TUBERCULOSIS CONTROL Experience of Guyana Dr Jeetendra Mohanlall

The National Tuberculosis Programme Mission Statement To reduce the incidence and prevalence of tuberculosis and to mitigate its impact through a multisectoral response that provides high quality and equitable prevention, treatment and support services.

TB Clinics in Guyana One central site in 2000 to Progress from 1 central TB clinic in 2000 to 18 decentralized clinics in 2013

Laboratory Network NPHR Lab Bartica Mahdia Kato Lethem Annai Aishalton EX-QC NPHR Lab Quality Control Bartica Mahdia Kato Lethem Annai Aishalton Karasabai Sand Creek Mabaruma Port Kaituma, Moruca Matthew’s Ridge Fort Wellington WDRH Linden NA Skeldon Suddie Charity

1 2 3 4 7 5 6 10 8 9 Essequibo Islands West Demerara Mahaica Berbice East Berbice Corentyne Upper Demerara-Berbice Barima-Waini Cuyuni Mazaruni Potaro-Siparuni Areas DOTS being expanded Areas DOTS Operational Areas to be further integrated into the PHS Pomeroon Supenaam 2 3 4 Demerara-mahaica 7 5 6 10 8 9 Upper Takatu/ Upper Essequibo

TB/ HIV TRENDS 2005 -2012

Strengths of the NTP Strong political commitment Strong support from Technical Partners and funding agencies (GF, CDC, PAHO etc.) Phase 2 of GF grant in the process of being implemented. Implementation of the 5 components of DOTS Implementation of all 12 WHO recommended TB/HIV Collaborative Activities - PPM, TB/HIV inclusion in HIV Vision 2013-2020 and HIV GF phase 2 proposal National TB Guidelines, Strategic plan 2013-2020 and training tools developed National TB M& E plan developed (2013-2015)and compendium of indicators

The Integration of TB services Coordination by a central management unit -forecasting and budgeting for TB medication, development of guidelines and policies for TB control and supervision of TB services provided by TB clinics Human Resource Capacity: Main Coordinators and most of the support staff employed in programme. Dedicated staff at Clinics in the regions. Strong M&E function for informed decision making at the NTP. Mobile teams – supporting DOTS programme daily in the high burden region and also involved in default tracking. Laboratory Services: Robust network of 20 sputum microscopy sites around the country and the NPHRL has developed the capacity for TB cultures and DST.

DOTS supervisor for prisons hired. TB CONTROL IN PRISONS Interventions- DOTS supervisor for prisons hired. Case detection - Respiratory Symptomatic register at all Facilities DOTS (all facilities) Isolation Area (5 facilities) Enabler’s programme for inmates diagnosed with TB.(milk supplement) Mass screening done periodically. Proposed procurement of mobile unit. Hiring of key staff by prison’s authority.

Challenges The need for further decentralization of TB services into the PHC system. Cure rate still at a level below the recommended WHO target (over 85%) Default rates – especially among mobile population, substance abusers, homeless Lack of a proper in patient facility for difficult TB patients (e.g. homeless MDR TB patient). TB step-down care facility on stream to be completed by end of 2013.

Opportunities Potential linkages with countries with successes in TB management- Technical Co-operation (Suriname, French Guyana), Histoplasmosis study supported by CDC. PPM – Davis and St. Joseph Mercy Hospital Phase 2 ,Round 8th Global Fund TB project approval. Technical collaboration from PAHO and technical assistance from CDC. Operational Research. Increased focus on TB/HIV in HIV GF proposal IMAI expansion for increased integration in PHC services

RISKS Migration of Skilled Health Workers/ high staff turn over Potential reduction in available external funding Patients continue to default on TB treatment. Co-morbid Conditions including diabetes, HIV and TB The emergence of MDR TB .

National Tuberculosis Strategic Plan 2013-2020 Projections Toward Universal Coverage The overarching goal of the National Strategic Plan for Tuberculosis (NSPTB) is to reduce the incidence and prevalence of tuberculosis all across Guyana. This goal takes cognizance of the targets set by international conventions including the Millennium Development Goals (MDG’s) and the Stop TB Partnerships.

Pursue high-quality DOTS expansion and enhancement Goals and Objectives Pursue high-quality DOTS expansion and enhancement 1. Increase TB case detection rate of all forms of TB from 82% in 2012 to 90% by 2015. 2. Increase treatment success from 71% in 2010 to 85% by 2015 3. Decrease defaulters’ rate from 18% in 2010 to 7% in 2015 and to less than 5% in 2020.

Goals and Objectives Cont’d 4. Strengthen the Supervision, M&E system at all levels to ensure that at least 95% of all planned activities are implemented effectively and efficiently. TB/HIV collaborative activities 5. Increase and sustain the proportion of TB patients tested for HIV from 96% in 2012 to 100% by end of 2015 6. Ensure that 100% of TB/HIV co-infected patients receive Co-trimoxazole prophylaxis. 7. Ensure that 100% of HIV patients receive INH preventive therapy (IPT) at their HIV Care & Treatment Sites.

Goals and Objectives Cont’d 8. Increase the proportion of TB/HIV co-infected patients who are receiving antiretroviral therapy (ART) from 92% in 2011 to 99% in 2020. 9. Establish infection control in all health care facilities (100%) providing both DOTS and ART services by 2020. Establish MDR-TB services 10.Establish a routine drug resistance surveillance system by the end of 2013.

Goals and Objectives Cont’d 11.Ensure that all High Risk Groups including Category 2 failures have access to lab diagnosis services for MDR by the end of 2013 and all Category 1 failures by the end of 2013. 12.Provide second-line anti-TB drugs to 100% of diagnosed MDR cases annually and by the end of 2020.

Goals and Objectives Cont’d Engaging all care providers (PPM): Strategic alliances with academic, private and other members of civil society. 13.Scale up PPM services within the private institutions, military, police, prisons, and chronic disease clinics such that it contributes to at least 20% of total TB cases detected by the end of 2020

Goals and Objectives Cont’d Research 15.Develop and strengthen capacity for research on TB, TB/HIV, and MDR-TB at all levels. -Nation wide KAPB study (knowledge ,Attitude, Practice and Belief) -MDR study

Key Strategies STRATEGY 1: Pursue high-quality DOTS expansion and enhancement STRATEGY 2: Address TB/HIV, MDR-TB and the needs of poor and vulnerable populations STRATEGY 3: Engaging all care providers (PPM): Strategic alliances with academic, private and other members of civil society. STRATEGY 4: Advocacy, Communication and Social Mobilization (ACSM)

Thank you Questions?