LESSONS FROM IMPLEMENTATION Dr Kgomotso Vilakazi Nhlapo TB/HIV SOUTH AFRICA LESSONS FROM IMPLEMENTATION Dr Kgomotso Vilakazi Nhlapo Date: 16 July 2018

PRESENTATION OUTLINE WHO Global TB Report Background TB in RSA Considerations for implementation Key challenges Success factors Conclusion

Global TB Report 2017 : Key Facts Tuberculosis (TB) is one of the top 10 causes of death globally In 2016, 10.4 million people fell ill with TB, 1.7 million died from the disease (including 0.4 million among people with HIV). Over 95% of TB deaths occur in low- and middle-income countries. Seven countries account for 64% of the total, with India leading the count, followed by Indonesia, China, Philippines, Pakistan, Nigeria, and South Africa(7). In 2016, approximately 1 million children became ill with TB and 250 000 died of TB (including children with HIV associated TB). TB is a leading killer of HIV-positive people: in 2016, 40% of HIV deaths were due to TB. Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. WHO estimates that there were 600 000 new cases with resistance to Rifampicin – the most effective first-line drug, of which 490 000 had MDR-TB. Globally, TB incidence is falling at about 2% per year. This needs to accelerate to a 4–5% annual decline to reach the 2020 milestones of the End TB Strategy. An estimated 53 million lives were saved through TB diagnosis and treatment between 2000 and 2016. Ending the TB epidemic by 2030 is among the health targets of the Sustainable Development Goals.

END TB Strategy Reduce deaths by 90 % in 2030 compared to 2015 levels Reduce number of new cases by 80 % Ensure no family is burdened with catastrophic costs due to TB

BACKGROUND The National HIV, TB, STI Strategic Plan 2017-2022 aims to; Decrease deaths due to TB by 50% Decrease incidence of TB by 30% The department of Health adopted the 90-90-90 targets for TB (and HIV) by 2020 Losses across the TB care cascade will impede the attainment of the 90-90-90 targets The QI methodology implemented to address the losses across the TB care cascade

HEALTH SERVICES IN SOUTH AFRICA (2015) GP 22.4% LP 11% NC 2.2% Population: 52,981,991 Provinces: 9 Districts: 53 Sub districts: 253 Health facilities: 4 790 MDR-TB beds: Approx. 3 000 DR-TB treatment initiation sites: 645 NW 6.4% MP 7.2% KZN 21.4% FS 5.5% WC 10.5% EC 13.5%

TB in South Africa South Africa has the 7th highest incidence of TB cases (WHO, 2016) TB leading cause of mortality in South Africa (Statistics South Africa) TB Incidence 781/100 00(2016) 60% – 80% of all TB cases co-infected with HIV. (WHO, 2009; Gandhi et al., 2006).2016 estimated average :59% HIV/TB Mortality-181/100 000 Estimated % of TB cases with MDR/RR-TB-New cases: 3.4%,Retreat Cases:7.1% New and relapse cases registered in 2015-Success: 81% (291 793) HIV-positive TB cases registered in 2015 :80% ( 167 335/244 053) % of HIV-positive people (newly enrolled in care) on preventive treatment (IPT/TPT):51%,contributing to 41% of Global TPT uptake Dr Norbert Ndjeka

Registered DSTB cases 2005 - 2013 5/12/2019 8

DSTB– New SS+ Treatment Success (2005 - 2012) 5/12/2019 9

DEFINITIONS Mono resistance: TB strains that are resistant to at least one anti-TB first-line drug (R or H or Z or E) Poly resistance: TB strains resistant to more than one drug other than Rifampicin and Isoniazid combined MDR-TB: TB strains resistant to Rifampicin and Isoniazid with or without resistance to other first-line TB drugs XDR-TB: TB strains resistant to Rifampicin, Isoniazid, any second line injectables (Am, Km or Cm) and to any fluoroquinolone

NEW DEFINITION Rifampicin Resistance TB (RR-TB): TB strains resistant to Rifampicin detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs RR-TB includes any resistance to Rifampicin, whether Mono resistance, polyresistance, MDR-TB or XDR-TB

DR-TB BURDEN IN RSA 82.4% 50 % 20% TB patients initiated on treatment decreasing: 406,082 to 318,193 (2009 and 2014) Treatment success rate: 82,4% for 2013 cohort MDR-TB numbers initiated on treatment doubled between 2010 and 2014 (5,313 to 12,148) MDR-TB treatment success rate of 50% (2012 cohort >8,000) XDR-TB treatment success rate was 20% (2012 cohort) Approximately 7000 XDR-TB cases diagnosed in South Africa 2004 to 2014: 4606 received treatment with high mortality (44 %)

SCREENING & TREATING TB: HOW DO WE FARE? Number of people screened for TB: 70m (10m in 2014, 36m in 2015, 61m in 2016) but screen positive and linked to treatment unknown 230/242 correctional services centres conduct routine TB screening but screened positive and linked to treatment unknown Number of people screened and counselled for raised blood sugar: 8m in 2015 and 24m in 2016 and 14m in 2017 but number of these also screened for TB unknown 4THqtr 2016/17 treatment success rate: 84.4% (target for 2019 is 85%) In 2017/18 the loss to follow-up rate was 7.1% (target was 5.4%); need to reach 5% of less by end of 2019

% OF HIV+ ADULTS AT DIFFERENT LEVELS OF ENGAGEMENT IN HIV CARE (JOHNSON, 2018)

TB CASCADE

GOVERNANCE AND TECHNICAL SUPPORT Think Tank NDOH NTP leadership technical support to NDOH NDOH Project Team technical support to Provincial leaders Provincial Teams DHMT Teams technical support to DHMT and facility teams Subdistrict teams

CRITERIA FOR DISTRICT SELECTION

IMPLEMENTING SUB DISTRICTS

KEY ACTIVITIES Development of implementation guides and protocols QI capacity building for provincial, district and sub-district managers and partners Team work Joint planning Quarterly Sub-district Learning Sessions/ collaboratives sharing of experiences and lessons learned training Monthly coaching and mentoring visits Involvement of PHC supervisors, Quality Assurance managers, Facility mentors , technical partners

KEY ACTIVITIES,cont….. Improving processes and efficiencies in health facilities Process mapping Teamwork Addressing data gaps Training Completion of patient records Facility data flow processes Compliance with DHMIS policy Monthly coaching and mentoring visits Involvement of PHC supervisors, QA managers, facility mentors, partners

TB CARE CASCADE

MODEL FOR IMPROVEMENT Sustain the improvement AIM PLAN DO STUDY ACT Sustain the improvement Adapt the change, increase the scale, test in different contexts MEASURES Small test of change CHANGES:

Poor tracing of contacts and community linkages Clinic sytems Medicine Stock outs Patient flow Data flow not clear Poor infrastructure Poor tracing of contacts and community linkages Poor integrations of services No dedicated staff to sort lab results   5/12/2019 Staff Factors Eligibility unknown Staff attitude and belief Poor recording Poor history taking Lack of integrations Poor health education to clients Shortage of staff/ overworked Laziness Resistance Lack of program ownership Patient factors Patients’ rights Stigma Alcoholism Substance abuse Attitude Shopping around Pill Burden Lack of knowledge Language barrier Poverty Religious beliefs Denial Side effects   Leadership Lack of supervision by OM Suboptimal teamwork Poor mentoring and couching Limited support by DHMT and Partners   Data Poor recording Lack of understanding of data definitions Poor capturing Lack of data validation DHIS uses average than median TB register in TB room to record TB initiation Data element on TB initiation not on PHC tick register  

analysis Change idea PDSA cycle Monitoring through run charts Root cause analysis Change idea PDSA cycle Monitoring through run charts

TB DATA FLOW PROCESS Facility Data Quality Checklist TB Data Quality Audit Tool HEADCOUNT REGISTER (Reception) COMPREHENSIVE TICK REGISTER (Consulting, Vital signs room) TB IDENTIFICATION REGISTER (TB/ Consulting Room) TB REGISTER ELECTRONIC TB REGISTER (ETR) MONTHLY DATA INPUT FORM DHIS WEEKLY TALLY SUMMARY

PRELIMINARY RESULTS Buy-in by DHMT in all 9 districts 715 facility, sub district, district and provincial staff trained 223 Facilities are implementing QI in 10 sub districts 19 Learning sessions for facility clusters held Facility supervision rate is 86%

CHALLENGES Quality of screening still remains weak resulting in a low yield Team work at facility level sub optimal Quality of data poor Incomplete and incorrect completion of PHC registers Lack of understanding of data elements Missing data elements in PHC tick registers and facility monthly data input forms resulting in these not reported in the DHIS Onsite mentoring and coaching weak Variations in implementation

KEY POINTS FOR SUCCESS Management buy-in and ownership at all levels is critical for successful implementation Mentorship and support during the initial phases of implementation required to sustain the momentum Quality data is an essential component for monitoring the success of the project

CONCLUSION Quality Improvement methodology Data driven process Forces facility staff to analyse and act on data Simplifies processes at facility level Patient flow Data flow Applicable in any program Expansion to quality of clinical care and community services

CONCLUSION Drug-susceptible TB case notification is decreasing MDR-TB cases continue to increase (> 13,000 during year 2015) MDR-TB is a public health crisis and a threat to tuberculosis control globally

ACKNOWLEDGEMENT Drs Y.Pillay,L.Mvusi,N.Ndjeka National and Provincial DoH WHO PEPFAR PARTNERS,IHI PATIENTS and FACILITY STAFF

Thank you