Step forward to Health System Strengthening: the impact of scaling up of ART services on TB services in rural settings, Zambia

Christopher Dube, Nangana Kayama, Shinsuke Miyano, Naoko Ishikawa,

Ikuma Nozaki, Gardner Syakantu

Background• Zambia has the 7th highest HIV

prevalence (14.3% 1) and the 9th highest TB incidence rate (506 per 100,000 population2) in the world .

• Seventy percent of incident TB cases have HIV co-infection.2

• The DOTS strategy has been implemented nationwide in Zambia and achieved 100% DOTS coverage since 2003. 1. ZDHS, 2007 2.WHO, 2009

Background• Antiretroviral therapy (ART) services in Zambia - 2005~ Free of charge at hospital levels - 2007~ Expanded to some rural health centres(RHCs) as “Mobile ART services”

RHC

Volunteers

Clients

Hospital

Health staff(MD, Ns)

Health staff(CO,Ns)

Volunteers

Clients

- ART, Adherence- Laboratory exam- Capacitate RHC

staff

Mobile Team

Long distance

Background• Mobile ART services in Mumbwa district has been

supported by Japanese International Cooperation Agency (JICA) in collaboration with the Ministry of Health, Zambia.

   

Kabwe Urban

Lufwanyama

Kaputa

KawambwaMporokoso

ChinsaliMwense Luwingu

ChamaChilubi

Samfya

MwinilungaMpika

Solwezi Lundazi

Serenje

ChililabombweChingola Mufulira

Kabompo

KitweLuanshya

LukuluKatete Chadiza

KaomaKalabo

Mumbwa District

MonguLuangwa

Mazabuka

Sesheke

Choma

Sinazongwe

Shangombo

Senanga

ZambeziChavuma

KazungulaKalomo

Kafue

Chongwe

Lusaka (capital)

Chibombo

MkushiKapiri Mposhi

Mpongwe

Nyimba

Petauke

MambweChipata

Isoka

Nakonde

KasamaMungwi

MbalaMpulunguNchelenge

Mansa

Milenge

GwembeSiavonga

NamwalaItezi-Tezhi

Monze

KasempaMufumbwe

Kalulushi

Chiengi

Kabwe

NdolaMasaiti

Objectives• To analyze the impact of the scaling up process of

ART services to rural settings on TB services in Mumbwa district, Zambia

• To explore the challenges to improve the integration of TB and HIV services in rural settings as a step forward to health system strengthening

Methods

• The data of TB clients from July 2006 to September 2009 were obtained through “National TB Treatment Registers” and reviewed retrospectively.

• TB clients enrolled to anti-TB treatment in all RHCs in Mumbwa district (8 RHCs with ART services, 15 RHCs without ART services) were included.

• The clients categorized as “transfer out” or “unknown” for treatment outcome were excluded.

Results

Comparison of All TB clients at each health facility in Mumbwa district (n=681)

RHCs with ART services(n=257)

RHCs without ART services

(n=429)P value

Gender (%)Female

Male101(39.3)156(60.7)

203(47.3)226(52.7)

0.041

Age group (%)0-14

15-3435-

24(9.3)100(38.9)133(51.8)

39(9.1)180(42.0)210(49.0)

0.730

Site of diseases(%)Pulmonary

Extra-pulmonary 182(71.7)72(28.3)

321(77.2)95(22.8)

0.078

Comparison of All TB clients at each health facility in Mumbwa district (n=681)

RHCs with ART services(n=257)

RHCs without ART services

(n=429)P value

HIV tested (%)Tested 222(86.4) 276(64.3) <0.001

HIV tested_Gender (%)FemaleMale

90(40.5)132(59.5)

138(50.0)138(50.0)

0.035

HIV positive (%) 134(52.1) 197(45.9) 0.115

Refer to PreART/ART services (%)

74(55.2) 118(59.9) 0.307

Comparison of All TB clients at each health facility in Mumbwa district (n=681)

RHCs with ART services

(n=257)

RHCs without ART services

(n=429)P value

Treatment Success Rate

89.9 77.4 <0.001

Treatment Outcome (%)Cured

CompletedDied/Failed

Defaulted

56(21.8)175(68.1)

19(7.4)7(2.7)

94(21.9)238(55.5)74(17.2)23(5.4)

<0.001

Comparison of TB/HIV clients on ART at 8 RHCs Before and After ART services started

Before (n=37) After (n=61) P valueGender (%)

FemaleMale

22(59.5)15(40.5)

22(36.1)39(63.9)

0.024

Sputum smear examined (%) 19(70.4) 33(75.0) 0.669Sputum smear positive (%) 5(26.3) 21(63.6) 0.010Treatment Success Rate 73.0 88.5 0.049Treatment Outcome (%)

CuredCompleted

Failed/DiedDefaulted

4(10.8)23(62.2)8(21.6)2(5.4)

17(27.9)37(60.6)

5(8.2)2(3.3)

0.089

Comparison of TB/HIV clients on ART at 8 RHCs Before and After ART services started

Before (n=37) After (n=61) P valueAge group (%)

0-1415-34

35-

3(8.1)13(35.1)21(56.8)

1(1.6)19(31.1)41(67.2)

0.238

Site of disease (%) Pulmonary

Extra-pulmonary27(75.0)9(25.0)

44(73.3)16(26.8)

0.857

DiscussionScaling up of ART services to RHCs has resulted in:• Improved DCT for TB patients at RHCs• Improved access to TB/HIV services for male clients• Strengthened clients follow-up system• Improved treatment outcome• Enhanced quality of sputum smear examination for

TB/HIV clients

DiscussionChallenges remain at:• Linkages between TB and HIV services - weak referral of HIV positive TB clients to preART/ART services• Data management – incomplete recording of TB register

Conclusion• Positive impact of the scaling up of ART services on

TB services at RHCs were identified.• Improvement of access to services, case

management and laboratory services may well contribute to the overall health system strengthening at/from RHCs level.

• Further improvement is needed for integration of TB and HIV services.

Thank you !!