTP were together able to successfully build on years of partnership and experience to effectively engage the HIV/AIDS and DM programs in unprecedented ways. The level of TB-DM collaboration has helped position Mexico as a leader in the fight against this less understood and particularly under-served co-morbidity throughout Latin America.

The following are selected transformative contributions of STB4: • Improved comorbidities diagnosis and screening, nationally and in the 5 participating

jurisdictions. There has been a 154% increase in the prevalence of TB-HIV in Mexico when comparing 2007 to 2011 data. TB-DM prevalence increased 73% between 2007 and 2011. In the five participating jurisdictions, the average percentage increase from 2011 to 2012 in the number of people with TB tested for HIV was 71.1%. Similarly the average percentage increase for DM testing was 73%. A total of 25,089 individuals were screened for comorbidities in the five participating jurisdictions from January 2010 to September 2012.

• Established comorbidity training programs. A total of 4,582 nurses, physicians and other health workers received training in Directly Observed Therapy, Short-course (DOTS) and comorbidity prevention and care and the NTP is working to extend comorbidity training to all states in the country.

• Integrated care for TB-HIV and TB-DM. STB4 and the National TB, DM and HIV/AIDS programs organized the first National Summits for Comorbidity Experts in México in September 2012. The summits each convened over 20 experts from across the country and resulted in joint recommendations for improved comorbidity care. Additionally, the meetings resulted in the submission of coordinated recommendations during the revision of the TB Prevention and Control Norm related to improved comorbidities prevention and care.

• Carried out the first Comorbidity User Satisfaction Study. The “Tuberculosis and Comorbidities (DM and HIV): Health Services User Satisfaction Exploratory Study” was conducted with 178 participants in all five partner jurisdictions from October 27 to November 14, 2011. Overall, 90% of the participants (150 out of 177 participants) rated their satisfaction from moderate to high.

• Developed a comorbidities information system. PCI and the NTP developed a comorbidities database utilized for reporting on testing, diagnoses and referrals carried out in the 5 participating jurisdictions which will serve as the basis for future modifications to the national health information system. At the national level, indicators for testing of HIV/AIDS for individuals with TB and of TB in individuals with HIV/AIDS were elevated to the criteria of Indicators of Excellence, which signifies that these two indicators will be part of dashboard indicators utilized by the National and State level MOH to assess and rank the quality of health systems throughout the country.

• Established joint planning for HIV/AIDS, DM and TB programs. All five jurisdictions are now developing, implementing and monitoring comorbidities plans. In 2012, the NTP, CENSIDA and the National DM program developed a comorbidities national supervision format and, for the first time in the history of TB control in México, carried out joint supervision visits to the five jurisdictions. Moreover the NTP expanded a staff position to promote, support and coordinate comorbidities interventions across the country.

• Established joint outreach and public awareness activities. Through STB4, over 10.5 million people were reached through ACSM activities such as TV, radio and/or newspaper interviews, or coverage of various outreach events. At the state and jurisdiction levels, awareness and

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mobilization activities are conducted jointly around World TB Day in March, DM Awareness in November, and World AIDS activities in December in all five jurisdictions. A decision to continue with this joint coordination of outreach activities has been expressed by all five participating jurisdictions.

Several 'firsts' occurred through the implementation of STB4 including the following:• First National TB-DM and TB-HIV Experts Summits

• First satisfaction study carried out for comorbidities

• First national inter-programmatic monitoring site visits and monitoring tool developed.

• Transformation of TB-HIV coordination 'entities' into full-fledged planning in the five

jurisdictions and plans for expansion nationally. • The national coordination position for TB-HIV was modified to incorporate TB-DM control.

• A call to action was developed by national, state and jurisdiction participants of the final STB

meeting in November 2012 which calls for greater investment in TB prevention, and public and private commitment to stop TB, and renewed energy and resources for preventing TB, TB-HIV and TB-DM deaths, and zero discrimination related to these diseases.

The main challenges identified by PCI are related to systems, operations and context. The main clinical challenge faced by PCI's STB4 was the insufficient utilization of IPT for individuals with HIV/AIDS and without TB. This challenge relates to the way the health system is structured and the lack of sufficient integration between the HIV/AIDS and TB programs. In terms of operations, collaboration agreements established at the national level at the beginning of STB4, and subsequently replicated at the state and municipal levels, were not easily translated into practice. For example, once joint screening and detection procedures were agreed upon and carried out at the health centers, it was difficult for health workers to document service integration due to the lack of integrated reporting formats. Thirdly, contextual challenges existed due to the varied levels of violence in the five jurisdictions that occasionally affected the program's and MOH's staff ability to travel.

A number of lessons were learned during STB4 implementation including lessons related to: • How best to facilitate the process of integration, building on early successes and focusing in on root causes and key drivers of success. • Strategic analysis of local cohort data to facilitate learning, identification of areas of

improvement, and commitment to change. • Adaptation and modification of information system, including the development or adaptation of documentation and reporting tools, are essential for success. For example, once screening formats were in place, reporting and annual projections improved.

The User Satisfaction Study resulted in several suggestions for opportunities to improve the quality of services provided to people with comorbidities: • Increase educational activities by physicians and nurses for TB, DM, and HIV/AIDS affected persons during regular health care visits to augment their awareness about the risk of comorbidity. • Increase the number of, and ensure the availability of, personnel and testing and diagnostic materials for screenings. • Improve the quality of information about TB Comorbidities (i.e. importance and risks) provided to health care personnel, affected persons, and to the public.

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Overall recommendations based on STB4 implementation include the following: • Continue to expand the comorbidities care and prevention model throughout all states and

jurisdictions in the country, including establishment of comorbidity committees to carry out joint data analysis, planning, monitoring and reporting.

• Ensure an official MOH information system continues to incorporate key comorbidity service indicators (e.g. screening and referrals). • Continue and expand ACSM strategies to strengthen participation of those affected by TB and TB-HIV and TB-DM, and effectively address stigma and discrimination. • Continue to invest in awareness and education campaigns that include messages addressing myths related to transmission and care of TB which contribute to stigma and discrimination. • Continue to invest in training of health workers to fully adopt a person-centered care model for

the delivery of TB and comorbidities services.

An important program goal of this STB4 project was to support partners in the design of a sustainability and phase-out plan and related tools to ensure that comorbidity strategies and enhanced collaboration amongst partners continue at the national, state, and local levels beyond the support of PCI and USAID, and to examine jointly with the NTP the potential expansion of the TB comorbidity strategies to other jurisdictions and states. In addition to recommendations listed above, key sustainability strategies identified include:

• Maintain a comprehensive vision that integrates all factors surrounding comorbidities• Continue empowering staff and affected persons through training and other key activities• Utilize the rich array of documents and tools developed throughout the life of the STB to share

the approach, strategies and results more broadly, including a custom-tailored set of documentation tools and videos developed at the end of STB4 precisely for this purpose (See Annex C)

Beyond the life of STB4, comorbidity service expansion has continued, and comorbidity recommendations have been incorporated into several national guides and standards. At the final STB meeting in November 2012, all five states reported the expansion of comorbidity services into other jurisdictions within their state. Recommendations developed during the TB-HIV Experts Summit were incorporated into the updated Guide for Utilization of Antiretroviral Medications produced by CENSIDA, to be further disseminated through three regional trainings in 2013 co-organized by NTP and CENSIDA. The NTP will present a modified Mexican Norm for TB Prevention and Control, including recommendations to improve prevention and care for TB-HIV and TB-DM, to the National Committee on Norms in April 2013. At the national level, the MOH has incorporated TB-HIV screening indicators into the Indicators of Excellence system which ensures close follow up by health authorities and is utilized across Mexico to score and compare state health systems annually.

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II. Background

2The SOLUCION TB Project Phase 4 (STB4) was launched on October 1, 2010 to improve comorbidity care and prevention outcomes related to TB, HIV and DM through close collaboration, capacity building, and technical activities at the national, state, and jurisdictional levels of the MOH in México. The project was planned to be implemented in two fiscal years: Y1 (October 2010 to September 2011) and Y2 (October 2011 to September 2012), with a no-cost extension period ending on December 31, 2012. STB4 was implemented by PCI in close partnership with the Mexican MOH through the National TB Program (NTP) [Programa Nacional de TB], the National Center for the Prevention and Control of HIV/AIDS (CENSIDA) [Centro Nacional para la Prevención y Control del VIH/SIDA] and the National DM Program.

Five jurisdictions and states participated in the program: Tijuana in Baja California, Ciudad Juárez in Chihuahua, Guadalupe in Nuevo León, Reynosa in Tamaulipas, and Zapopan in the state of Jalisco. These areas were selected based upon the level of need in terms of TB-HIV and TB-DM, and also because of these states' potential for improved results.

The STB4 program's main goal was to contribute to the reduction of morbidity and mortality rates related to TB-HIV and other Comorbidities. The goal was achieved through the Strategic Objective (SO) of improved access to comorbidity prevention and care services for targeted persons in the five participating jurisdictions. The SO was achieved through the following four interrelated intermediate results (IRs):

1. IR1: Improved communication, collaboration and coordination between TB, HIV and DM programs

2. IR2: Improved quality of services provided to target populations3. IR3: Improved systems for strategic information management and decision-making 4. IR4: Improved care-seeking and care-taking behaviors

STB4 directed efforts to two different target populations: health providers and affected individuals. The intervention model (Figure 1) aimed to promote integrated person-centered services on which the affected populations were at the center of the strategy:

• People affected by TB (PATB) to improve awareness, detection, prevention and treatment of TB HIV and TB-DM

• People living with HIV (PLHIV) to improve awareness, detection, prevention and treatment of TB-HIV

• People affected by DM (PADM) to improve awareness, detection, prevention and treatment of TB-DM

The first phase of SOLUCION TB was implemented from 2004 to 2008 in the state of Baja California. The second phase was called 'Expansion' (or STBE) and was implemented from 2006 to 2009 in 13 states. The third phase STB project spanned the period from January 2010 to September 2010 in 7 states in Mexico.

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Figure 1. STB4 Model for Comorbidities Management

TBProgram

PATB,PADM,PLHIV

HIVProgram

DMProgram

TB Program provides prevention and detection of DM and HIV and referrals as appropriate

HIV Program provides testing for DM, prevention and detection of TB, and referrals as appropriate

DM Program provides prevention and detection of TB and HIV and referrals as appropriate

The primary role of STB4 local staff was to help with coordination and collaboration, provide technical support, facilitate trainings for MOH health professionals to improve the management of comorbidities and help transfer skills and technical expertise as the STB program transitions out. Jurisdictional STB4 staff also participated in direct service-provision and health promotion, prevention, and Advocacy, Communication and Social Mobilization (ACSM) activities with people affected by any of these three diseases. During the final quarter, jurisdictional STB4 staff help transferred and supported transition activities to ensure MOH staff adopt and continue with the STB4 strategies and activities in the future.

The Centro Ambulatorio de Prevención y Atención en Sida e ITS (CAPASITS) are centers providing services to HIV positive persons and those affected by sexually transmitted diseases.Grupos de Ayuda Mutua (GAM) are mutual support groups.The Unidades de Especialidades Médicas (UNEME) are medical units for specialized care for persons with DM and related chronic diseases.

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For all three affected population groups, STB4 and MOH staff provided information and services regarding Comorbidities. When diagnoses were made, individuals were referred to the appropriate

3 4 5services. The comorbidity services were provided in health units, CAPASITS, GAM, and UNEME . See Figure 1 describing the comorbidity management model of the STB4 program.

III. Achievements

Strategic Objectives

The overall SO of STB4 is improved access to comorbidity prevention and care services for targeted persons in the five participant jurisdictions. This was accomplished by the following.

Prevalence of TB-HIV co-infection increased 154% nationally from 2007-2011 when 1,520 co-infection cases were reported. Before, only an increase of 8.3% was reported from 2003 (593 co-infection cases) to 2007 (652 cases). For TB-DM, prevalence increased by 73.4% in 2011 (4,262 cases) compared to 2007 (3,130 cases); and before, an increase of 46.9% was reported from 2003 (1,469 cases) to 2007 (3,130). Testing of HIV in persons with TB increased 20 percent points nationally, from 36.5% to 56.5% in the final year of program implementation (from FY11 to FY12).

While STB4 strategies and activities concentrated on improving a subsection of the entire jurisdiction, official data is available only jurisdiction-wide. The following data is reported by jurisdiction for FY11 (Oct 2010-Sep 2011) and FY12 (Oct 2011-Sep 2012):

6Table 1. Comorbidity Testing 2010-2012 by Jurisdiction

Jurisdiction % of individuals with TB tested for HIV/AIDS in the entire jurisdiction

% of individuals with TB tested for DM in the entire jurisdiction

2010-2011 2011-2012 2010-2011 2011-2012

Tijuana, Baja California 10.5 37.5 7.9 19

48.5 56.3 48.9 51.3

Zapopan, Jalisco 75.7 96 75.7 96.1

Guadalupe7, Nuevo León 38.7 36.5 32.3 25.7 Reynosa, Tamaulipas 55.2 95 32 77 Total Average 45.7 64.2 39.3 53.82 Average percentage change 71.1% increase in FY12 compared to

FY11

73% increase in FY12 compared to FY11

Ciudad Juárez, Chihuahua

8Additionally, according to SOLUCION TB data, a total of 25,089 individuals with TB, HIV/AIDS or DM were screened for comorbidities in the 5 participant municipalities including data for STB3 and STB4 (Oct 2010-Sep 2012).

Furthermore, all individuals newly diagnosed with a comorbidity TB-HIV or TB-DM were referred to the appropriate program for further testing, treatment, and follow up, either at an MOH health unit or to another government health agency such as Mexican Social Security System [Instituto Mexicano del Seguro Social or IMMS]. According to the final results of the STB4 database, a total of 478 people were newly diagnosed with comorbidities during the STB4 project period: 233 with TB-HIV and 245 with TB-DM. See Figure 2 with detailed achievements per jurisdiction.

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Source: National System for Epidemiological Surveillance/Unique Information Platform (SINAVE/PUI)This is the data available for Nuevo León from official sources. PCI was informed that an error in the system prevented accurate data captured in some municipalities (jurisdictions) including Nuevo León.Source: internal STB reports

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a)Proportion of clients newly diagnosed with a comorbidity who are referred for treatment

Figure 2. Persons Newly Diagnosed with TB-HIV and TB-DM

b) Proportion of clients expressing satisfaction with comorbidities prevention or care services

All partner jurisdictions collaborated successfully in the implementation of the TB and Comorbidities (DM and HIV): Health Services User Satisfaction Exploratory Study. The study aimed to 1) document how satisfied the persons affected by TB, HIV/AIDS and/or DM participating in the program's target areas are with the health care services provided, and 2) assess if users received information and services about any of the additional programs (e.g. TB, DM, HIV/AIDS) during their health care visit.

The Institutional Review Board of the University of Texas at El Paso approved the study. Interviews were conducted from October 27 to November 14, 2011 for a total of 178 participants, 35-36 from each jurisdiction. Participants were approached and interviewed in the health units, CAPASITS, UNEME, and in GAM of each jurisdiction at varied times and days of the week. Interviews lasted 15-30 minutes. The instrument requested demographic information (age, education, occupation) and ask respondents to rate the quality of the services provided regarding comorbidity, as well as the level of satisfaction with the services received.

Study participants averaged 44.5 years of age with 8.5 average school years completed, and 53% of the participants were male. In summary, of the 178 participants, 71% received additional information about a disease other than the one that prompted their visit to the health center. Of these, 74% reported receiving information on TB, 58% HIV/AIDS, and 59% received additional information on DM and over 63% of the participants waited a half hour or less to receive services.

In general, the average level of satisfaction was 33.38 points with significant difference between jurisdictions (p<.001) and sites of the interview (p<.05). The jurisdiction of Tijuana resulted with the highest average points (36.1, n=36) and Reynosa with the lowest average points (29.1, n=35). The sum of points (range from 10 to 40 points) was categorized as low satisfaction (range 15 to 26 points), as moderate satisfaction (range 27 to 33 points), and as high satisfaction (range 34 to 40 points). Overall,

990% of the participants (150 out of 177 participants) rated their satisfaction from moderate to high (See Figure 3).

Sample size of 177, because one participant did not score some of the statements.9

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10The report of this study was presented at the STB4 First Annual Meeting of 2012 held from February 29 to March 2, 2012 in Guadalajara, Jalisco to TB, DM and HIV partners. Additionally, the results of the study were presented by STB4 Director Blanca Lomeli at the XVI National TB Update Conference held from June 11 to 15, 2012 in Mexico City, and organized by the MOH. Over 500 medical and high level staff from the Mexican state jurisdictions of the TB departments attended the conference.

The study was an important project milestone, as it allowed STB4 to assess the impact of strategies and activities on service provision as perceived by its primary audience: people affected by TB, HIV/AIDS and DM. While there was no baseline, the STB4 partners agreed that the study provided evidence of integrated care and information being provided to individuals with TB, HIV/AIDS, and DM. It is generally understood that higher satisfaction leads to higher treatment adherence and greater integration of messages results in earlier detection of comorbidities. Due to potential changes in personnel, health prioritization, and federal budgets wrought by the Mexican presidential election, coupled with restrained time and resources, STB4 was unable to replicate the study during this project period as suggested by partners. The methodology and tools should be replicated in participant or additional jurisdictions, STB4 has electronically distributed the report methodology, tables, and graphs to partners at the local, state, and federal levels for further use. Interest in replication has already been expressed by other jurisdictions.

10The report of the User Satisfaction Study is available in Spanish.

IR1: Improved Communication, Collaboration and Coordination Between TB, HIV, and DM Programs

All five partner jurisdictions developed working plans for each period and reported satisfactory implementation of these plans. The results of Year 1 helped partners to determine Year 2 goals based on achievements and analysis of challenges and lessons learned. Coordination, communication and collaboration between program representatives at the local, state, and federal levels were achieved through national and local meetings, technical fieldtrip exchanges, electronic newsletters, and constant communication by phone and Skype conferences

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Figure 3. Overall Level of Satisfaction with Comorbidities Prevention and Care Services

To improve coordination, local and state representatives of each TB, HIV and DM programs held 381 total joint planning meetings partners; 186 meetings were organized from the 152 planned for Year 1 (122% achieved), and 195 joint meetings from the 159 meetings planned for Year 2 (123% achieved). This resulted in an average of 16 meetings per month by all five jurisdictions.

STB4 organized several opportunities for partners to collaborate and exchange information. This platform helped partners identify strategies, challenges, and lessons learned to improve collaboration between TB, HIV and DM programs in their own states and jurisdictions. STB4 organized various STB4 organized four bi-annual national meetings, two national meetings with STB4 jurisdictional coordinators, five technical exchange visits conducted between jurisdictional coordinators, and two Experts' Meetings between TB and HIV and TB and DM representatives (See Table 2 for details).

Additionally, PCI staff designed and electronically distributed 26 newsletters to partners (from October 2010 to September 2012), available on the STB Website (http://soluciontb.org/ soluciontb.org). The newsletters announced achievements and provided updated information about person-centered approach, stigma and discrimination mitigation, quality of services, and approaches to address prevention and treatment of comorbidities, among other topics.

Reynosa established a regular jurisdictional comorbidity committee to reporting on the progress of joint activities. This meeting on July 2012 included representation from the state epidemiologist, head of the MDR TB clinic, state coordinator of DM, NTP department chief, and the national comorbidity manager.

Bi -annual National Meetings

Jan. 11-13, 2011

México City

México City

Sep. 7-8, 2011

Guadalajara, Jalisco Feb. 29-Mar. 2, 2012

Mexico City Nov. 13 14, 2012

STB4 Coordinators Meetings Tijuana, Baja California Mar. 29-31, 2011

Tijuana, Baja California Apr. 24 -27, 2012

Technical Exchange Visits between jurisdictional coordinators

Coordinator of Ciudad Juárez in Guadalupe, Nuevo León Jan. 25-27, 2012

Coordinator of Guadalupe in Ciudad Juárez, Chihuahua Dec. 13-15, 2011

Coordinator of Reynosa in Tijuana, Baja California Jan. 16-18, 2012

Coordinator of Tijuana in Zapopan, Jalisco Jan. 25-27, 2012

Coordinator of Zapopan in Reynosa,Tamauli Feb. 8 10, 2012

Comorbidity Experts Summits México City Sep. 20, 2012 with TB -HIV

Sep. 21, 2012 with TB -DM

Purpose Place Date

Table 2. Meetings to Exchange and Identify Strategies, Challenges, Lessons Learned and Recommendations

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IR2: Improved Quality of Services Provided to Target Populations

a) Technical Trainings

In STB Phases 3 and 4, a total of 4,582 nurses, physicians and other health workers received training in Directly Observed Therapy, Short-course (DOTS) and comorbidity prevention and care (Source: STB reports). Comorbidity training is now a standing topic of the NTP's national annual TB conference. Similar to NTP, all participant jurisdictions made commitments to continue comorbidity training in their states and jurisdictions, and the NTP is working to extend comorbidity training to all states in the country.STB4 supported all partner jurisdictions for the organization of trainings and symposiums for public and private sector health personnel, community workers, and representatives of community organizations. The trainings covered service quality related with TB and its Comorbidities HIV and DM; prevention; symptoms and signs; MOH procedures for referrals to diagnosis and treatment services; DOT; IPT; stigma; person-centered approach; and other topics. Applying pre- and post-tests was feasible in some of these activities, and results showed improved learning. Table 3 details the gender of participants per period from all sectors and organizations attending these trainings.

Table 3. Summary of Technical Trainings Supported by STB4

Males 227 352 579

Females 514 759 1273

Total 741 1111 1852

Participants Y1 Y2 Total

b) People Outreached, Screened, and Diagnosed

Overall, 19,375 persons affected with TB, HIV or DM received information and were asked about specific symptoms or signs of comorbidities. Of these, 6,299 persons were tested for TB, HIV, or DM, and 478 were confirmed as new persons with a comorbidity of TB-HIV or TB-DM. Each confirmed case received support, follow up, and referral/treatment. The following figures are documented through STB4 monthly reports from PCI coordinators at the jurisdiction levels and validated by MOH representatives before submission to PCI headquarters:

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Nurses from Ciudad Juárez, Chihuahua review materials at a comorbidity training session.

• 1,334 persons affected by TB received information and were tested for HIV, of which 73 tested positive for HIV

• 1,253 persons affected by TB received information and were screened for DM, of which 88 tested positive for DM

• 774 persons affected by HIV received information and were screened for TB, of which 160 persons tested positive for TB.

• 2,938 persons affected by DM received information and were screened for TB, of which 157 tested positive for TB

A nurse and STB coordinator in Tijuana conducts a presentation on TB symptoms. Screening activities began with information about TB for those individuals with diabetes or HIV/AIDS to identify those who met the selection criteria for further testing.

Table 4 details the targets set and achieved by each jurisdiction for the IR2 concepts. These indicators include the percentages of targets met on the IPTT at the end of this report.

Table 4. Service Quality Targets Set and Achieved by Jurisdiction

Co ncept Y1 Y2

Goal Achieved % Goal Achieved %

2.2. T argeted HIV -positive people who were screened for TB in HIV care or treatment settings (CAPASITS) (PEPFAR C2.4.D)

2,519 2,298 91% 2,312 2,219 96%

2.3. Number of eligible HIV positive persons starting IP T

(PEPFAR C2.6.D)

292 124 42% 157 45 29%

2.4. Number of PATB who had an HIV test r esult recorded in the TB regist ry (PEPFAR C3.1.N)

854 661 77% 938 636 68%

2.5. Number of PATB who had a DM test result recorded in the TB register

766 625 82% 706 585 83%

2.6. Persons with DM screened for TB in DM care or treatment 6931 5813 84% 5968 6061 102% settings (i.e. Unidades de Especialidades Médicas, or UNEME)

Note on indicator 2.3 results: Only 42% and 29% of IPT targets respectively were achieved according to STB4 data in FY11 and FY12. There were two important barriers towards achieving targets set by STB4 and participant jurisdictions. Some of the jurisdictions reported interruptions in the supply of Isonizide (including Ciudad Juárez, Zapopan and Tijuana). More importantly, discussions on IPT utilization highlighted differences between the HIV/AIDS and TB program criteria for the exclusion of non-pulmonary TB. HIV/AIDS service providers (CAPASITS) required the participation from an HIV specialist and stricter criteria for exclusion of the disease. Ultimately, the decision to start IPT relied on the local HIV/AIDS specialist in charge. While CENSIDA participated in information dissemination and regional trainings to recommend utilization of IPT, local service providers were not inclined to decide to start IPT because a) there was a lack of sufficient or appropriate tests for non-pulmonary TB; and b) they were

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afraid of contributing to any form of INH resistance and decided to err on the side of caution in order to prevent any negative reactions from organized NGOs working in HIV/AIDS.

Note on indicator 2.4 results: Regarding information on HIV/AIDS testing carried out for individuals with TB, the main barrier faced by program providers was the perception of barriers to information sharing for confidentiality reasons. Accordingly, the HIV/AIDS program does not utilize a nominal database but one based on numeric identifiers. Information and recommendations related to indicators 2.3 and 2.4 were addressed at the Comorbidity Experts Summits described in other sections of this report. It is expected that joint recommendations disseminated by both programs will result in improvements in these two indicators in the future.

As table 4 above shows, results on TB-DM were met at 83% and 102% for indicators 2.5 and 2.6 respectively. Better results in this area compared to HIV/AIDS was likely related to the fact that screening of TB and DM for individuals with DM or TB (respectively) are carried out in the same facility, while TB and HIV/AIDS services are provided at different facilities. Also, the TB and DM programs report to the same sub-secretariat (National Center for Disease Prevention and Control, or CENAPRECE for its acronym in Spanish, which might have facilitated coordination and communication. Figure 4 describes the percentage of diagnosis carried out in the five jurisdictions, comparing testing by TB and HIV/AIDS programs, from Oct 2010 to Sep 2011.

In all locations except Tijuana, more co-infection diagnoses were made by CAPASITS (HIV/AIDS service provider) than by TB programs. Figure 5 describes percentage of diagnosis of TB-DM carried out by municipality and by program from Oct 2010 to Sep 2011:

Figure 4. Percent of People detected with TB-HIV from all Persons Tested by Program

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Figure 5. Percent of People detected with TB-DM from all Persons Tested by Program

IR3: Improved Systems for Strategic Information Management and Decision-Making

a) Comorbidities Database

Early in the project, PCI supported the NTP's initiative on the design of a database to register and track the comorbidities activities by each partner jurisdiction, aiming to offer accurate and ad hoc information to decision makers. The macro database was piloted from May to December 31, 2011. Later, the NTP postponed the macro database design because the MOH planned to develop a new enhanced national database. The new RIEM (Red de Inteligencia Epidemiológica Mexicana) [Mexican Epidemiological Intelligence Network] designed by the Direccion General de Epidemiología [General Directorate of Epidemiology] aimed to integrate information and variables from the macro Comorbidities Database.

The Comorbidities Database and the inter programmatic monitoring form included information on key screening activities based on existing programmatic forms like the diabetes detection form pictured above.

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b) Inter-programmatic Supervision and Monitoring

Led by the NTP, the TB, DM, and HIV program representatives designed a unified monitoring form. The “TB/DM and TB/HIV Comorbidities Operationalization Monitoring Form” (Cédula de Monitoreo para la Operación de los Binomios TB/VIH, TB/DM) was designed with specific indicators of screening, test, diagnosis, and care of people with a comorbidity. The form was piloted through on-site visits to select health care sites of each program (TB, DM and HIV) such as TB health units and GAMs, CAPASITS, and UNEMEs of all partner jurisdictions. Sites and dates of the field visits were as follows: Guadalupe, May 28-31; Ciudad Juárez, June 5-7; Reynosa, June 20-22; and Zapopan, June 27-29; and Tijuana, July 1-2, 2012.

Aiming to adhere to the national standards about care and quality of service of each program, the inter-programmatic form was also piloted through various activities such as meetings, interviews, and documentation check outs. National representatives of the TB and DM and PCI participated in these pilot visits.

A total of 20 health centers were visited by the joint monitoring team. The analysis shows that the five jurisdictions met over 60% of the indicators identified by the national programs as standards for comorbidities care (See Figure 7). Overall, the matrix generated the following recommendations that should be considered as priorities by the five jurisdictions visited:

• • Provide program comorbidity training regularly so it reaches all health center personnel• Annually testing for TB among health staff• Ensure all health centers have TB detection questionnaires• Improve coordination with local HIV/AIDS and DM NGOs as appropriate• Establish an infection control plan for all health centers in the jurisdiction to strengthen prevention of TB• Widely disseminate information on the comorbidities coordinating body and their activities

Guarantee continued supply of Isonizide at CAPASITS

Figure 6. Results of the Inter-Programmatic Assessment of Comorbidities' Indicators

% of co-morbidity process indicators present at the time

of the visit, according to the co-morbidities montoring

matrix

63.5

79.568.8

62.8 62.2

0

20

40

60

80

100

Reynosa Tijuana Guadalupe Zapopan Cd. Juarez

Of note, this joint monitoring format and supervision visits was the first time such monitoring collaboration has taken place in México. Thanks to the support provided by the STB4 project, the three national programs were able to identify the indicators of quality of care and service about TB-HIV and TB-DM at the state and local (jurisdictional and health center) level. The results of this effort will serve as a baseline for future application and evaluation of activities. At the end of this STB4 project, representatives of the three programs expressed their commitment to revise the matrix and supervision form and use the results as a baseline for future evaluation and decision making.

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IR4: Improved Care-Seeking and Care-Taking Behaviors

a) Dissemination of Information to the Public

Over 10.5 million people were reached through ACSM activities such as TV and radio interviews, newspaper inserts, and health fairs organized and facilitated by STB4 staff and partner jurisdictions.

11Partner jurisdictions distributed 35,000 STB-produced printed materials in waiting rooms, health 12 fairs, and in public events. Educational materials included brochures, flyers, T-shirts, agenda,

calendars, games, and posters disseminating information on topics related to comorbidities' signs, symptoms, access to treatment, stigma prevention, and myths, among others. Additionally, STB4 designed a brochure to disseminate the results of the study about Knowledge, Attitudes, and Practices of TB conducted in 2010 (Resultados resumidos del estudio de conocimientos, actitudes y prácticas en TB en México. 2009-2010” [Summary Results of the Knowledge, Attitudes, and Practices Study on TB in México 2009-2010] (Annex C).

18,000 brochures in FY11 and 17,000 in FY12. These included: TB general information; TB charter of rights and responsibilities; TB myths and realities; I have TB what should I do?; IPT use; Collaborative framework for TB and diabetes control; Why should I care about HIV/AIDS if I have TB?; and Why should I care about TB if I have Diabetes?Electronic files of such materials will be available in the ACSM Toolbox at the STB4 website (http://soluciontb.org/ soluciontb.org) by the early of 2013. These materials are now available and being distributed electronically by the NTP to all 32 states in the country.

11

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A variety of educational materials were developed and adapted by STB, for two different audiences: health workers and people affected by TB and comorbidities. These included but were not limited to: information on the WHO's recommendations for IPT use and I have TB how do I take care of myself? For a comprehensive list of materials developed, please see Annex C.

Overall, STB helped bring ACSM from theory to practice through a variety of methodologies (Voices and Images, Nuestra Casa, and related trainings and planning). The NTP has now designated a full time position to coordinate and oversee ACSM activities throughout the country. One of the key results of ACSM is the inclusion of individuals affected as important partners in the disease and its prevention. The language utilized and the perceptions expressed have changed to increasingly incorporate the concept of a partnership established between the service provider and the 'person affected by the disease' demonstrating both respect and consideration for individuals' feelings as well as their assets and participation in their own care. A toolkit of ACSM tools and methodologies was compiled throughout all phases of SOLUCION TB. The toolkit will be disseminated widely throughout México by the NTP.

In 2012, STB4 co-sponsored and supported the National Workshop “Monitoring and Evaluation of ACSM Activities to support TB Control in México and the Photovoice Methodology” in Guadalajara, Jalisco on August 6-10, 2012 to continue expanding the approach to additional states in Mexico. The workshop was attended by TB coordinators from 11 states and jurisdictions. All jurisdictions were new STB participants, as well as 7 of the 11 states.

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b) ACSM and Integrated Care Results

STB4 and the National TB, DM and HIV/AIDS programs organized the first National Summits for Comorbidity Experts in México in September 2012, one each to convene experts in TB-HIV and TB-DM. The summits each convened over 20 experts from across the country and resulted in joint recommendations for improved comorbidity care. The timing of the meeting also resulted in the submission of coordinated recommendations and contributions during the public revision of the TB Prevention and Control Norm (NOM 006) related to improved comorbidities prevention and care.

The NTP advocated for the importance of comorbidity care which resulted in the elevation of TB-HIV comorbidity testing into the MOH Indicators of Excellence. This is a clear result of higher prioritization of this important issue which will support the sustainability of results beyond the end of the program. A number of 'firsts' occurred through the implementation of STB4. These are especially relevant given the design of the Mexican public health system which is based on each program operating independently with minimal opportunities or structures that facilitate collaboration or integration of services.

Norma Oficial Mexicana (NOM 006) for the Prevention and Control of Tuberculosis, update published for public review in November 2012. A final version will be presented on April 8th for approval to the National Norm Consulting Committee (Comité Nacional Consultivo de Normalización).

13

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• and recommendations to improve care and prevention.

• First satisfaction study carried out for comorbidities. • First national inter-programmatic monitoring site visits and monitoring tool developed.

Transformation of TB-HIV coordination 'entities' into full-fledged planning in the five jurisdictions and plans for expansion nationally.

• Very importantly, the work in TB-DM began under STB4. The national coordination position for TB-HIV was modified to incorporate STB-DM control. Increasingly more research is being conducted on this important topic including a study being carried out by the NTP. Mexico is now considered a pioneer in TB-DM work in Latin America.

th• A call to action was developed on November 13 , 2012, by national, state and jurisdiction participants of the final STB meeting on November 2012. This document calls for greater investment in TB prevention, and public and private commitment to stop TB, and renewed energy and resources into preventing TB and TB-HIV and TB-DM deaths, and zero discrimination related to these diseases.

First National TB-DM and TB-HIV Experts Summits which resulted in concrete protocols

Previous collaboration between PCI and the MOH during the first three phases of STB provided the foundation for the successful implementation of STB4. Several key ACSM contributions this phase built upon the Expansion phase (Phase 2), which was implemented in 35 jurisdictions across 13 states as well as nationally. They include, but are not limited, to:

• Elevated importance of integration of ACSM activities, highlighted in part by the inclusion of 14México in the Advocacy, Communication and Social Mobilization for TB Control, collection of

country-level good practices by the STOP TB Partnership, November 2010 (See Annex C).• Adoption of GIPA (Greater Involvement of People Affected by TB) as a strategy for

prevention and control of TB as part of national, state and jurisdictional TB programming.• Development of 9 Voices and Images galleries which continue to be displayed around

World TB Day and relevant training events.

http://www.stoptb.org/assets/documents/resources/publications/acsm/ACSM_final_24%20Nov.pdf.México's PCI and MOH experience included in pages 50-53; a program participant from Baja California is cited also on page 7 of the document

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• Development and Expansion of the “Nuestra Casa” an interactive art exhibit which waslaunched at the University of Texas at El Paso, and subsequently exhibited at the International Union for TB Prevention and Control annual conference in Cancún México, the City of Oaxaca, Reynosa, and at Tijuana's Cultural Center, before a two month exhibit at the CDC Museum in Atlanta. A smaller version of Nuestra Casa is currently on display at the University Texas at El Paso Museum, and will be subsequently displayed by the State of Nevada (location to be confirmed) this 2013 (See Annex C).

• Transformation of DOTS' philosophy as an opportunity to establish true partnerships between people affected by TB and the service provider, as opposed to a mere observation of medication intake.

Other contributions have been documented in other reports and documents developed by STB (for more information please see Annex C for a list of tools, reports and other documents).

IV. Challenges

The three main challenges to comorbidities identified by PCI were related to systems, operations and context.

The main clinical challenge faced by PCI's STB4 was the insufficient utilization of IPT for individuals with HIV/AIDS and without TB. IPT is a proven TB prevention mechanism, which is utilized both for infant contacts of active TB cases, or to protect individuals with a compromised immune system. This challenge relates to the way the health system is structured and the lack of sufficient integration between HIV/AIDS and TB programs. The HIV/AIDS program in México is in charge of clinical decisions related to HIV+ individuals, including decisions to initiate TB treatment or IPT in those without TB. The Comorbidities Experts Summits carried out in September 2012 were designed to address these issues the best way possible. Summit recommendations on improving screening and care for TB comorbidities have been and will continue to be disseminated widely by the NTP starting with the National Evaluation meeting in late November 2012. HIV/AIDS recommendations have been incorporated into the updated Guide for Utilization of Antiretroviral Medications, and will be included in joint TB-HIV workshops implemented by NTP and CENSIDA in May, August and October 2013. The impact of these recommendations and their dissemination was not measurable by the time STB concluded in December.

STB4 faced operational challenges due to the fact that each participant program at the national, state, and municipality level is designed to primarily operate independently from one another. While integration of services should occur naturally at the health center level (where an individual seeks medical or preventive care), the healthcare system design did not provide strong integration of care. Collaboration agreements established at the national level at the beginning of STB4, and subsequently replicated at the state and municipal levels, were not easily translated into practice. TB screening and care traditionally do not call for the early testing or awareness of HIV/AIDS or DM. If an individual is not aware of his or her DM or HIV/AIDS status, a diagnosis will not likely occur until health complications are identified. The situation is similar for DM and HIV/AIDS care and TB screening. Similarly, once joint screening and detection procedures were agreed upon and carried out at the health centers, it was difficult for health workers to document service integration due to the lack of integrated reporting formats. STB4 successfully assisted the MOH in planning, implementation and documentation of comorbidity work; drafting new and adapting existing reporting tools; and supporting the design of a

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new parallel information system (comorbidities database). These strategies addressed documentation and information system challenges to integrated comorbidity screening and care.

These are members of the inter-disciplinary TB team in Reynosa, one of the jurisdictions that had to reschedule field activities due to levels of violence in the communities served.

Thirdly, contextual challenges existed due to the varied levels of violence at the five municipalities that occasionally affected the program's and MOH's staff ability to travel to particular health centers for monitoring, supervision, and technical assistance purposes. Regional travel to attend training was also affected by insecurity as some roads and highways previously used to expedite travel between participant municipalities were not deemed safe throughout the life of the project (mainly transportation between Monterrey, Guadalupe, and Reynosa). Violence levels in the five municipalities remain a constant reality to which both PCI and MOH learned

to adapt by programming site visits according to daily reports, and by utilizing only air-travel transportation for regional meetings.

V. Lessons Learned and Recommendations

Key Lessons Learned

Facilitated Integration:

There are different areas where comorbidities programming can be integrated in support of improved quality of services and earlier prevention, diagnosis and referral: budgeting, screening and referrals, or full service integration. Each alternative should be selected according to a country's health data, availability of funding and feasibility of system modifications. In the case of the NTP, with the support of STB4, integration took place mainly at the screening and referrals end of service provision. This was identified to be the most appropriate mechanism to achieve best possible results with minimal modifications to departmental policies. These changes resulted in higher awareness of comorbidities, improved monitoring and information systems, and improved screening, detection, and reporting. STB4 built upon what the MOH had previously designed for TB-HIV collaboration to improve results, and incorporated TB-DM as new important priority for the MOH.

Transformational Analysis:Another important lesson identified by STB4 was that strategic analysis of local cohort data facilitated learning, identification of areas of improvement, and commitment to change. When state and municipality teams were presented with updated cohort data for TB-DM and TB-HIV, they were able to identify programmatic areas to address, adhere to plans for integration of screening and referral services, and strategize on improved reporting mechanisms. A sustained commitment to change on behalf of program managers and staff was necessary to support new screening and referral tasks added to existing busy schedules.

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Information System Changes for Sustainability of Results:Adaptation and modification of information systems included the development or adaptation of documentation and reporting tools. Initial observation and situational analysis demonstrated inadequate documentation of comorbidity screening activities. This not only resulted in the perception that comorbidity screening was minimal or none existent, but also limited information for the development of annual targets. Once screening formats were in place, reporting and annual projections improved. Indicators were incorporated into a new information system developed by NTP and PCI. This comorbidity database was managed by the NTP, but informed joint planning carried out by the three areas: HIV/AIDS, DM and TB. Through improved awareness, learning, reporting, and analysis the prevention and care of comorbidities became a higher priority locally and nationally. Subsequently, the MOH decided to elevate comorbidity testing (HIV in TB and TB in HIV care) into a higher part of the reporting hierarchy within the MOH. These screening indicators are now included in the Indicators of Excellence system which ensures close follow up by health authorities and is utilized across Mexico to score and compare state health systems annually.

Modification of existing official information systems to incorporate joint work in TB, HIV/AIDS, and DM will be necessary to sustain progress made through STB4 in comorbidity screening, diagnosis, and referrals. The comorbidities database developed by the NTP and PCI, while useful, does not represent an official information system and needs to become institutionalized to guarantee utilization. Lastly, lessons learned in TB-HIV suggest that the recommendations from the Experts Summits should be widely disseminated and followed. Furthermore, improvements in coordination with community-based organizations working in HIV/AIDS and with individuals who are HIV positive should be achieved to increase understanding on the importance of IPT utilization and demand for its use.

RecommendationsThe Satisfaction Study produced suggestions for opportunities to improve the quality of services provided to people with comorbidities. These are:

a) Increase educational activities by physicians and nurses for TB, DM, and HIV/AIDS affected persons during regular health care visits to augment their awareness about the risk of comorbidity.

b) Increase the number of, and ensure the availability of, personnel and testing and diagnostic materials for screenings.

c) Improve the quality of information about TB Comorbidities (i.e. importance and risks) provided to health care personnel, affected persons, and to the public.

d) Conduct periodic meetings of representatives of each department to examine the quality of services and to identify barriers to, and opportunities for, quality improvement in each department and as a whole.

e) Establish regular supportive monitoring site visits to health centers and health units where services are provided to ensure quality person-centered, integrated services are being provided.

Overall recommendations include the following:

• Continue to expand the comorbidities care and prevention model throughout all states and jurisdictions in the country, including establishment of comorbidity committees to carry out joint data analysis, planning, monitoring and reporting.

• Ensure an official MOH information system incorporates key comorbidity service indicators (e.g. screening and referrals).

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A person with TB in Guadalupe Nuevo Leon, at the Tierra Propia health center. Nurses and physicians regularly educate on and screen for comorbidities.

The progress achieved by the MOH in México through the results of the STB collaborative program, demonstrate that key investments produce meaningful changes. Sustaining investment in these innovative ACSM and TB-comorbidities interventions will remain key to the sustainability of the results reported in this document. Special attention should be given to identifying mechanisms that effectively allow higher utilization of IPT for individuals with HIV/AIDS. As DM continues to be a growing problem for México, the work in TB related to early detection, education and treatment success, will continue to be crucial for the health of the country and those affected.

VI. Close Out Strategy

Sustainability

An important program goal of this STB4 project was to support partners in the design of a sustainability and phase-out plan to ensure that comorbidity strategies and enhanced collaboration amongst partners continue at the national, state, and local levels beyond the support of PCI and USAID, and to examine jointly with the NTP the potential expansion of the TB comorbidity strategies to other jurisdictions and states.

PCI initiated a strategy that included conversations and meetings around sustainability of activities through various approaches. Two meetings were held between USAID, PCI, PATH, and representatives from NTP, DM, and HIV programs. The objectives of these meeting were to 1) enhance coordination and synergy between the TB stakeholders funded by USAID; 2) analyze the status, achievements, and constraints of the TB program in México; 3) develop a draft sustainability plan with objectives, indicators, and key activities to be further informed by the NTP and to be undertaken during FY12; and 4) determine roles and responsibilities of PCI, PATH, and USAID to promote the sustainability of key activities after USAID funding ends.

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• Continue and expand ACSM strategies to strengthen participation of those affected by TB and TB-HIV and TB-DM, and effectively address stigma and discrimination.

• Invest in awareness and education campaigns that include messages addressing myths related to transmission and care of TB which contribute to stigma and discrimination.

• Continue investing in training of health workers to fully adopt a person-centered care model for the delivery of TB and comorbidities services.

PCI made sustainability a topic of all programmatic meetings, including state-level monitoring visits and national-level meetings. During the bi-annual national meeting held from February 29 to March 2, 2012, participants discussed strategies and actions toward the sustainability of the Comorbidities project achievements. The key strategies identified were:

a) Maintain a comprehensive vision that integrates all factors surrounding Comorbiditiesb) Continue regular communication and coordination between programs (TB, HIV/AIDS, DM)

through working committees, monthly meetings, and joint efforts on dissemination and education (including, but not limited, to World TB Day, International HIV/AIDS Day, and DM Day)

c) Continue empowering staff and affected persons through training and other key activitiesd) Unify the information system and the monitoring activities between departments/programs e) Continue the process of joint planning, monitoring, and decision-making

During the final STB4 project meeting held on November 13-14, 2012, participants confirmed these strategies would help sustain the project. All five states reported the beginning of expansion of comorbidity services into other jurisdictions within their state.

15The STB4 Project Coordinators of each jurisdiction met on April 24-27, 2012 in Tijuana, BC to address various close-out and sustainability issues. This meeting helped clarify the additional activities necessary to ensure the adequate close-out and sustainability of the project. Three of the participant jurisdictions have submitted a Comorbidities program plan for 2013. These plans will be submitted to their MOH authorities for approval.

The CAPASITS in Ciudad Juárez appointed a physician to collect, enter, and analyze data and TB-HIV care registries. Additionally, the portfolio of the existing TB-comorbidities State Coordinator in Tamaulipas has been modified to include coordination of ACSM activities as well. A Comorbidities Coordinator equivalent has been designated for the Reynosa Jurisdiction. Plans are in place for the absorption of STB4 personnel in Ciudad Juárez, Reynosa and Guadalupe. The state of Jalisco has already over 20 TB-

16exclusive positions in place, including an ACSM Coordinator.

The NTP has disseminated the comorbidities model for screening integration through national communication, site visits, and national trainings, including the dissemination of STB results, throughout the 32 states in México. Recommendations developed during the Experts Summit on TB-HIV were incorporated into the updated Guide for Utilization of Antiretroviral medications produced by CENSIDA, and will be further disseminated through 3 regional trainings in 2013 co-organized by NTP and CENSIDA. The NTP will present a modified Mexican Norm for TB prevention and Control, including recommendations to improve prevention and care for TB-HIV and TB-DM, to the National Committee on Norms in April 2013.

“Coordinators Meeting Report” is available in Spanish. As stated in reports from previous STB phases, the state of Jalisco advocated for increased funding to absorb over a dozen STB

staff from previous phases. Those positions continue to this date, and have been supplemented with additional staff.

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Documentation and Dissemination of Results

STB4 and MOH partners designed and implemented a documentation strategy to facilitate positioning, educational and sustainability activities beyond the end of the STB Program. The products of this process consist of two documents and one video specific to each of the five participant jurisdictions. The documents are a programmatic and an executive summary describing program objectives and its progress to date. The executive document includes a summary of key achievements in the corresponding jurisdiction, a list of recommendations, and a call to action for continued support. The other programmatic 'operations' document includes more detailed information on the program's goals, objectives, and activities implemented.

STB4 will illustrate both documents with local photographs and create a video to summarize the executive document. A video-documentation team conducted field visits to all partner jurisdictions to develop an awareness and sustainability video including interviews with health providers, people affected, and national representatives of the NTP. The 15-18 minute video and the two documents will serve as awareness and advocacy tool for local program managers to advocate for continued support for TB and comorbidities' activities.

These tools will primarily be directed to MOH authorities and decision-makers. Videos and tools will be utilized extensively during national evaluation meetings, World TB Day, International DM Day, and World AIDS Day in 2013. PCI will disseminate program results, lessons learned and recommendations through conferences, list serves, presentations, and reports such as the following:

• • CORE Group spring meeting, Baltimore, Maryland, April 22-26

th• USAID brown bag meeting. Washington DC, April 30• National TB conference, México City, June 2013

17• PCI external blog

• STOP TB Partnership• International Union of Tuberculosis and Lung Disease • Other NTP events and website• NCD list serves

World TB Day events 2013 –dissemination of videos and reports

http://www.pciglobal.org/endpoverty/17

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Project Concern International SOLUCION TB Co-morbidities Phase 4, Final Report FY2011 and FY2012 Annex A March 30, 2013

1

GOAL Contribute to reduced mortality and morbidity related to TB-

HIV/AIDS and DM Comorbidities in México

Intermediate Result 2 Improved quality of services

provided to target populations

Intermediate Result 4 Improved care-seeking and care-

taking behaviors

Key Activities 1.1. Follow up on collaboration agreements developed for HIV/AIDS-TB and TB-D programs to ensure optimal communication, coordination and collaboration. 1.2. Conduct joint planning meetings between TB, HIV and DM programs. 1.3 Develop and implement jurisdictional annual Comorbidities collaborative work plans.

Key Activities 2.1. Conduct technical trainings for health personnel in the management of Comorbidities with a focus on gender and a person-centered, and quality improvement approach to service delivery. 2.2. Ensure that all eligible persons living with HIV are tested for TB and have access to TB preventive therapy. 2.3. Improve HIV and DM testing among PATB.

Key Activities 3.1. Develop one Comorbidities database (Macro CM) with national-level (NTP) input 3.2 Assess current national guidelines for HIV/TB/DM comorbidity management. 3.3. Standardize monthly reporting of participant jurisdictions and states through Macro CM. 3.4 Determine, along with NTP, feasibility of expanding the use of Macro CM to a wider audience of priority states in the country for decision making after six months of database validation.

Key Activities 4.1. Train and disseminate key messages on prevention and control of Comorbidities that correct misinformation and myths identified through SOLUCION TB to reach communities, Civil Society Organizations (CSOs), support groups, PATB and others. 4.2 Foster greater involvement of PATB and Comorbidities through ACSM activities. 4.3. Raise awareness among CSOs and communities about the need for prevention of Comorbidities. 4.4. Promote access to HIV/AIDS and DM prevention, detection and treatment services among PATB.

Intermediate Result 3 Improved systems for strategic information management and

decision-making

Intermediate Result 1 Improved communication,

collaboration and coordination between TB, HIV and DM

programs

Strategic Objective Improved access to comorbidity prevention and care services for targeted persons in the five participating jurisdictions.

- SO1. Proportion of participant clients expressing satisfaction with Comorbidities prevention or care services.

- SO2. Proportion of participant clients newly diagnosed with a comorbidity who are referred for treatment.

Annex A. Results Framework with Key Activities

Project Concern International SOLUCION TB Co-morbidities Phase 4, Final Report FY2011 and FY2012 Annex B March 30, 2013 ____________________________________________________________________________________________________________________________________________________________

Annex B. Indicator Performance Tracking Table (IPTT)

Indicator Direction of change

desired (+) (-)

Baseline

Year 1 (Oct. 1, 2010 – Sept 30, 2011) Year 2 (Oct. 1, 2011 – Sept 30, 2012)

Target Actual % Target Met Target Actual % Target Met

GOAL: Contribute to reduced mortality and morbidity related to TB/HIV and other Comorbidities in Mexico Strategic Objective: Improved access to comorbidity prevention and care services for targeted persons in the 5 participating jurisdictions SO1. Proportion of participant clients expressing satisfaction with Comorbidities prevention or care services

(+) N/A 60% N/A N/A 80% 90%1 112.5%

SO2. Proportion of participant clients newly diagnosed with a comorbidity who are referred for treatment (+) N/A 80% 100% 125% 90% 100% 111%

Intermediate Result (IR) 1: Improved communication, collaboration and coordination between TB, HIV and DM programs 1.1. Percent of planned coordination meetings conducted, disaggregated by State and jurisdictional levels (+) N/A 80% 122% 153% 100% 123% 123%

1.2. Percent of target jurisdictions that establish annual comorbidities collaborative work plans (+) N/A 80% 100% 125% 100% 100% 100%

1.3. Percent of target jurisdictions reporting satisfactory implementation of annual Comorbidities collaborative work plans

(+) N/A 60% 100% 167% 80% 100% 125%

IR 2: Improved quality of services provided to target populations 2.1. Number of people (medical personnel, community based health workers etc.) trained in DOTS with USG support

(+) TBD 300 1,127 375% 200 1,111 555%

2.2. Percent of targeted HIV-positive people who were screened for TB in HIV care or treatment settings (CAPASITS) (PEPFAR C2.4.D)

(+) 50% 80% 91% 114% 90% 96% 107%

2.3. Number of eligible HIV positive persons starting IPT (PEPFAR C2.6.D) (+) N/A 292 124 43% 50%2 453 90%

2.4. Percentage of PATB who had an HIV test result recorded in the TB register (+) 40 60% 77.4% 129% 70% 68% 97%

1 150 out of 177 participants rated their satisfaction with services from satisfied to highly satisfied. 2 This indicator was established provisionally to await the NTP and CENSIDA definition of IPT guidelines. However, these guidelines were identified in the last quarter of the STB4 project during the experts retreat held on Sept 21, 2012. Partner jurisdictions established 157 as the goal of eligible persons with HIV for IPT. 3 The existing IPT guidelines from NTP and CENSIDA had been applied discretionally among clinicians responsible of HIV treatments according to the CD4 and viral count. The retreat with experts on HIV and TB supported by STB4 held on Sept. 21, 2012 resulted in a joint list of recommendations to be disseminated in all state jurisdictions in the future.

Project Concern International SOLUCION TB Co-morbidities Phase 4, Final Report FY2011 and FY2012 Annex B March 30, 2013 ____________________________________________________________________________________________________________________________________________________________

Indicator Direction of change

desired (+) (-)

Baseline

Year 1 (Oct. 1, 2010 – Sept 30, 2011) Year 2 (Oct. 1, 2011 – Sept 30, 2012)

Target Actual % Target Met Target Actual % Target Met

(PEPFAR C3.1.N) 2.5. Percentage of PATB who had a DM test result recorded in the TB register

(+) 20% 60% 81.6% 136% 70% 83% 119%

2.6. Percentage of targeted persons with DM screened for TB in DM care or treatment settings (i.e. Unidades de Especialidades Médicas, or UNEME)

(+) 30% 60% 83.9% 140% 80% 102% 128%

IR 3: Improved information systems for strategic information and decision-making 3.1. Development of Comorbidities database (Macro CM) with national-level (NTP) input (+) No Yes Yes 100% Yes Yes 100%

3.2. Percentage of participant jurisdictions reporting monthly through Macro CM. (+) 0 80% 80% 100% 100% 100%4 100%

3.3 Percent of participant TB jurisdictional managers who report utilization of Macro CM for decision-making after six months of implementation.

(+) N/A 80% Pending Pending 100% 0%5 0%

IR 4: Improved care-seeking and care-taking behaviors 4.1. Percentage of partner organizations that receive training or information on infection control and TB/HIV or TB/DM co-infection

(+) N/A 90% 100% 111% 100%6 121% 121%

4.2. Number of PhotoVoice projects implemented at the jurisdictional level (+) N/A 4 4 100% 4 37 75%

4.3. Number of health care facilities that distribute and/or exhibit materials to correct misinformation and myths about TB, HIV and DM

(+) TBD 100 624 624% 129 908 70%

4 Macro database was operational until December 2011. See note #19 for further information. 5 The macro database was designed for the STB4 project and piloted from June to December 2011. The macro database was not subsequently applied for decision making because the MOH was in the process of creating the RIEM, and STB4 partners proposed including the macro database indicators. However, further decisions at the MOH resulted in postponing/cancelling the design of the RIEM, and thus, the macro database was not applied for decision making. 6 Partner jurisdictions established a goal of 42 NGOs to receive training/information; 51 NGOs were approached and trained during Y2. 7 The jurisdictions of Ciudad Juárez, Guadalupe and Zapopan completed the Photovoice process. Tijuana was unable to conduct an evaluation of past Photovoice members as planned. 8 Partners established a goal of 129 average number of facilities/health care sites in their jurisdictions to exhibit and/or distribute information in Y2, achieved 94 in average per month, ranging from 68 to 169 facilities per month.

soluciontb.org

PCI y Secretaría de Salud para el control de la Tuberculosis

PCIGlobal.org

Annex C - SOLUCION TB Tools, Products, and Documents

Reports

Advocacy, communication and social mobilization for TB control: collection of country-level good practices. World Health Organization (2010).

The purpose of this document is to highlight cases in which Advocacy, Communication and Social Mobilization (ACSM) interventions have contributed to a positive outcome of tuberculosis control activities directed to a range of audiences and settings. It is intended for on-the-ground stakeholders who are interested in successfully integrating ACSM strategies and activities into TB control programming, as well as for decision-makers who can provide greater political and financial support for ACSM activities at the national, sub-national and international level.

STB Timeline of Milestones.This timeline provides a sequenced list of key milestones from the different phases of the SOLUCION TB Program, from October 2004 to December 2012.

PCI Promising Practices in ACSM: The Mexican National Experience – STB PCIA collection of Advocacy, Communication and Social Mobilization strategies and promising practices based on the SOLUCION TB Experience in 13 states and 35 jurisdictions in México. The successful integration of ACSM strategies into traditional public health TB programming, helped identify a series of lessons learned, promising practices and approaches that worked successfully for PCI and the Ministry of Health in México.

From Cough to Cure -Knowledge, Attitudes and Practices in TB in México, 2009.Household Survey Findings Report.This study report includes a basic overview of the socio-demographic profile of the households involved in the study, utilization of health services, specific patterns of knowledge about TB, the sources of information used to obtain health care, personal attitudes towards TB, and their perspective on stigma and discrimination associated with TB. The report contains key recommendations to improve TB control and prevention in México. The study was carried out in close collaboration with the National TB program, and implemented in partnership with the Alliance for Border Collaboratives, with funding from USAID México.

Voces e Imágenes de la Tuberculosis, Manual de Capacitación (Voices and Imagesof TB Training Manual, in Spanish).This is an adaptation of the Spanish translation of the TB photovoice manual originally developed by Practical Public Health Applications, and translated by the US-México Border Health Association. This version was edited and adapted by SOLUCION TB for trainings carried out for the National Tuberculosis Program as part of the implementation of SOLUCION TB. The facilitator's manual includes a suggested training agenda, a description of the photovoice methodology, and corresponding formats and tools needed to carry out training in the photovoice methodology.

www.stoptb.org/assets/documents/resources/publications/acsm/ACSM_final_24%20Nov.pdf

www.socialwork.utep.edu/pdf/Promising%20Practices%20in%20TB%20Final%20Sep%2023%20(1).pdf

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Luchando por Una Voz (English Translation)It is a collection of 4 stories from people affected by TB in México. The stories describe what normal life was like for these individuals before TB, and what their life is like after the diagnosis. It emphasizes their dreams and hopes, helping humanize TB care for those who work in TB. This power point presentation is directed at health worker and it was developed by a volunteer consultant of the Ministry of Health in Tijuana, in collaboration with SOLUCION TB.

Resumen Ejecutivo de SOLUCION TB 2012 (Executive Summary of SOLUCION TBComorbidities, in Spanish):This document was developed to support the National and State TB programs sustainability efforts. Designed for health officers, decision-makers and other health personnel, this document describes the main TB and TB-comorbidities interventions as well as key achievements at the national, state and jurisdictional levels. The purpose of the document is to help TB program managers make the case for continued support. Audience: Health managers, decision-makers and health workers.

Resumen Operacional de SOLUCION TB 2012 (Operational summary of SOLUCIONTB, in Spanish).This document was developed to provide a summary of key interventions and achievements as well as an expanded description of strategies and activities carried out through SOLUCION TB. This document intends to provide program managers with a general framework of implementation of a TB and comorbidities program that includes a person-centered approach. Audience Health managers, decision-makers and health workers.

Recomendaciones de Reuniones de Expertos en TB-VIH/SIDA y TB-Diabetes,Septiembre 2012 (TB-HIV/AIDS and TB-Diabetes Experts' Summits, September2012, in Spanish).These summaries of recommendations to improve TB-HIV/AIDS and TB-Diabetes prevention and care in the Mexican context, describe the collective agreements resulting from the meetings of selected Mexican experts that took place for the first time in 2012. Audience: Decision-makers, TB, HIV/AIDS and Diabetes managers and service providers. Llamado a la Acción, November 2012 (A Call to Action, November 2012, in Spanish).This Call to Action was developed by national, state and jurisdiction level health and TB managers who participated in the final national meeting of SOLUCION TB in November 2012. The document urges decision-makers to continue their support to TB and comorbidities programs and activities so current results are sustained and expanded; request higher investment in public awareness of TB and comorbidities, and solicits adherence to the pledges of Zero deaths by TB and the movement to stop TB during our lifetime of the World Health Organization and the STOP TB Partnership, among other things. Audience: Decision-makers, health managers and health workers.

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Educational Videos

Link to 4 educational videos in Spanish (listed separately below): A collection of educational and training videos developed by SOLUCION TB to support training and education of health workers and communities affected by Tuberculosis.

Mitos y Realidades sobre la TB (Myths and realities of TB video, in Spanish): This video utilizes humor to communicate key messages directly addressing some of the most common myths about TB transmission in México. The video also includes correct information about transmission and calls for better support for people affected by TB. Audience: General public.

TB y Diabetes (TB and Diabetes in Spanish) video:This video includes basic information about the importance of Diabetes in México and how the disease relates to Tuberculosis. It describes the importance of treatment adherence, treatment completion and appropriate management of TB. Audience: General public.

13) TB y control de infección (TB and basic infection control in Spanish)This video contains basic information about what TB is and how it is transmitted, emphasizing basic prevention (infection control) measures that should be avoided to prevent infection. Audience: primary health service providers.

Información básica sobre la TB (General TB information in Spanish)This video contains Basic information about TB, how it is transmitted, and what a person affected by TB should do to ensure treatment success. Audience: General public.

Nuestra Casa Initiative short video:This short video gives a brief description of the Nuestra Casa Initiative, a powerful innovative advocacy tool designed to provide visitors with an opportunity to experience what it is like to live with Tuberculosis in México's northern border. Audience: General public.

Interview with Damian Schumann, artist from South Africa who created “Nuestra Casa” on the soluciontb.org webpage.This is a taped interview with the creator of the Nuestra Casa exhibit. He describes the process he went through interviewing individuals affected by TB and HIV/AIDS along the US-México border, and how it all culminated with the Nuestra Casa design. Audience: General public.

www.youtube.com/user/soluciontb

www.youtube.com/watch?v=FSFik3jATJk

www.youtube.com/watch?v=H0hB2P8jufA

www.youtube.com/watch?v=YsK-rs0boK0

www.youtube.com/watch?v=b7wXh4YK9bw

www.youtube.com/watch?v=JGm8hfH4Nbc

www.soluciontb.org/principal/nuestraCasa.php

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Educational Brochures Designed by PCI's SOLUCION TB Program

Resultados Resumidos Estudio CAP en TB (Summary findings of KAP in TB Study in Spanish).This brochure summarizes key findings and recommendations of the first Knowledge, Attitudes and Practices in TB in México, carried out by PCI and the National TB Program in 2009 and published in 2010. Audience: TB managers and health workers.

Mitos y Realidades de la TB (TB Myths and Realities, in Spanish).This illustrated brochure addresses some of the most common myths and misinformation about the transmission of TB, based on findings identified in a series of focus group in México. Audience: General public.

Por qué debe importarme la TB si lo que tengo es Diabetes? (Why should I careabout TB if what I have is Diabetes? In Spanish).This illustrated educational brochure is directed to people with Diabetes and provides basic information about their increased vulnerability to TB, the basic symptoms, prevention and detection information they should be informed about. Audience: People with Diabetes and general public.

Por qué debe importarme la TB si lo que tengo es VIH? (Why should I care about TB if watt I have is HIV? In Spanish).This illustrated educational brochure is directed to people with HIV/AIDS and provides basic information about their increased vulnerability to TB, the basic symptoms, prevention and detection information they should be informed about. People living with HIV/AIDS and general public.

Carta TB –Carta de Derechos y Responsabilidades de personas con TB. (Charter ofRights for people with TB in Spanish). Audience: People affected by TB, their familymembers, health workers, and general public.This illustrated charter of rights lists the basic rights and responsibilities of people with TB

Tengo TB, cómo me cuido? (I have TB, how do I take care of myself? In Spanish).This educational brochure provides basic information on transmission, care and prevention for individuals who have been diagnosed with Tuberculosis, emphasizing the importance of treatment adherence. People affected by TB, their family members, health workers and general public.

Caja de Herramientas para ACMS en TB (ACSM in TB toolkit, in Spanish)This is a collection of Tools developed or adapted by PCI in collaboration with the NTP that were utilized and made available for program implementers throughout different phases of SOLUCION TB. Audience: Health workers and TB managers.

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Boletines Informativos SOLUCION TB (SOLUCION TB Newsletters, in spanish)This monthly newsletters were developed as a mean to improve communication and awareness between different TB and comorbidities partners accross the country. The newsletters include technical updates, ACSM tools, success stories, and key report information of different activities of STB and partners. External relevant links and resources, are also included. Audience: Health workers, TB managers and general public.http://soluciontb.org/principal/boletines.php

TPI –Terapia Preventiva con Isoniazida (Isonazide Preventive Therapy, in Spanish).SOLUCION TB translated a document produced by the basic working group for HIV/AIDS and TB of the STOP TB Partnership. A call to action is issues to health providers to strengthen utilization of Isoniazide in individuals who are HIV positive, to prevent Tuberculosis. Audience: TB and HIV/AIDS managers and health workers.

Guía Práctica de Abogacía en TB (Basic Advocacy Guide in TB, in Spanish)This is a translation and adaptation of the WHO's World TB Program's Advocacy and Promotion Guide. Audience: Health managers and health workers.

Additional brochures and materials, adapted, translated and/or edited by SOLUCION TB

Additional video-documentaries that can be provided upon request

Videos de documentación del progreso de SOLUCION TB a nivel nacional, estatal Jurisdiccional 2012 (National and State/jurisdiction documentation videosdocumenting local context and achievements of SOLUCION TB, in Spanish) one per participant state/jurisdiction.Developed as part of the sustainability strategy implemented during the final year of implementation, these short (15-minute) videos one for participant state/jurisdiction document the need, the challenges and the progress made by the NTP-PCI partnership. Including interviews with persons affected by TB or TB comorbidities, the videos intend to improve understanding about the need for quality services, stronger collaboration, and the inclusion of a person-centered approach to service delivery. The videos include interviews with key program implementers and a list of selected results achieved in each State and jurisdiction. Their objective is to help further position TB in the public health agenda and sensitize audience to the needs and challenges of people affected by TB and comorbidities, and those faced by health managers.. Audience: Decision-makers, health managers and health workers.

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All materials listed here that do not include links to online documents

are posted at SOLUCIONTB.org, unless indicated otherwise.

Some of these materials can also be found at: CENAPRECE's webpage

(Mexican National Center for Disease Prevention and Control)

For more information on these materials please contact Blanca Lomeli

at

www.cenave.gob.mx/tuberculosis

blomeli@pciglobal.org

soluciontb.org

PCI y Secretaría de Salud para el control de la Tuberculosis

PCIGlobal.org

7

SOLUCION TB (STB) begins in Baja California. Greater participation of people affected by TB, and TB-exclusive staff are incorporated into the public health model.

SOLUCION TB Expansion STB strategies expanded to total of 13 states and 35 priority jurisdictions accounting for over 65% of all TB cases in México.

STB Expansion includes strong ACSM and person-centered approach components. Collaborative planning in 13 states; 13 MOUS signed, and over 120 TB-exclusive staff deployed.

“With the voices and images of TB, we have been able to sensitize health personnel, community and other affected persons who recognize themselves in these stories… The reflect in stronger adherence to treatment, improved cure rate and decreased stigma and discrimination”

First gallery of Voices and Images completed and exhibited in Tijuana. First Voices and Images advisory committee formed.

Innovative prevention and control strategies are carried out including: Integration of ACSM and DOTS strategies: Empowering DOTS, Person-Centered Care, TB Support Groups, ‘internal’ ACSM and public-public and public-private collaboration.

Eight Voices and Images of TB galleries produced and exhibited.

First Knowledge, Attitudes and Practices in TB Study and first TB Stigma Study carried out in México by STB.

SOLUCION TB ACSM promising practices document produced.

Nuestra Casa exhibit launched at the University of Texas at El Paso and is exhibited at the World Union Conference in December

“Reduction of stigma within the health services is a great result of our ACSM activities” Dr. Artemisa Tovar, TB Coordinator in Michoacán

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r STB Expansion concludes: Treatment success rate of 91.2% and 0.8% treatment default rate, on average, at the 35 jurisdictions. 3.8 million Individuals reached through ACSM activities; 1,531 health workers trained in DOTS, ACSM and person-centered care. 48% of STB’s 127 health workers are hired by state TB programs.

“This project helped demonstrate the need for TB-exclusive staff. We successfully advocated for 18 new hires dedicated to TB. This will allow us to continue to increase cure and detection rates.” Dr. Manuel Sandoval, TB Coordinator in Jalisco

SOLUCION TB Timeline

SOLUCION TB Phase 3: TB and Comorbidities. First TB-Diabetes strategy for Mexico. Improved TB-HIV/AIDS collaboration resulting in 390 new comorbidities; 53 individuals with HIV/AIDS start IPT; and 982 health workers trained in DOT and TB and comorbidities, in the 7 participant jurisdictions.

“Before SOLUCION TB we were not doing in-depth cohort analysis on a regular basis. Now we do, and can better identify areas and interventions that need attention”. Dra. Zhélyca Sarmiento, TB Coordinator in Guadalupe, Nuevo León.

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Nuestra Casa exhibits in Oaxaca, Reynosa and Tijuana, and the CDC Museum in Atlanta.

“Talking about TB is talking about a disease that is linked to the history of humanity itself… Controlling TB requires broad innovative strategies, not just the same old interventions that have been part of the public health model in the past” Testimonial from Nuestra Casa Exhibit visitors

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SOLUCION TB Phase 4 begins. Implemented from October 2010 to December 2012.

Mexico included in the ‘ACSM good practices’ document from the STOP TB partnership.

Prevalence of TB-HIV/AIDS increases 154% between 2007 to 2011, compared to only 8.5% increase between 2003 to 2007. In the 5 jurisdictions: 71.1% in screening of HIV/AIDS and 73% increase in screening of Diabetes in persons with TB.

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First National Expert Summits for TB-HIV/AIDS and TB-Diabetes take place for the first time in México. Recommendations from summits are widely disseminated.

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2 Final STB transition meeting takes place.

A call to action is developed.“PCI represented a breakthrough for TB control in México; a person-centered approach to service delivery, improved awareness of disease, and improved comorbidity services for HIV/AIDS-TB and Diabetes-TB are direct results of this partnership”. Dr. Martín Castellanos, National TB Program Director in México

SOLUCION TB Timeline