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Uganda 100-day TPT scale up
Dr. Kiggundu Josen
Senior Program Officer – DSD
Ministry of Health – AIDS Control Program
13th November 2019
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The CQUIN Project
• Introduction
• Trends in IPT uptake in Uganda
• National IPT Targets
• The 100-Day Accelerated IPT Scale-Up plan
• TB Prevention for PLHIV in DSDM
• Results
• Conclusions
2
Outline
The CQUIN Project 3rd Annual Meeting | November 10-14, 2019
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Introduction
❑ In 2018 the UNHLM political declaration put TB prevention as one of the key elements to ending the TB epidemic.
❑A ¼ of the world’s population (1.8 billion) have LTBI and carry a lifetime risk of getting sick with active TB disease.
❑This risk can be substantially reduced by TB Preventive Treatment (60% among PLHIV and 70% in U5 contacts).
❑Tuberculosis is the leading cause of death among People living with HIV even in the era of ART
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Introduction
❑In 2017, 32% of the AIDS related deaths were due to TB globally
❑To End TB, it is not only essential to treat active TB when it happens but to prevent it from happening. “Closing the tap”
❑Uganda endorsed a form of TPT called Isoniazid preventive therapy (IPT) and has been providing IPT to PLHIV for about 5 years now
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Trends in IPT uptake in Uganda
❑ Prior 100-day IPT scale up plan, uptake of this important intervention was still low even with Surge efforts.
0
10000
20000
30000
40000
50000
60000
70000
80000
Jan-Mar2015
Apr-Jun2015
Jul-Sep2015
Oct-Dec2015
Jan-Mar2016
Apr-Jun2016
Jul-Sep2016
Oct-Dec2016
Jan-Mar2017
Apr-Jun2017
Jul-Sep2017
Oct-Dec2017
Jan-Mar2018
Apr-Jun2018
Jul-Sep2018
Oct-Dec2018
Jan-Mar2019
Mar-Jun2019
Start of IPT in
Uganda
Start of IPT surge
❑ The 100-day plan is a critical intervention that will put Uganda back on track towards achieving the UNHLM and END TB targets.
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National IPT Targets
2018 2019 2020 2021 2022
TB prevention
Among PLHIV
and children
under 5 yrs Gap to be covered
by the 100 day
scale-up plan
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The 100-Day Accelerated IPT Scale-Up plan
❑On 3rd July 2019 was the launch of an accelerated plan to reach 300,000 PLHIV with TPT within 100 days
❑AIM;
▪ To help initiate 50% of all PLHIV in need of this life saving treatment
❑The 100 days was the first step towards complete roll out of IPT
❑MOH organized and set in place all the tools & supplies needed to accomplish this task (IPT scale up toolkit)
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Systems Approach to TPT coverage and retention
8
• INH/ B6
• Competent H/W
• Data tools – IPT registers
• Job aids, guidelines, ICF tools
• Coaches/ district mentors
Inputs
• System to identify all eligible clients ( line listing, file review, separating files and stickers)
• System to reach all eligible clients ( clients brought to the facility, H/W goes out to the clients, phone calls, CHWS)
• Efficient system to attend to the clients when they come ( identified clients, pre-packing of INH with ARVs, fast tracking stable clients, education and counselling)
• System to follow up and retain clients on TPT
• Data management systems
• System to sustain INH/ B6 stock levels
Processes to improve coverage and retention
• All eligible clients identified
Output
Outcome
• Reduced TB incidence and mortality
Impact
QI
All eligible clients receive TPT; TPT clients complete therapy
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Key Action Areas
2. INH/ B6 Stocks• Improve Provider
Skills for Stock Management.
1.Systems for IPT Delivery: • Address Client Flow and Facility
systems for delivery for Fast track clients, new clients,
• Plan to reach stable clients in the community based DSDM
3. H/W competence and skills• Provide ‘just in time’ skills
building to a multi-disciplinary team and job aids
• Focus on reducing ‘know-do’ gap
5. Create awareness/ demandSimple key messages DAILY for the clients to address adherence and increase demand
4. Availability of data tools and use:• Share targets, create a
plan for meeting the daily clinic targets.
• Use data on PLHIV in care and ever enrolled on IPT to determine gap
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TB Prevention for PLHIV in DSDM
❑All PLHIV & U5 contacts have their IPTinitiated at the Facility where thehealth worker;▪ Screens clients to exclude active TB &
contra-indications of isoniazid
▪ Prepares the patient or caretaker for IPT
▪ Prescribes the recommended dose for theclient’s weight
▪ Records in the IPT register
❑Align IPT and ART refills
❑Developed SOPs for guidance onproviding IPT in community models
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Monitoring for IPT 100-day scale-up intervention
❑Indicators reported on weekly by districts
▪ Number of individuals initiating IPT
▪ Number of individuals completing IPT from among the previous cohort (quarterly).
❑Weekly dashboard shared with NTF, IPs and DHOs every Friday
❑Detailed analysis at all levels on performance of districts and facilities. Those not achieving targets were engaged for improvement.
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Role of District Health Teams
❑Commissioning of TPT at facilities to be undertaken to re-assure confidence of HCW and clients
❑Oversight for IPT implementation in the district
❑DHOs/MMS ensure drug availability, emergency drug redistribution, adverse drug reaction reporting etc.
❑With support from IPs, assist in quantification and redistribution of child courses to facilities in district
❑Conduct weekly monitoring meetings with all stakeholders including Networks of PLHIVs
❑Ensure reporting of IPT coverage from implementing facilities
❑Ensure accountability for performance on IPT uptake and completion at facilities
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The Role of the Implementing Partner
❑ Collaborate with MoH NTF to plan & execute a multi-stakeholder response
❑ Support the identification of health facilities suitable for increase in coverage and uptake of TPT for PLHIV and retention through CQI approach
❑ Conduct entry meeting with DHO & DHT to sensitize about the 100 Days
❑ Analyse & address capacity building & mentorship gaps at the H/Facilities
❑ Facilitate the collection and transmission of routine weekly data from sites
❑ Support collection of monthly data on medicines
❑ Ensure drug availability, emergency drug redistribution, adverse drug reaction reporting, etc
❑ Support conducting CQI projects to strengthen IPT implementation
❑ Engage DHTs in the TPT scale up process and share weekly dashboard with the DHO and health facility teams
13
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Expected results
Primary Result
❑ 300000 PLHIVs screened and initiated on IPT at 382 selected H/facilities
❑ 100% completion rates for individuals that initiated IPT in quarters: October-December 2018, and January-February 2019.
Outcomes
❑ Increase in availability of INH 300mg and Vitamin B6 at central stores and at initiating sites
❑ Increased routine screening use of diagnostics to rule out active tuberculosis amongst PLHIV
❑ Increase in collaboration and integration of planning and implementation for HIV and TB services at national, district, facility and community levels.
❑ Increase health worker skill and confidence in initiating IPT
❑ Increased in the application of quality improvement science in identifying and in action on barriers to IPT uptake.
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RESULTS
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Over half a million PLHIV initiated on TB IPT between 1st Oct 2018 & 6th Oct 2019
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Wkly
Incr
em
ent
Cum
m. I
nitia
ted o
n T
PT
Period
Overall TPT Initiation Trends
Cum. Initiated on TPT Wkly Increment
Pre-Campaign Mobilization
100-Days Campaign launch
65.3% of all initiations were during the 100-days period
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17
Overall 100-day performance is 343,674/ 304,391 (113%)
NON-PRIORITY sites contributed 17% of the total IPT initiation during the campaign period
343,674
19,789
26,549
30,558
36,475
33,061
35,855
31,971 30,400
24,344
19,791 18,711
15,688
13,516
6,966
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
-
50,000
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200,000
250,000
300,000
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wkly
incr
em
ent
Cum
. In
itia
ted o
n T
PT
Period
100 Day Cumulative and weekly TPT Initiation Trends
Cum. Initiated Wkly Increment
86%
84%85%
80% 83% 81%84%
82%
84%83% 85%
85%82%
84%
19,673
26,449
30,444
36,030 32,989
35,811
31,904 30,253
24,201
19,742 18,672
15,649
13,491
6,866
0
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# o
n IPT
# o
n IPT
Reporting Period
83% of IPT initiations were in Priority SITES and this was
relatively uniform every week of the campaign period
Total # Initiated on TPT , Pink Bar represents % in Non-Priority sites
# and % Initiated on TPT in Priority sites
Weekly Target
100-Days weekly performance trends by priority facility status
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100-Days IPT Performance by HF level
11/13/2019 18
38,653
16,710
101,161
85,475
72,456
27,719
1,500
48,191
11,653
53,906
75,866 79,655
35,121
0
80%
143%
188%
113%
91%
79%
0%
20%
40%
60%
80%
100%
120%
140%
160%
180%
200%
-
20,000
40,000
60,000
80,000
100,000
120,000
Clinics (includes
special clinics in
MNRH)
HC II HC III HC IV Gen. Hosp RR Hosp. Other
Perc
enta
ge initia
ted o
n IPT
# o
n IPT
Axis Title
# initiated on IPT Target Target Performance
There was variability in Performance by HF level with GH,RR hospitals and Clinics
including those in Mulago performing lower than their target
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11/13/2019 19
AGE & GENDER DISSAGREGATION FOR PLHIV WHO INITIATED IPT DURING 100-DAYS CAMPAIGN
PLHIV, < 5 Yrs, 2,499 , 1%
PLHIV, 15+ Yrs, Female,
211,506 , 62%
PLHIV, 15+ Yrs, Male,
117,729 , 34%
PLHIV, 5-14Yrs, 11,940 , 3%
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• Overall, 526,354 PLHIV have initiated IPT, representing ~ 41.5% of the MoH UG TX_CURR
target for FY19
• 65.3% of the IPT initiations above occurred in the 100-DAYS campaign period
• The 100-DAYS IPT scale up campaign performance was successful with 113% performance
of the targeted 304,391 PLHIV.
• Overall, HC IIs, HC IIIs & HC IVs exceeded their targets while RR hospitals and General
hospitals did not achieve their 100-days target
• 17% of the clients initiated on IPT during the campaign period were in NON-PRIORITY IPT
facilities
• PLHIV aged <15 yrs constituted 4% of those who initiated IPT in the campaign period. A
total of 3,467 HIV negative children initiated IPT in FY19 of whom 32% were initiated during
the campaign period
11/13/2019 20
Conclusions
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Acknowledgements
❑MoH, ACP and NTLP
❑Development and Technical partners
❑CDC
❑USAID
❑Defeat TB
❑Global Fund
❑ DLGs
❑Implementing Partners
❑Civil Society Organizations and PLHIV networks
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PREVENT TB