Session 13: TB/HIV

February 25 – March 2, 2018 Internal Use Only

2

Mozambique TB Country Profile

• Population: 29 million (2016)

• TB incidence: 551 per 100,000 (2016)

• TB cases estimated:159,000

• TB cases Notified: 73,470

• 85,530 (54%)TB cases are

missing

• Estimated MDR/RR-TB cases among

notified pulmonary TB cases: 3,400

• MDR-TB cases notified:868

• 2,532 (72%) MDR/RR-TB are

missing

• HIV prevalence: 13.2%

• HIV prevalence among TB: 44%

3

High Uptake of HIV Testing and ART Initiation

76763 73011

31511 28538

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

Total

Nu

mb

er

of

TB

Cas

es

TB/HIV Cascade, 2017 (APR)

Sum of TB STAT (Den) Sum of TB STAT (Num)

Sum of TB_ART (Den) Sum of TB_ART (Num)

91%

95%

39%

4

TB/HIV Achievements Driven by Case Detection

85876

76763

85876

73011

44773

31511

44773

28538

Sum of TB STATCOPTarget

(Den)

Sum of TB STAT(Den)

Sum of TB STATCOPTarget

(Num)

Sum of TB STAT(Num)

Sum of TB_ARTCOPTarget

(Den)

Sum of TB_ART(Den)

Sum of TB_ARTCOPTarget

(Num)

Sum of TB_ART(Num)

TB/HIV Cascade Target vs Results, APR17

89% 85% 70% 64%

5

TB Case Detection Gradually Improving, but Remains Low

6

COP Planning Decision Tree: TB Case Detection

Problem

Diagnosis

Strategic

Objective

Approach

Low TB

case

detection

Increase

TB case

detection

Problem

Statement/Indi

cator

Poor screening

in all entry

points

Delay seeking

health care

Low TB

suspicion

among priority

population (PP)

Under

utilization of

GeneXpert

Deficient

contact tracing

Monitoring

and Partner

Management

TB

cascade

monitoring

GeneXpert

utilization

rate

Expansion of

Cough officers to

improve HF TB

Screening

Strengthening TB

diagnosis Capacity

(including

optimization of

Xpert)

Improve active

case finding

among TB contacts

& PP

7

PEPFAR Support to Improve TB Case Detection

Site-level support

• Setting ambitious targets jointly

with ministry

• Monthly partner’s meetings

• Semi-annual review of APR and

SAPR results IPs representatives

• TB/HIV focal points at the central,

provincial and in some provinces

regional/district levels

• Support for increased utilization of

GeneXpert

• Strengthening integrated sample

transport

• Trainings and intensive supportive

supervision

• Implementation of FAST strategy and

expansion of cough officers: Find TB patients

Actively identify patients with current

cough, fast track them to be screened

for other symptoms suggestive of TB

Separating safely

Treatment

• Household TB contact tracing (Gaza)

• Incorporating TB education/screening

into community interventions

• Targeted outreach to miners and their

families

Central support

8

Activities to Support Gene Xpert Expansion & Utilization

• Provider & laboratory trainings

• Gene Xpert maintenance and connection to GX Alert

• Support integrated sample transport and results return

• Monthly review of TB cascade data with partners to improve support

9

Targets for Aggressive Achievements in COP18

Indicator

COP16

(APR17)

Achievement

COP17

(FY18)

Target

COP18

(FY19)

Target

TB_STAT 73,011 77,909 99,269

TB_ART 28,538 40,155 28,631

TX_TB

(Den) 817,421 333,471 1,586,904

• Targeting for 27%

increase in TB cases

detected from FY17

• 100% HIV testing

among TB Patients

• 100% ART initiation

among TB/HIV

patients

• 100% of persons on

ART to be screened

for TB

10

COP Planning Decision Tree: IPT

Problem

Diagnosis

Strategic

Objective Approach

Inadequate

uptake and

completion

of IPT

Increase IPT,

initiation,

completion and

documentation

Problem

Statement/

Indicator

Inadequate TB screening Health workers lack confidence to prescribe IPT Limited availavility of IPT registers & inadequate documentation Availability of a continuous supply of INH and B6

Monitoring

and Partner

Management

TB_PREV

(Den and

Num)

Provide

enhanced

support for IPT

uptake and

completion

Increase

availability &

use of M&E

tools to monitor

IPT completion

11

TB Diagnostic Cascade and IPT Initiation & Completion

FY17 Current on Treatment

995,547

FY17 New on Treatment:

317,171

Screened for TB:

817,432

(82% of TX_Curr)

Started on TB TX:

23,601

(2% of TX_CURR)

Started IPT :

300,970

(30% of TX_Curr)

(95% of TX_NEW)

Completed IPT:

179,013

(59%)

12

COP18 Activities to Improve IPT Completion

Improving IPT cohort monitoring/M&E

• Dissemenate revised TB/HIV Guidelines

• Health care worker refresher trainings

• Revitalize job-aids/checklist for TB screening & IPT prescription

• Improve patient education and literacy through patient and family center approach

• Assure availability of IPT at site-level

• Improve the availability of appropriate IPT registers and M&E tools at all necessary sectors

• Close monitoring of IPT completion, adverse events

• Establish mechanism for monthly reporting of IPT

• Close follow-up of IPT initiation and TB PREV during TB HIV TWG and TB partner meetings

Increasing IPT Uptake & Completion

13

Targets for Aggressive Achievements in COP18

Indicator

COP16

(APR17)

Achievement

COP17

(FY18)

Target

COP18

(FY19)

Target

TB_PREV

(DEN) 190,022 335,501 352,849

TB_PREV

(NUM) -- 226,768 299,922

• Assumes 85% of new

on treatment to

receive IPT

• 85% IPT Completion

rate

14

COP Planning Decision Tree: TB Infection Control (TBIC)

Problem

Diagnosis

Strategic

Objective Approach

Lack of

systematic

implement-

ation of

TBIC

measures

Improve

implementation

of IC measures

in HF and

congregate

settings

Problem

Statement/

Indicator

Insufficient

implementation

of core IC

measures

Lack of routine

monitoring/over

sight of IC

Facility

design&

infrastructure

challenges

Monitoring

and Partner

Management

TBIC

dashboard;

HCW

surveillance

data

(partners)

Support

broader uptake

of IC at

HF/congregate

settings

Expand HCW

surveillance as

core TB IC

activity

Support the

use of IC dash

board in large-

volume HFs

15

Monitoring ICTB using simplified dashboard

• Ministry TB Infection Control Policy and Plan (2010)

• Direct support to HF to implement TBIC (2012)

• Routine HCW Surveillance for TB at select sites (2012)

Core Activities to Improve TB-IC Supported by JHPIEGO

HCWs attended

Workplace Clinic: 39,097

Screened for TB: 39,097

(100%)

No TB Symptoms:

28,619 (73.2%)

TB symptoms/ tested for TB:

10,478(26.8%)

Diagnosed with TB: 218 (2%)

Started on TB treatment: 218

(100%)

Counselled for HIV: 12,595

(32.2%)

Tested for HIV: 9,208 (73%)

HCW diagnosed HIV positive: 355

(3.9%)

Started on ART: 355 (100%)

Not tested for HIV: 3387

(27%)

JHPEIGO HCW Surveillance

Data (2017):

16

Monitoring ICTB using simplified dashboard

• Routine monitoring using standardized dashboard/checklist (2014)

• Development of abbreviated TBIC monitoring jointly with CDC (2017)

• Direct support to 44 health facilities (2017)

• Performed the internal evaluation using simplified dashboard;

• Action plans were prepared together with managers of HF

• At least 25 HF achieved a performance ≥ 80% using dashboard;

Core Activities to Improve TB-IC Supported by JHPIEGO

17

COP 18 Plans for Improving TBIC Implementation

Clinical Partners:

• Support to IC focal point to

implement IC plan

• Routine monitoring with TBIC

dashboard

• Support implementation of

HCW surveillance

• Support for minor renovations

to improve IC

JHPIEGO:

• Development and

dissemination of IC materials

• Training & Coordination

• Intensive support in 1-2 high

burden provinces

18

1940 2330 2160 2800 3400 266 444 544 646 911 213 313 482 646 897

14% 19%

25% 23% 27%

80%

70%

89%

100% 98%

0%

20%

40%

60%

80%

100%

120%

0

500

1000

1500

2000

2500

3000

3500

4000

2012 2013 2014 2015 2016

MDR-TB Notification and Treatment Trend, 2012 - 2016

Estimated Lab confirmed MDR-TB

Patients started MDR-TB Tx % Diagnosed

% of those diagnosed who initiated treatment

MDR Case Notification is Extremely Low

19

Problem

Diagnosis

Strategic

Objective Approach

Low MDR

Case

Detection

and

Treatment

Completion

Strengthening

Program

Management of

MDR-TB

(PMDT) at all

levels

Problem

Statement/

Indicator

Inadequate

screening/

suspicion for

MDR-TB

Under-

utilization of

GeneXpert in

targeted

population

Patients not

retained on

treatment/Low

treatment

sucess rate

Monitoring

and Partner

Management

MDR

Cases

Detected,

Treatment

Outcomes

(Non-

PEPFAR)

Strengthening

MDR-TB

Mentorship

Implementation

of MDR TB

short course

Enhanced

MDR-TB

retention/

psychosocial

support

COP Planning Decision Tree: MDR-TB

20

Progress Towards Improving MDR-TB Management

Core Ministry of Health Activities

to Improve PMDT

• Participation in GLC auditing and

supervision

• National training and supportive

supervisions (On-going)

• Long Term DR-TB plan including in

National TB Plan (2014-2018)

• National DR-TB TWG and Provincial

MDR Focal Points (2015)

• Updated National DR-TB Guidelines

(PMDT) (2017)

• Introduction of MDR Short Course

Regimen and New Drugs (Bedaquilin)

(Starting 2017)

PEPFAR-Support to PMDT:

• Support training and supervision at

provincial and district level

• Support increased utilization of

Gene Xpert

• Follow-up return of results and

confirm MDR patients initiated on

treatment

• Implementation of retention/

psychosocial package for MDR-TB

patients

• Support provincial management of

commodities to ensure availability of

drugs & materials

• Support implementation of quality

assurance programs

21

TB/HIV Activities for Miners

IOM:

• Providing comprehensive

TB/HIV screening services at

annual recertification

• Work with clinical partners to

ensure linkage to treatment

• Follow-up on miners on return

to S. Africa to ensure

treatment continuation

Clinical Partners:

• Ensuring linkage to treatment

for patients identified with TB

• Household TB contact tracing

for identified TB Miners

22

Core Package of Services for TB/HIV Care in Prisons

HIV

Systematic HTS at

entrance

Linkage to C&T

services

Psychosocial support

Transport of samples

to LAB (VL, CD4 and

return of results for

clinical decision)

Ensure continuum of

treatment before

incarceration and after

release

Tuberculosis

Screening for TB at

entrance and

periodically

Ensure GeneXpert

for all TB suspect

Ensure DOT during

period of

incarceration and

after release

IPT for HIV-positive

persons

Human Resources

and Infrastructures

Trainings of Prison

staff

Technical

assistance

Rehabilitation of

existing prison

infrastructures

Peer educators:

HIV sessions in

prison

Follow up after

release to ensure

linkage to care

23

Coordination

Using various Task Working Groups, partners meetings and other mechanisms, the NTP coordinates activities from various sources:

Thank You!

Obrigado! Kanimambo