1. TB Screening in the Antenatal Care Setting in Malawi Symposium: Exploring the intersection between TB and maternal and neonatal health: from research to implementation Florence Kayambo Senior HIV/TB Technical Advisor TB Lung Conference Barcelona, Spain 28th October – 1st November 2014

2. Presentation Outline  Background  Program Objectives  Program Activities  Achievements  Challenges  Recommendations  Conclusion 2

3. Background: Malawi IndicatorMalawi Population13.1 million HIV prevalence in Adults (2010) 10.6% TB incidence163 per 100,000 MTCT rate17,000 infants infected yearly MMR675 per 100,000 TB/HIV co-infection63% TB case detection rate65% 3

4. Program Objectives  Increase early TB case detection and management in pregnant women accessing ANC/FANC by 50%  Accelerate integration of TB screening in ANC  Accelerate national scale-up of effective and comprehensive PMTCT services (Option B+)  Improve the quality of PMTCT program  Contribute to the reduction of maternal and newborn mortality through strengthening linkages between maternal health and TB management 4

5. Process  Discussion with National TB Control Programme, HIV Directorate, RHD and TB Care II  Procurement of 2 microscopes and IP supplies  Development of job aids to standardize implementation (FANC/TB card and tape measure)  Revised M&E data collection tools  Orientation of service providers 5

6. Program Activities  One-day orientation for providers  Training of HSAs in TB microscopy  Procurement of microscopes and laboratory supplies  Demand creation and awareness through community mobilization activities  Integration of TB screening into MCH platform  Clinical mentoring  Supportive supervision  Documentation  Operational research 6

7. Program Activities, Continued  Task shifting HSAs trained in TB microscopy  HIV testing and counseling by HSAs  Provider initiated testing and counselling in ANC settings  Initiation of ART in ANC by nurses  Establishment of sputum collection and microscopy sites  Sputum sample collection and slide fixing  Quarterly review meetings 7

8. Monitoring and Evaluation Expected OutcomesOutcome IndicatorsTarget Enhanced case finding among ANC attendees Percentage increase in pregnant women screened for TB signs/symptoms in intervention sites 50% Number/percentage of mothers screened have symptoms of TB n/a Percentage increase in reported TB cases referred from ANC in the district post-intervention 100% Prompt diagnosis Percentage of ANC clients with symptoms of TB with at least one sputum sample tested for TB and results returned within 24–48 hours 50% Percentage increase in ANC clients with symptoms of TB with documented diagnosis and HIV ascertainment 100% Prompt treatment Time to initiation of TB treatment from initial symptom screening < two weeks Percentage improvement in time to initiation of ART in those women who do or do not have symptoms of TB 50% 8

9. Achievements  Modification of data collection tools to include TB case diagnosis and lead time to treatment initiation  PITC/HTC integrated within ANC setting  ART initiation within ANC  TB screening, including referral sputum collection to those eligible  TB-positive clients treated according to guidelines and protocols  PMTCT is fully integrated into maternal and child health services  Very high (93%) ANC attendance rate, providing an exceptional opportunity to identify and reach women in need of TB management 9

10. Achievements  Support from District Health Management Team  Oriented 300 providers in FANC/TB  6 HSAs and 4 laboratory technicians trained in TB microscopy (3 weeks)  Development of job aids: fundal height tape measure with key messages, routine TB screening in ANC  FANC/TB guide  Draft TB/HIV training manual for community 10

11. Summary of Results Total ANC Attendees5,474 Women screened for signs/symptoms of TB in ANC 3,920 (71.6%) Women with signs/symptoms of TB68 (1.7%) Women with signs/symptoms of TB diagnosed with TB 4 (5.9%) Women with signs/symptoms of TB diagnosed with HIV 8 (11.8%) 11

12. Challenges  Human and financial resource  High workload in the ANC setting, average 45–60 on clinic day  No laboratory facilities in 3 of the 5 facilities  Long distance to treatment initiation centers 30–50 kms  Inadequate documentation (data quality)  Inadequate infrastructure at health centers  No courier system for transportation of sputum samples/slides  Delays in lead time to access results range 1–3 weeks 12

13. Recommendations  Intensify and regularize follow-up visits from all levels  Onsite orientation of all members of staff  Define roles and responsibilities of the health center staff  Conduct monthly onsite coordination and review meetings to assess progress  Develop ANC/TB screening implementation schedule  Use community mobilization and sensitization, key to the uptake of the program  Decentralize TB initiation centers  Develop courier system for transportation of sputum samples/fixed slides, including feedback of results 13

14. Zambia Conclusion  Integration TB screening in ANC setting is feasible  Lifelong ART for all HIV-infected pregnant women will ensure virtual elimination of MTCT is achieved  TB diagnosis and management will contribute to reduction of MMR, reduce number of orphans  For sustainability, a concerted effort is needed from all funding and development partners for development and successful implementation of TB as part of the eMTCT strategy 14

15. “At first I was scared, but after being counselled by Mr. Mbwagha, I started taking the TB drugs. I did not have any problem or labor complication during birth to my twins up until I finished my regime and now I am fine. TB is curable in pregnancy”, Elizabeth said jovially. 15

16. Lesotho PSE Tuberculosis Specific Tasks (Skills) Tuberculosis (TB) Screen for TB based on patient symptoms Contact tracing of TB patient family members, including sputum sample collection Trace lost to follow-up within the communities Counsel TB patients and immediate contacts, e.g., family on adherence Train communities and community health workers on the administration to and supervision of patients on DOTS Administer initial and follow-up DOTS TB treatment 16