Dr Fred Busuulwa Medical Officer, TB / HIV

1. Roles and experiences in TB care Dr Fred Busuulwa Medical Officer, TB / HIV

2. Summary • Background: Good Shepherd Hospital • HIV / TB service integration • DOTS • Intensified Case Finding • INH prophylaxis • Global Fund Round 8 • MDR-TB patient follow-up • Service decentralisation

3. About Good Shepherd • Mission Hospital and Nursing School • Regional hospital for Lubombo • Serves largely rural population of around 208,000 • Mixed funding including major contribution from Government of Swaziland • Regional TB diagnostic and treatment centre, managing 900+ TB patients per year • Strong community linkages

4. HIV / TB service integration • Programmes department: • HTC, ART (incorporates pre-ART), PMTCT, TB, Home-Based Care, roll-out teams • Other hospital departments: • Out-patients, In-patient wards (medical, surgical, paeds, TB), maternity

5. Integrated patient flow

6. DOTS • Good Shepherd was the first institution in Swaziland to introduce a community DOTS programme for TB (including MDR-TB) • Integrated community-based programme incorporates: • Patient-nominated treatment supporters • Basiti (expert clients) • Motorcycle adherence officers (MAOs) • Rural Health Motivators • Home-Based Care

7. Intensified Case Finding • 3-stage pathway: screening, sputum smear diagnosis, TB treatment initiation • TB screening tool (questionnaire) administered by nurses and lay counsellors • Screening offered at all HIV service entry points in clinics and hospital regardless of symptoms • After piloting in 16 clinics, ICF became established as a routine aspect of TB and HIV integrated care in Lubombo • Effective in detecting smear positive TB

8. Isoniazid prophylactic therapy (IPT) • Prevention of TB in pre-ART and ART patients by treatment with Isoniazid • Only adult IPT pilot site in Swaziland • Pilot ran 2008-2010 in 14 sites; 518 patients • Patients enthusiastic, default rate low • Following success of pilot, GSH will be leading site for national implementation of IPT beginning 2011

9. Global Fund Round 8 • Good Shepherd is sub-recipient of funds • Project began April 2010 • Provision of incentives to CBOs for TB patient care and follow-up • Objective: to improve treatment completion rate and decrease default rate to combat drug-resistance • Focuses on third component of DOTS: standardised treatment with supervision and treatment support • Project will run to December 2011 • Progress is good with over 1000 patients supported so far

10. MDR-TB patient follow-up • Follow-up provided for MDR-TB patients on out-patient basis • 34 patients are currently in the programme • Financial assistance provided for patient transport costs to attend appointments – supported by COMDIS (Leeds University) and South African Bishop’s Conference

11. Service decentralisation • Current programme of decentralisation of HIV services to affiliated clinics in Lubombo, including: • Roll-out of HTC, pre-ART registration, ARV refills is well underway • ART initiation (Doctor-led started 2009; Nurse-led from 2011) • TB testing and treatment beginning 2011 • Decentralisation is in collaboration with NTP, ICAP RHMT, ICAP, COSPE and other partners

12. SIYABONGA