module 14: isoniazid preventive therapy programme
TRANSCRIPT
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Module 14:Isoniazid Preventive Therapy
Programme
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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.
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• 10% lifetime risk of developing active TB if infected with M. tuberculosis alone
• 5-10% annual risk of developing active TB if co-infected with HIV
• IPT is therefore, meant to prevent progression of latent TB to active disease
Rationale for IPT
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• 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).
TB and HIV
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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
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TB Notification Rates 1999-2005
TB Rates 1999-2005
537 595 620 649 615 603 602
0
200
400
600
800
1999 2000 2001 2002 2003 2004 2005
Reporting Year
Rat
e/ 1
00,0
00
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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
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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
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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
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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
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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
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Other Findings
• Treatment completion was good 69%
• M& E component was found to be burdensome
• Turnover of nurses during the pilot was high
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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%)
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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
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Current IPT Program
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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
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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
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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
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Client Screening
• Algorithm is the main tool used
- Subjective data
- Physical assessment
- Investigations as necessary (e.g sputum, chest x-ray)
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IPT Documents
• Facilitators’ guide
• Health workers’ guide
• Brochures
• 3 types of video cassettes
• Still developing posters/and other IEC materials
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IPT Records
• Patient outpatient card
• Register and compliance record
• Dispensary Tally Sheet
• Patient Transfer form
• Monthly report form
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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
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Enrollment Data
• Clients counseled – 30,592
• Clients enrolled – 24,840 (81%)
• Clients completed treatment- 6721 (27%)
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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
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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!
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MONITORING AND EVALUATION
• Monthly reports
• Quarterly reports
• Support visits using checklist
(quarterly/when necessary)
• Review meetings with districts
• IPT/TB programme evaluation
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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
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Achievements (Cont’d)
• Increased IPT officers at national level
• Necessary equipment purchased
• Database developed
• Improved support visits
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Challenges
• Irregular data submission by facilities
• Inadequate transport for support visits
• Poor record keeping by health workers
• Lack of commitment by health workers