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

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

3. 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 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 new cases with resistance to Rifampicin – the most effective first-line drug, of which 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.

4. 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

5. 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 targets for TB (and HIV) by 2020
Losses across the TB care cascade will impede the attainment of the targets
The QI methodology implemented to address the losses across the TB care cascade

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

7. 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/
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% ( )
HIV-positive TB cases registered in 2015 :80% ( / )
% of HIV-positive people (newly enrolled in care) on preventive treatment (IPT/TPT):51%,contributing to 41% of Global TPT uptake
Dr Norbert Ndjeka

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

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

10. 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

11. 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

12. 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 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 XDR-TB cases diagnosed in South Africa to 2014: received treatment with high mortality (44 %)

13. 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

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

15. TB CASCADE

16. 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

17. CRITERIA FOR DISTRICT SELECTION

18. IMPLEMENTING SUB DISTRICTS

19. 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

20. 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

21. TB CARE CASCADE

22. 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:

23. 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

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

26. 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

27. 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%

28. 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

29. 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

30. 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

31. 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

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

33. Thank you