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IPT BOTSWANA EXPERIENCE. Oaitse I Motsamai RN, MW, B Ed, MPH Ministry of Health Botswana 11 th November 2008 Addis Ababa, Ethiopia. OUTLINE. Botswana context Rationale for IPT in Botswana Pilot Current Programme Administration IPT Programme Evaluation. Background of Botswana.

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Ipt botswana experience

IPT BOTSWANA EXPERIENCE

Oaitse I Motsamai RN, MW, B Ed, MPH

Ministry of Health

Botswana

11th November 2008

Addis Ababa, Ethiopia


Outline

OUTLINE

  • Botswana context

  • Rationale for IPT in Botswana

  • Pilot

  • Current Programme

  • Administration

  • IPT Programme Evaluation


Background of botswana

Background of Botswana

  • Population 1.7 million

  • HIV prevalence in general population 17% (2004)

  • HIV prevalence in antenatal women 33.4% (2005)

  • TB notification rate 514/100,000 (2006)

  • HIV seroprevalence among TB patients 60-86%


Tb services in botswana

TB Services in Botswana

  • National TB Program (Disease Control Unit, MOH)

  • Tuberculosis treatment free and universally available

  • >600 health facilities provide TB and IPT services

  • 24 Districts each with TB Coordinator

  • TB surveillance through electronic TB register


Hiv tb program context

HIV/TB Program Context

  • Anti-retroviral therapy (ART) has been available since 2001 and is free to all Batswana citizens

  • Policy on Routine HIV Testing (RHT) introduced 2004

  • Under national ART guidelines, TB patients eligible for ART; initiation based on CD4 count

  • There are 35 ART centers in Botswana


Rationale for ipt in botswana

Rationale For IPT In Botswana


Ipt timeline

IPT Timeline

1998: Joint WHO/UN Guidelines on HIV/AIDS

recommending 6 months of IPT

1999: Formation of an IPT Working Group

2000: Pilot conducted in three districts in

to assess feasibility of national scale-up

2001: Pilot completed in April; evaluated in

October 2001

2001: National roll out commenced

2003: IPT office established (3 officers)

2004: Complete roll out


Progress of enrolment 2001 2007

Progress of enrolment: 2001-2007

Database

rolled out

Roll out

completed

Programme Review

Coag signed

National office

Pilot study


Pilot study goals

Pilot Study Goals

  • Assess motivation to undergo testing and accept IPT;

  • Determine if IPT would increase HCW workload; and

  • Determine whether HCWs could successfully exclude clients with active disease


Pilot findings

Pilot Findings

  • IPT well-integrated into general clinic services

  • Acceptable to clients; clients motivated to test by knowledge that HIV interventions (IPT/ART) available

  • CXR should not be used for ASX patients

  • Reporting and recoding methods too cumbersome for HCWs

    Recommendation:

    Overall, IPT is feasible and should be implemented.


Current programme

Current Programme

  • Screen and enroll medically eligible patients referred from VCT/RHT/PMTCT

  • 6 months self-administered in 6-9 mos.

  • Monthly follow-up visits

    • Side effects counseling

    • TB screening

    • Compliance

    • Prescription refill


Eligibility criteria

Eligibility Criteria

  • Confirmed HIV-infected

  • 16 years and above

  • Not currently pregnant

  • No active TB

  • No terminal illness

  • No hepatitis

  • No history of INH intolerance

  • No History of TB in the past 3 years


Enrolment

Enrolment

  • History and physical examination

    • Exclusion of persons with cough and fever

  • Client counseling

  • Monthly review

    • Side effects assessment

    • TB screen

    • Drug re-supply


Enrollment 2001 2007

Enrollment 2001-2007*

Registered

N=75,235

Eligible

n= 73,263

Eligible and started IPT

n= 71,541

Completed

n=25,075

(33%)

Other exclusions

(7%)

Non-completers

n=43,313

(59%)

Unknown

reason

(70%)


Major challenges

Major Challenges

  • Referral to IPT

    • Difficult to estimate % eligible captured

  • Medical Screening

    • Eligibility

    • Active TB (prior to and during treatment)

  • Treatment adherence* (preliminary data, n= 71,541)

    • Median- 4 follow-up visits

    • Duration of therapy 98 days

  • Monitoring and evaluation

    • High levels of incomplete data

    • Recording and data entry barriers

  • Staff turn over: IT no data manager (national)


Ipt programme administration

IPT Programme Administration


Ipt staffing

IPT Staffing

  • National Level: MOH

    • National Coordinator

    • Regional Coordinators (2)

    • Data officers (3)

    • IEC officer

  • Implementation at the district level

    • Doctors and nurses (MOLG, MOH)

    • Complementary staff


Support supervision

Support & Supervision

  • District-level TB Coordinators (DTBCs) placed at District Health Teams

  • TBCs are supervised by the District Health Teams

  • District-level activities supervised by TBCs

  • The national level monitors a sample of facilities on quarterly basis

  • DHTs are given feedback on their performance

  • TBCs hold workshops (twice a year)

  • Training for IPT, TB/HIV surveillance and TB case management, Community TB care for HCWs


Reporting and recording

Reporting and Recording

  • Patient out-patient card (pink/blue)

  • Register and Compliance record

  • Dispensary Tally Sheet

  • Patient Transfer form

  • Monthly Report Form


Other documents database

Other Documents & Database

Other IPT Documents:

  • Training guides: Facilitators’ & Health workers’

  • IEC materials: Brochures, video cassettes

    Electronic Database:

  • Developed and Funded with the assistance of CDC (BOTUSA)

  • Rolled out to all 24 districts in November 2005

  • Built-in reporting and error functions


Programme funding

Programme Funding

  • Second-Five year cooperative agreement between CDC and MOH; (2002-2005, 2005-2010)

  • Ministry of Health provides: infrastructure, drugs & technical support

  • Clinical staff supported thru Ministry of Local Government O Ministry of Health

  • CDC provides funds for salaries, training, purchase of equipments; 2001-2007: Over $2 million + technical support


Ipt programme evaluation

IPT Programme Evaluation

  • Conducted in May 2008 (external)

  • Await final report

  • Reviewed key functions

    • Referral systems

    • Medical screening

    • Adherence

    • Reporting/recording for M&E

    • HCW training

    • Patient counseling

  • Assessed programmatic implications


Acknowledgements

Acknowledgements

  • Botswana National TB Program Staff

  • CDC Division of TB Elimination

  • CDC Global AIDS Program/BOTUSA


Thank you

Thank You


Backup slides

Backup Slides


2006 programme targets

2006 Programme Targets


Caliber trained

Caliber Trained

  • Health professionals:

    • Doctors

    • Nurses

    • Pharmacy Technicians

    • Health Educators

    • Social Workers

  • Non-professionals

    - Family Welfare Educators

    - Lay Counselors

    - Health auxiliary


Challenges encountered

Challenges Encountered

  • Overstretched national staff

  • Inadequate counseling of some clients

  • Loss of clients who are still on treatment

    • Lack of clients’ follow up (defaulters)

    • Transport problems particularly in the districts

    • High mobility of clients

    • Wrong addresses given by clients


Challenges cont d

Challenges Cont’d

  • Recording and Reporting problems

    • Incomplete clients’ records

    • Lack of timely reporting

  • Personnel

    • High turnover in districts including TBCs

    • Weak supervision especially at district level

  • Training: Continuous re-training of HCW necessary


Botswana drug resistance surveys

Botswana Drug Resistance Surveys

  • Since 1995, 3 resistance surveys done

  • Fourth resistance survey in progress

  • Results expected by 4th quarter 2008.


Isoniazid mono resistance

Isoniazid Mono-Resistance


Multi drug resistance

Multi Drug Resistance


Plans to prevent drug resistance

Plans To Prevent Drug Resistance

  • Emphasis on constant & proper use of the algorithm on screening of clients

  • Screening of clients at each visit

  • Thorough investigation of TB suspects

  • Extensive adherence counseling of clients


Integration of tb hiv care

Integration of TB & HIV Care


Ipt as part of hiv care and treatment

IPT as Part of HIV Care and Treatment

  • Implementation of routine HIV testing from January 2004.

  • HIV testing of TB patients is routine but so far at 68%

  • IPT is prescribed in all health facilities by

    doctors and nurses.

  • IPT is given as (often first) package of HIV care

  • Other sources of referral to IPT

    • PMTCT

    • VCTs

    • NGOs

    • ARV programmes


Integration of tb hiv services

Integration of TB/HIV services

  • IPT provides a systematic way to screen PLWH for TB

  • Policy to provide HAART to HIV-infected TB patients

  • TB/HIV integrated surveillance rolled out 2005

  • TB/HIV advisory body established

  • TB/HIV care issues in the new TB manual


Reason for non completion 2001 2007

Reason for non-completion: 2001-2007


Achievements challenges

Achievements&Challenges


Achievements

Achievements

  • TOTs in all 24 districts (average; 5 per district)

  • Trained (65%) of all health workers

  • IPT programme officers at national level

  • IPT available in all 24 districts and all 636 facilities

  • Public awareness & uptake has increased

  • Improved paper based reporting from districts

  • Computers purchased for all districts


Achievements continued

Achievements Continued

  • Database available in all districts

  • Designated TB coordinators in almost all districts

  • Enabled linkage of IPT to TB and ARV databases through the use of national ID

  • Improved frequency & quality of support visits


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