Dr Anna Scardigli, also with ICAP, described some of the challenges to beginning an IPT programme in Mozambique. The country has a high HIV prevalence (~16%) (though it is around 23% in Maputo), a high TB incidence: 431 cases per 100,000 population and a high burden of co-infection — about 60% of TB patients tested for HIV in 2008 were HIV-positive. Mozambique began to scale up TB/HIV collaborative activities in 2006. Last year, it began to pilot an IPT programme.2
“There were various constraints getting the programme started, first of all the availability of isoniazid as a single drug (rather than coformulated with other TB drugs), and then the coordination between the TB services and ART facilities,” she said. TB services and ART facilities are often physically separated, with the TB service storing isoniazid. On top of this, there were the traditional concerns about the ability to rule out active TB and that well patients would not be adherent to IPT.
“As most PLWH who start IPT are in good health and do not require frequent visits, strategies to improve adherence to monthly follow-up visits for a preventive therapy are needed,” said Dr Scardigli.
They decided to limit the size of the initial programme to the amount of isoniazid that was available, and to store it at the pharmacy of the health unit. But the programme was first piloted in one ART facility (at Mavalane Hospital in Maputo) supported by ICAP after using a TB screening checklist that ICAP had also helped develop.
In July 2008, a workshop was held for all 20 staff members at the ART clinic that focused on IPT eligibility (how to rule out active TB), isoniazid delivery, IPT register completion and follow-up of patients. The nurse designated as the TB/HIV focal point was responsible for coordination of the IPT programme.
The clinic had already had experience using the symptom checklist to screen for TB in all the patients enrolled at the ART facility. With the launch of the IPT programme, doctors began prescribing IPT for all eligible patients who screened negative for TB, and monthly follow-up was performed by nurses. Patients were told to return to the clinic monthly for follow-up visits and to pick up their next month’s supply of isoniazid (rather than for their next ART consultation).
Almost all of the patients had stage one or two HIV disease. All were on ART (which is because doctors who prescribe isoniazid only see patients on ART rather than pre-ART patients).
During the first six months of implementation, 109 HIV patients initiated IPT. No patient discontinued due to toxicity, and only two quit drug because of pregnancy.
But as Dr Scardigli anticipated, adherence was not great. After the first month, only 13/34 (38%) patients who had started IPT returned for their follow-up visit and to get their supply of isoniazid.
When many of the patients who defaulted on IPT returned for their ART consultation, they reported that they had ‘forgotten’ about their IPT appointment. Dr Scardigli said that one possible reason for this was that the ART consultation was with the clinician, but the IPT consultation was with a nurse in another room.
So they decided to strengthen the counselling at IPT initiation to emphasise the importance of adherence. In addition, IPT was also recorded on the patient card and file envelope, in addition to the IPT register, so that IPT patients could be tracked better and more healthcare staff such as the receptionist and pharmacist could be involved in patient follow-up and remind the patient of the importance of adhering to the programme.
Gradually, adherence improved. By month three, 78% returned for their follow-up visits — although about 42% came in about a week late. The team worked more on strengthening counselling and staff commitment to the programme. By month six, the proportion returning for follow-up reached 91% (99/109) and only 32% came in somewhat late. This was more likely to occur when they had another hospital consultation scheduled soon afterwards
Overall, 92 (84.4%) are believed to have completed six months of IPT. There were 15 (13.8%) who were defaulters to some point of follow-up.
“So IPT implementation in an ART facility (or HIV/AIDS consultation) is feasible, but commitment of the whole staff involved in the care of the patient — and not just one person — is needed to increase adherence and keep better track of the patient, and of course intensive counselling and education of patients especially prior to initiating IPT,” she said.
She said that getting patients to come back to the first follow-up visit is the most challenging, but after that point they rarely miss further visits. Even so she stressed that “combining IPT visits with other visits and ART pick-up can reduce missed visits and avoid delays.”
They now plan on expanding TB screening in all people with HIV (at all entry points to care). They plan to strengthen follow-up even beyond six months on IPT to evaluate the effectiveness of the programme.
During the question and answer session, Dr Scardigli was asked about the timing of starting IPT in people on ART. “It’s important to consider the risk of interaction between ART and IPT and the risk of toxicity, “ she said, “and recent studies suggest waiting about four months on ART before starting IPT. In our case, most of the patients had already been on ART for a long time. But it was the clinician’s decision rather than a criteria. Now they are thinking to give a clear recommendation to wait for six months before starting on IPT.“
She was also asked about the limited roll-out of the programme at one ART facility.
“The TB screening tool is now used in all the supported facilities,” she said, “but IPT has only been started in one facility which was also the first to begin using the TB screening tool. I think it is important because we can’t just start to implement IPT at any site. We had to select sites with the appropriate condition, both in terms of human resources and in the uptake of the TB screening tool. There are provinces in Mozambique where they have decided that they won’t start IPT yet, because they want to make sure that they are doing better at TB screening before starting IPT.”