Botswana IPT Programme: Effectiveness & Impact Evaluation

1. Module 14:Isoniazid Preventive TherapyProgramme

2. Definition Use of an ATT drug called Isoniazid (INH) given to individuals with latent (dormant) mycobacterium tuberculosis infection in order to prevent its progression to active disease.

3. Rationale for IPT • 10% lifetime risk of developing active TB if infected with M. tuberculosis alone • 5-10% annualrisk of developing active TB if co-infected with HIV • IPT is therefore, meant to prevent progression of latent TB to active disease

4. TB and HIV • Studies have shown that as many as 50% of persons with HIV infection may develop active TB • Studies in Zambia/Uganda/Kenya demonstrated efficacy in preventing TB • UNAIDS/WHO recommend the use of the Isoniazid Preventive Therapy for people living with HIV in any settings where the prevalence of TB/HIV is high (1999).

5. Rationale for IPT in Botswana • HIV prevalence is 17.1% in general population (BAISII) , 33% in pregnant women TB case rate increased ~ 3-fold in 1990s • 1989: 202 /100,000 • 2002: 623 /100,000 • 2003: 594 /100,000 • Recent survey estimates 84% of registered TB cases also have HIV co-infection • 1999 KABP study in Botswana showed patients will seek HIV testing if they would receive health benefit such as IPT • TB is the leading killer of persons with AIDS in Botswana

6. TB Notification Rates 1999-2005

7. How IPT Programme Came About • Followed recommendation in 1998 by - World Health Organization - UNAIDS • IPT Working group formed 1999 • Government approved pilot in 2000 (July) • Guidelines and training materials developed • 500 health workers trained before pilot

8. IPT Pilot Overview • Determine the operational feasibility of IPT • Acceptability to patients • Burden to HCWs • Develop optimal screening algorithm • Create M&E system • Pilot started August 2000-April 2001 • Evaluation of the pilot –October 2001

9. IPT Pilot Programme • 7 month pilot: August 2000 - March 2001 • 3 Pilot sites • Francistown (447) • Gaborone(406) • SE district (82) • Total: 935 patients • Female 71% • Required validation activities • Capacity to enroll clients • Ability of nurses to exclude active TB • Determine utility of CXR to screening algorithm

10. Findings of the Pilot • Main source of referrals to IPT Program • VCT • PMTCT • Majority of patients asymptomatic @ assessment • Suspicion of active TB main exclusion criteria • CXR findings for asymptomatic clients mostly normal

11. Findings Cont’d • Of the 24 Abnormal CXR results • 16 Pneumonitis • 0 confirmed TB cases • 1 Cardiomegaly • Only 1 case of TB (pleural effusion) • MOs & nurses assessments concurred

12. Other Findings • Treatment completion was good 69% • M& E component was found to be burdensome • Turnover of nurses during the pilot was high

13. Pilot Conclusions • IPT algorithm successfully excludes patients with suspected TB • Candidates for IPT can be safely screened by nurses and started on IPT • CXR was an obstacle for asymptomatic clients due to high dropout rate & low yield for active TB (5%, 17%)

14. Recommendations These followed evaluation of pilot: • IPT was to be rolled out nationwide • CXR was excluded from the algorithm for asymptomatic clients • Clinic and dispensary registers were to be consolidated into one register for patients on IPT

15. Current IPT Program

16. Funding of the IPT Programme • Funded by the US Centers for Disease Control through PEPFAR • Five year agreement between the two governments (2002-2007) • Funds for salaries, training, supervisory travel, purchase of equipment • At district level-Botswana government funds

17. Eligibility Criteria • Confirmed HIV positive • 16 years and above • Not currently pregnant • No active TB • Not terminal AIDS • No hepatitis • No recent history of TB • No history of INH intolerance

18. IPT Staffing National Level: • National Coordinator • Regional Coordinators (2) • Regional Data Clerks (2) • IEC officer District Level: • All district health facilities staffed by doctors and nurses • IPT Program supervised by TB Coordinators

19. Client Screening • Algorithm is the main tool used - Subjective data - Physical assessment - Investigations as necessary (e.g sputum, chest x-ray)

20. IPT Documents • Facilitators’ guide • Health workers’ guide • Brochures • 3 types of video cassettes • Still developing posters/and other IEC materials

21. IPT Records • Patient outpatient card • Register and compliance record • Dispensary Tally Sheet • Patient Transfer form • Monthly report form

22. IPT Database • Newly developed • Funded and developed through the efforts of BOTUSA • Currently entering data from inception to end of May 2005 • Entered about 15000 records from 10 districts

23. Enrollment Data • Clients counseled – 30,592 • Clients enrolled – 24,840 (81%) • Clients completed treatment- 6721 (27%)

24. Preventing Isoniazid Resistant TB • Emphasis on constant & proper use of the algorithm to prevent monotherapy • Screening of clients at each visit • Thorough investigation of those suspected of having TB • Ongoing counseling of clients

25. Plans (cont’d) • Exclusion of children & adults with history of TB within the last 3 years • Remove defaulters from the programme • Improve adherence • Improve monitoring and evaluation!

26. MONITORING AND EVALUATION • Monthly reports • Quarterly reports • Support visits using checklist (quarterly/when necessary) • Review meetings with districts • IPT/TB programme evaluation

33. Achievements • Have TOTs in all districts • A good number of health workers have been trained • Rolled out to all districts and facilities • Increased public awareness • Government commitment

34. Achievements (Cont’d) • Increased IPT officers at national level • Necessary equipment purchased • Database developed • Improved support visits

35. Challenges • Irregular data submission by facilities • Inadequate transport for support visits • Poor record keeping by health workers • Lack of commitment by health workers