1. Strengthening specimen referral and transport networks in resource-limited settings: a Nigerian pilot to improve diagnosis The 46 th UNION world conference on Lung health Cape Town, South Africa 2 nd – 6 th December 2015 S. Useni, S. Massaut, M. Gidado, J. Onazi, S. Gande, P. Nwadike, S. Kik

2. TB Situation – Nigeria (2015 Global TB Report) Population: 177,000,000 DOTS centers: 5,398 AFB microscopy centers: 1,515 Culture DST laboratories: 6 GeneXpert laboratories: 96 Incidence Rate: 322/100,000 Total notified cases 2014 all forms: 91,354 CNR all forms for TB 2014 (per 100,000): 15.4% HIV prevalence : 3.4 % TB/HIV co-infection: 19% (16,066 cases) ART centers : 491 (85% TB/HIV co-located) MDR among new TB cases: 2.9% MDR among previously treated TB cases: 14%

3. Why this pilot? Practical model to demonstrate feasibility of using Xpert MTB/RIF to ↑ TB diagnosis within routine HIV care setting Increase number of PLHIV tested for TB with Xpert & put on treatment Strengthen accessibility & quality of Xpert testing Inform policy & public health practices

4. The Pilot Model TB/HIV Services Intensified Case Finding Increase TB mindedness Strengthen R&R and Supervision Increase Access to Diagnostic Services Simplify care and treatment

5. Pilot timeline Nov-Dec 2013 Site Assessments Jan-Mar 2014 Model Design Apr-May Training and Preparation April/May-Dec Implementation Jan-May complete data collection and analysis

6. Geographical HIV prevalence by state National HIV prevalence – 3.4% National TB/HIV co-infection - 19% (16,066 cases) Nasarawa state Population 2,202,906 HIV Prevalence: 7.5% TB CNR: 128.2/100,000 Pilot Sites: Niger state Population 4,670,286 HIV Prevalence: 4.0% TB CNR: 35.9/100,000

7. Hub & Spoke Implementation XPERT Pilot Site 12 34 56 7 89 10 Nasarawa State Lafia (Dalhatu Araf Specialist Hospital) Niger State Minna General Hospital Existing XpertNew Xpert Referral SiteKm 1PHC New Market5 2GH Obi26 3PHC Doma Road, Lafia10 4PHC Kwandere (DOTS)12 5Family Health Clinic (FAHCI)5 6MCH Care Centre, Shabu11 7GH, Akwanga30 8GH Nassarawa Eggon22 9Ola Hospital, Akwanga32 10ERCC Alushi34 Referral SiteKm 1General Hospital Kuta80 2Rural Hospital Sarkin Pawa84 3MMM Fuka60 4Devine Mercy Hospital25 5Sabon Titi PHC Tunga Minna25 6Town Clinic Bosso25 7General Hospital Kagara120 8General Hospital Wushishi128 9IBB Hospital15 10FMC Gawu130

8. Specimen Transportation: Set-up Nonexistent at the start of operations Required implementation Reinforced proper specimen collection procedures Trained on triple packaging (cold box) Transportation (dispatch) Registry Sputa only with Lab request forms Variable means of transit (fuel provided) Transportation twice per week from 10 peripheral sites Included RETURN of test results (TAT= 3-5 days)

9. Number of samples received from peripheral sites - based on presumptive TB register - 60% 41% 82% 40% 59%18%

10. Increase in PLHIVs tested for TB (Baseline vs Pilot) BaselinePilot Baseline: 15% of pres. TB cases were known PLHIV 418 PLHIV tested Pilot: 42% of pres. TB cases were known PLHIV 1534 PLHIV tested

11. Number of PLHIV tested remarkably increased 3-fold increase in HIV positives tested for TB 1,534 HIV positives tested in pilot period (84% of those registered) 418 HIV positives tested in baseline period (78% or those registered)

13. Successful Interventions Strengthened sputum transportation/referrals by reducing physical movement of clients. 60% (1,066 out of 2,665) of all sputum specimens that were tested with Xpert were from referral sites through hub and spoke model Improved access to diagnosis by geographic coverage for TB screening among PLHIV due to implementation of effective specimen referral system (at baseline, only 9 PLHIVs were tested with Xpert and in pilot period 782) Intensified case finding among PLHIV of 1.9 fold increase for notified bacteriological confirmed TB cases (at baseline 180 cases compared to pilot of 347 cases)

14. Overall Challenges Changing current testing paradigm (ALL asymptomatic new PLHIV) Maintaining overall understanding and motivation Coordination/communication - onsite/remotely - staff of separate programs and different interests Unpredictable interruptions - Industrial strike action by HCW from Jun. – Aug. 2014 and Nov. – Dec. 2014 (end pilot activities) - Political/civil unrest in Nasarawa state - Fire at Laboratory building in Niger state Insufficient tools and commodities - - No approval by NTP to print revised National tools - - Improvised existing tools to capture indicators - - Periodic stock out of cups, R&R tools, and cartridges

15. Future impact Lessons learned for scale up… raising awareness on GeneXpert among clinicians in relation to TB/HIV case management increasing access to GeneXpert testing through a well- functioning sputum sample transportation system strengthening supportive supervision While the model was successful according to the results, there is need to focus on: basic elements of TB/HIV case management data recording at the facility level

16. A well-coordinated sputum transportation system to Xpert testing sites minimizes the movement of patients and increases access to diagnostic and care services; not only for TB but also HIV. Conclusion

17. Acknowledgments KNCV TB Foundation FMoH – NTBLCP & NASCP MoH Niger state - TBCLP & SASCP MoH Nasarawa state - TBCLP & SASCP