Using Mobile Phones to Monitor and Improve Adherence to Tuberculosis Medications In collaboration with: Central TB Division

Topics Covered What is 99DOTS Features and Benefits of 99DOTS Benefit to Patient Benefit to Field Staff Benefit to District Supervisors 99DOTS Workflow in TB-HIV collaborative intervention of ART and RNTCP department 99DOTS Dashboard Workflow Overview of ART and RNTCP Responsibilities in 99DOTS Detail Task Breakup of ART and RNTCP Responsibilities 99DOTS Video

What is 99DOTS? Strengthening DOTS monitoring through real-time adherence monitoring

What is 99DOTS? Goal: to provide 99% of the benefits of DOTS at a fraction of the cost and inconvenience to patients Anti-TB drugs are wrapped in envelopes which are printed with hidden numbers behind the pills When patients dispense a dose, they reveal a hidden TOLL FREE number which they call This call gets reflected on the 99DOTS dashboard immediately as a taken dose

99DOTS: Accurate Monitoring at Very Low Cost

How can the Patient data be accessed? Different ways of accessing the patient data – Web dashboard (www.99dots.org) Every center will be given their own login ID and Password to access their patients Different logins for ART center, DTC and field staff (with limited permissions) SMS Alerts for Staff and Treatment Supporters to take immediate action

Calendar View of Adherence

New patient (740XXXXXX) enrolled, Yelahanka district SMS Alerts from 99DOTS Reminders to Patients Alerts to Staff [0000] Two of your patients have missed doses SMS Message: SMS Message: [0000] Please Two of your take pills Please patients have missed doses today: Raj & take pills Om Raj (979XXXXXX) & Om (812XXXXXX) Notification of new patients Analytics and Reports for Program New patient (740XXXXXX) enrolled, Yelahanka district SMS Message: [0000] Please take pills

Features of 99DOTS Calls are completely free for patients Calls can be made even when the patient has no pre paid balance or the mobile is in roaming area Any call from a registered patient number is marked as a dose taken (personal, shared, land line) Numbers are not unique, but appear in an unpredictable sequence – ensures pill-in-hand adherence When patients call, they hear “Thank you” Calls immediately show up in the dashboard as taken doses Automatic alerts and reminders to patients and supervisors for non-adherent patients Adherence records available to field staff, medical officers, district staff and all other stakeholders in the program Two of your patients have missed doses Raj (979XXXXXX) & Om (812XXXXXX) SMS Message: today: Raj & Om

Field Staff/Supervisors Benefits of 99DOTS Less travel Increased convenience Patients Focused and more efficient care Field Staff/Supervisors Easy monitoring Accurate reports Program Officers

99DOTS Workflow for TB-HIV Co-Infected Treatment

99DOTS: Workflow - Summary Patient’s sputum is sent for testing to the RNTCP center CBNAAT testing for rapid microbiological diagnosis Patient at ART Centre with symptoms of TB Cough, Fever, Night sweats, Weight loss Continuous monitoring and follow up by RNTCP staff Patient is counseled at ART Centre to take medication in the 99DOTS packaging and registered on 99Dots website Patient identified positive for TB

TB Medication Regimen Most patients undergo treatment for 6 months FDC Intensive Phase (IP): 2 months (Isoniazid, Rifampicin, Ethambutol, and Pyrazidamide) – 4FDC Continuation Phase (CP): 4 months (Isoniazid, Rifampicin, and Ethambutol) – 3FDC FDC Pills/Day based on weight band Daily regime – easy with FDC If patient takes full course, near certain-cure After 2-3 weeks: feeling better After 6 months: negligible chance of relapse/resistance 4FDC 3 FDC

Does not receive FDCs or 99DOTS FDC Drugs by Weight WEIGHT CLASS # OF PILLS # STRIPS FOR 28 DAYS < 25 kgs Does not receive FDCs or 99DOTS 30 – 39 kgs 2 pills per day 2 40 – 54 kgs 3 pills per day 3 55 – 70 kgs 4 pills per day 4 > 70 kgs 5 pills per day 5 FDCs wrapped in custom 99DOTS envelopes based on weight (diagrams to follow)

99DOTS Envelopes 2 pills 3 pills 4 pills 5 pills

Patient counseling of 99DOTS ART Center staff nurses/counselors Explain 99DOTS, and importance of adherence (how many pills, every day, make free call) 6 months medication Call is free, even without balance and can be done free even when roaming Patient should follow path of pills Patient should come back every 28 days when pills are finished If patient has phone, administer first dose and make first call

99DOTS Website Workflow NOTE: For detailed information on how to use the 99DOTS Website to perform various tasks, see the 99DOTS Dashboard User Guide

Snapshots of 99DOTS Website Dashboard

Step 1 RNTCP – District Login : Maintain Staff Details at District and TU level using the Staff Details menu in the 99DOTS Website Step 2 ART Center Login: – Register Patient using the Add Patient menu in the 99DOTS Website Step 3 RNTCP – District Login: Assign correct TU for all new patients using the Treatment Center tab under patient details page in 99DOTS Website Step 4 RNTCP – District Login: Add treatment supporters (relatives, community workers) under district and TUs using the Treatment Supporters menu in the 99DOTS Website and link them to individual patients from patient details page. Do not add staff as Treatment Supporters Step 5 RNTCP – District and TU Login – Monitor patients for adherence using the Calendar menu in the 99DOTS website. Add Notes/Tags after interacting with patients, and perform various patient management tasks from the patient details page.

STEP 3: Assign Patients to TU STEP 1: Staff Details STEP 2: Add Patient STEP 3: Assign Patients to TU Using the District Login, add District and TU staff details. These staff will get SMS alerts for patients listed under their district and TUs. This is mandatory and extremely important. Register Patient on 99DOTS (using ART login) – When registering patient, select the correct District to which the patient belongs. This allows the relevant district to see the patient. From the list of Patients under District, select the required patient and allocate him/her to a TU within the district. Once patients are allocated a TU, TU Staff will start receiving alerts about the patient and see them from the TU login. STEP 4: Add & Link Treatment Supporters STEP 5: Patient Management S Perform various on-going patient management tasks such as: Edit Patient Details, Edit Attention Required, Adding Notes and Tags, Editing Treatment Center, Marking Manual Dosage, Closing and Reopening a Case, Downloading Treatment Cards, Reports Add list of Treatment Supporters under district and TUs. The Treatment Supporters won’t be automatically linked to patient. You have to go to individual patient details page and link Treatment Supporters to the patient. Staff like DPS / STS / TBHV should not be added here.

Patient monitoring by RNTCP Login to 99dots.org to see patient adherence/notes Follow up with patients with low adherence Respond to SMS alerts, and 99DOTS requests to follow up with patients DOTS+ Supervisor/RNTCP team to review adherence at regular meetings Add notes on patient behavior to log follow ups

99DOTS – Adherence scenario Patient ID Patient name 1 2 3 4 5 6 7 8 1423 Rahul K. Patient ID Patient name 1 2 3 4 5 6 7 8 1423 Rahul K. Today is the 8th day of Rahul’s treatment and he has not called in two days Rahul gets a message reminding him to take his daily dose The RNTC staff (STS, TBHVs, DPS, field staff) also gets a message alerting them that Rahul has not taken medication in 3 days [0000] Please take pills They call Rahul, and counsels him on the importance of taking drugs every day Rahul K. (740XXXXXXX) has not taken pills. Rahul takes his medication, and calls the hidden number, so his adherence can be logged

Roles and Responsibilities of ART and RNTCP staff for TB-HIV Co-Infected treatment

99DOTS TB-HIV Co-infected Treatment Responsibility Matrix Task Responsible Department Ensuring that drugs are sent to ART Centers RNTCP – District TB Office Adding Staff Details at District and TU Level in 99DOTS website. These staff will get SMS when a patient is added and when the patient misses to call the toll free number RNTCP – DPS, or any other staff designated by DTO Adding relatives or other persons close to the patient, community workers, etc. who would like to be intimated by SMS on non adherence and liking them to patients. Registering Patients on 99DOTS website (selecting correct district, adding phone numbers, and assigning correct weight band) ART Center – Data Manager Assigning Patients to the correct TU under the district RNTCP - DPS, or any other staff designated by DTO Counseling Patients about 99DOTS and how to make a call after each dosage Initially by ART Center Counselors/nurses/doctors while giving medicines. Later by RNTCP staff (for example, DPS, STS, TBHVs) who is responsible for monitoring patients adherence on 99DOTS website and responding to SMS alerts

Task Responsible Department Handing over 99DOTS wrapped drugs to patients ART Center – Pharmacist Ensuring that drugs are available, maintaining inventory, and issuing refills to patients ART Center - Pharmacist Editing Patient Details, like adding additional phone numbers, updating address change ART Center – Data Manager and RNTCP - DPS, or any other staff designated by DTO Monitoring patient list for adherence RNTCP - DPS, or any other staff designated by DTO Follow up with patience once non adherence SMS is received by the linked staff/provider RNTCP – STS, TBHVs, DPS, Field workers, or any other staff designated by DTO Adding Notes and Tags, marking manual doses, closing a case, downloading reports Changing Treatment Center details, for example in the case of change of TU/District/ART Center of patient. The DOTS Plus Supervisor (DPS) or any other staff designated by the District TB Officer (DTO) is accountable for all patients in his/her district. He/she can call patients directly after going through the dashboard and/or delegate this to the relevant field staff like STS, TBHVs, field workers, etc.

Detail Task Breakup of ART and RNTCP staff for TB-HIV Co-Infected treatment

TASKS TO BE DONE BY ART CENTER STAFF FOR HIV-TB CO-INFECTED TREATMENT UNDER THE 99DOTS TREATMENT PLAN USING FDC PILLS WRAPPED INSIDE 99DOTS BLISTER PACKS Sr. No. Task Description Details 1. EVALUATE HIV PATIENTS FOR TB SYMPTOMS Check for: Fever Cough Weight Loss Night Sweats 2. COLLECT SPUTUM Collect sputum even if any one of the four symptoms are seen in the patients 3. CBNAAT TEST Send the sputum sample to CBNAAT Lab for testing 4. DRUG PRESCRIPTION If the test result is positive and the patient is diagnosed for TB the doctor at ART centre prescribes appropriate FDC pills as per the weight band of the patient.

Sr. No. Task Description Details 5. REGISTER PATIENT ON 99DOTS WEBSITE The Data Manager at ART registers the new patient on the 99dots website. IMPORTANT: The Data Manager should select the correct district the patient belongs too. It is important because monitoring of the adherence will be done by RNTCP staff linked to that district or TU. Correct primary mobile number should be added without adding 0, 91, or +91. Use only 10 digits mobile number. There is a provision to add multiple phone numbers as secondary numbers. It is advisable that the Data Manager checks with the patient and accompanying relatives. These secondary numbers can also be used to give free call. The Data Manager should advise the patient to update the ART centre in case the mobile number changes in the future. 6. HANDING OVER THE MEDICINES The Pharmacist hands over the prescribed FDC blister pills for 28 days wrapped in the correct 99DOTS envelopes.

Sr. No. Task Description Details 7. COUNSELLING PATIENT ON USAGE OF 99DOTS FDC PILLS AND GIVING MISSED CALL The medical counsellor explains how 99dots FDC pills are to be consumed by the patient. IMPORTANT: The counsellor explains the importance of taking daily doses by following the arrows marked on the 99DOTS Envelop and also giving miss call to the toll free number provided. The counsellor should emphasise that the call is free of cost and can be made even if the patient does not have balance amount in the mobile. The counsellor should emphasise the importance of adherence and why it is important not to stop taking daily dose and to give the miss call. If the patient is accompanied by a relative or friend, the counsellor can counsel them too. 8. DAY ONE DOSE AT THE ART CENTER Once the patient in counselled on the usage of the pills, the counsellor/nurse should ensure that the day one dosage is taken at the ART centre followed by which the patient also gives a miss call to the revealed toll free number after dispensing the first day dose from the blister pack. The counsellor/nurse should advise the patient to repeat the procedure daily. If the patient is accompanied by friends or relatives they should also be shown the method. 9. MAINTAIN INVENTORY AND ENSURE THAT MEDICINES ARE AVAILABLE The Pharmacist should ensure that indent to get stock is sent to District TB office before the stock gets over.

TASKS TO BE DONE BY RNTCP CENTER STAFF FOR HIV-TB CO-INFECTED TREATMENT UNDER THE 99DOTS TREATMENT PLAN USING FDC PILLS WRAPPED INSIDE 99DOTS BLISTER PACKS Sr. No. Task Description Details 1. UPDATE STAFF DETAILS ON THE 99DOTS WEBSITE The DOTS Plus Supervisor (DPS) and other health staff designated by DTO can add multiple staff members to receive SMS whenever: A new patient is added in the district A patient fails to give miss call indicating that he/she is not adhering to the treatment plan So when a new patient is added in a particular district or TU, the corresponding staff (for example DPS, DTO, STS, TBHV, etc.) who is added to the 99DOTS under the district or TU receives an SMS. Similarly when the patient fails to adhere to the treatment an SMS is sent. 2. ASSIGN PATIENTS TO THE CORRECT TU UNDER THE DISTRICT The DPS, or any other staff designated by the DTO should ensure that all patients are assigned to the correct TU under the district in 99DOTS website. 3. MONITORING OF PATIENT ADHERENCE ON THE 99DOTS WEBSITE The DPS, or any other staff designated by DTO can login to the 99DOTS website and see the list of patients registered under his/her district or TU and can check if the patient is adhering to the treatment. This will help the staff to concentrate on high risk patients and follow up with only those patients. They do not have to spend time in following up with each individual patient’s. NOTE: The DOTS Plus Supervisor (DPS) or any other staff delegated by the District TB Officer (DTO) is accountable for all patients in his/her district. He/she can call patients directly after going through the dashboard and/or delegate this to the relevant field staff like STS, TBHVs, field workers, etc.

Sr. No. Task Description Details 4. FOLLOWUP WITH NON ADHERING PATIENTS UPON RECEIVING SMS ALERT If any patient does not call the toll free number after consuming pills in a day, the alert SMS is sent to the staff linked to the district or the TU of the patient. The staff (STS, TBHVs, and Field Staff) can immediately act upon the alert and make arrangements to either do a telephonic follow up or a home visit to the patient. 5. ADDING AND LINKING TREATEMMENT SUPPORTERS TO PATIENTS The DPS or any other health staff designated by DTO can also add and link relatives, community workers, or any other non-staff as treatment supporters at the district and TU level so that the non- adherence SMS can be sent to them. It is necessary to link these treatment supporters to individual patient. 6. MODIFY DETAILS BASED ON FOLLOWUP – PATIENT DETAILS, MEDICAL DETAILS, ADDING NOTES AND TAGS, MARKING MANUAL DOSES ADHERENCE, ALTERING ATTENTION REQUIRED, TRANSFERRING PATIENTS BETWEEN DISTRICTS, CLOSING CASES Based on the interaction and follow up with the patients the DPS or any other health staff designated by DTO staff can update details regarding patient, medication, add notes or tags, alter attention required, update manual doses in case there were issues with mobile connectivity, closing case after completion of treatment, reopening cases, transferring patients between districts etc. 7. DOWNLOADING RNTCP TREATMENT CARDS AND REPORTS Using the 99DOTS website DPS, DTO, or any other staff designated by DTO can download RNTCP Treatment cards for patients and also download various reports for analysis.

99DOTS Training Video http://bit.ly/99DOTS-ENGLISH http://bit.ly/99DOTS-HINDI