USAID TB CARE II Project

Quarterly Narrative Report October - December 2013

Funded by United States Agency for International Development, Malawi

University Research Co., LLC Bethesda, Maryland

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TABLE OF CONTENTS

1 EXECUTIVE SUMMARY ...... 5

2 INTRODUCTION ...... 6

3 MAJOR ACCOMPLISHMENTS ...... 6

4 ACCOMPLISHMENTS BY RESULTS ...... 8 4.1 Result Area 1: DOTS Expansion and Enhancement ...... 8 4.2 Result Area 2: Strengthening the Laboratory Network for TB ...... 10 4.3 Result Area 3: TB/HIV ...... 11 4.4 Result Area 4: MDR-TB Management ...... 12 4.5 Result Area 5: Health System Strengthening ...... 13

5 CONCLUSION ...... 13

6 ACTIVITIES FOR NEXT QUARTER ...... 13

October- December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 2

LIST OF ACRONYMS

AAFB Acid alcohol Fast Bacilli ART Anti-Retroviral Therapy CHAM Christian Health Association of Malawi COP Chief of Party CPT Co-trimoxazole Prophylaxis Therapy CRL Central Reference Laboratory CSCP Community Sputum Collection Point DHMT District Health Management Team DHO District Health Officer DIP District Implementation Plan DOTS Direct Observation Treatment Strategy DQA Data Quality Assurance EQA External Quality Assurance EPTB Extra- pulmonary Tuberculosis HCW Health Care Workers HIV Human Immuno Deficiency Virus HRH Human Resource for Health H.SA Health Surveillance Assistants HTC HIV Testing and Counseling MDR-TB Multi-Drug Resistant Tuberculosis M&E Monitoring and Evaluation MOH Ministry of Health MTB Mycobacterium Tuberculosis NAPHAM National Association of People Living with HIV and AIDS in Malawi NTP National Tuberculosis Control Program NLSP National Laboratory Strategic Plan PLHIV People Living with HIV/AIDS PMDT Programmatic Management of Drug resistant Tuberculosis PMT Program Management Team PTB Pulmonary Tuberculosis PY Project Year

October- December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 3 RH Rifinah (Rifampicin &Isoniazid) Rif Rifampicin SLD Second Line Drug SOP Standard Operating Procedures SSDI Support for Service Delivery Integrated TAT Turn Around Time TB/HIV Tuberculosis/Human immunodeficiency virus TB IC Tuberculosis Infection Control Tx Treatment USAID United States Agency for International Developments ZN Zeihl Neelson

October- December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 4

1 EXECUTIVE SUMMARY

This report covers activities completed during TB CARE II’s PY4 Quarter 1 (October - December 2013). A particular focus for this quarter was: decentralization of TB services; TB screening in pre-ART, ART, PMTCT and ANC settings; and strengthening of TB/HIV collaboration and services.

TB CARE II continues to support the decentralization policy to improve access to TB diagnosis and treatment. In this quarter, 11 new TB initiation and registration sites were opened as follows: two each in Ntcheu, Nsanje, Zomba and Nkhotakota districts and three sites in Balaka. Each center established was linked to at least two Community Sputum Collection Points (CSCPs) managed by volunteers from Community-Based Organizations (CBOs) in the areas.

TB CARE II intensified collaboration with CBOs already involved in TB/HIV work. During the quarter, 12 new CBOs were added and 55 (24M &31F) CBO volunteers in Phalombe, Zomba and Neno districts were orientated. They came from the following CBOs: Chikapa, Msamba in (Thondwe, Zomba); Chigwirizano in Matawale - Zomba; and Chiyanjano, Liwoni, Magareta and Ligowe Health Centres in Neno and Phalombe. As a result of these collaborative efforts the project is now working with a total of 31 CBOs (Nsanje (4), Mulanje (3), Mzimba (1) Neno (10), Phalombe (4) and Zomba (9)) to promote TB screening among people living with HIV and AIDS (PLHIV).

The community-based TB service delivery systems also continued to be strengthened with the support provided to CSCPs. During this quarter, CSP volunteers conducted community awareness meetings and data verification in their respective catchment areas. Challenges with time of recording, sample transportation and turn-around time were identified and sorted-out at Kambale CSCP in Neno district. TB CARE II also supported community programs in Neno with enablers (Gum-boots, T-shirts, and cups) at Chawe, Kambale and Nsambe.

The laboratory diagnostic network in target districts continued to be strengthened. In Zomba, ten microscopists were provided refresher training from four microscopy sites namely Matawale, St. Luke's, Cobe Barracks and Zomba Central Hospital. In Nsanje ten (7M & 3F) microscopists had refresher training at Hospital, Tengani, Sorgini, and Kalemba health centres. The project has been instrumental in supporting the rollout of GeneXpert technology for TB diagnosis especially among PLHIV and smear negative patients. In this quarter, TB CARE 11 conducted laboratory assessment at Nkhata Bay, Kasungu, Mchinji, Kamuzu Central Hospital, Kawale Health Centre, St. Gabriel and Limbe sites in collaboration with NTP in preparation for the installation of the seven Xpert® machines to be procured through PEPFAR funding. In addition, a GeneXpert refresher training was organized and supported by TB CARE II for 10 technicians (5 males each) from Ntcheu and Neno districts.

The project further strengthened the access to diagnosis of MDR-TB by procuring 100 cooler boxes for sputum specimen transportation from the peripheral health facilities to the National TB

October- December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 5 Reference Lab in Lilongwe and district hospital laboratories with Xpert platforms. In addition, TB CARE II distributed 5,000 N95 masks to all 28 districts in the country while taking the lead in initiating an electronic MDR-TB recording and reporting system and the setting up of a steering committee that will start operating in Q2. In addition, TB CARE II also supported NTP in distributing 20 biosafety cabinets (BSC) to district hospitals selected by NTP that are awaiting installation.

The project also played a key role in supporting NTP in meeting conditions to facilitate the release of Global Fund monies for Round 7 phase 2 TB grant, including collaborating with the NTP and Global Fund technical officers in the development of procurement and M&E plans for the revised implementation plan of the current grant. TB CARE II also provided technical support to the NTP M&E team during the revision of the recording and reporting tools some of which have been finalized, printed and distributed nation-wide through financial support from TB CARE II. Finally, TB CARE II supported NTP, both financially and technical, in developing the GeneXpert implementation plan for Malawi.

2 INTRODUCTION

In FY14 Q1, TB CARE II intensified technical support to the National Tuberculosis program to improve TB and TB/HIV services in its 12 impact districts (Balaka, Chikwawa Machinga, Mangochi, Mulanje, Mzimba, Neno, Nkhotakota, Nsanje, Ntcheu, Phalombe and Zomba) through implementation of strategic activities. In this quarter, particular focus was put on improved TB case finding, early initiation of treatment, care & support. The project provided support to improve partner’s collaboration, cooperation and coordination by DHMTs, roll out of new diagnostics as part of continuing efforts to improve universal access to TB diagnosis and treatment, TB/HIV integration and health system strengthening. The main objectives of the project are: (1) DOTs expansion and strengthening; (2) Programmatic management of drug resistant TB (PMDT); (3) integrated TB/HIV care and treatment; and (4) Health systems strengthening.

3 MAJOR ACCOMPLISHMENTS

The key achievements and challenges for the reporting period of October 1, 2013 – Dec 31, 2013 are summarized below:

3.1 Achievements

• TB CARE II launched the Year 4 TB and TB/HIV implementation work plan that was developed jointly by the NTP, TB CARE II and district stakeholders. The work plan was developed at a joint meeting among the NTP, Zonal NTP, TB CARE II and 12 district TB officials. District specific implementation PY4 work-plans were also developed.

• TB CARE II submitted the jointly revised annual work plan to USAID. The revised work- plan prioritizes improvements in TB/HIV implementation.

October- December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 6 • TB CARE II supported the participation of two NTP officers and one TB CARE II staff at the 2013 World Lung conference on TB organized by the International Union Against TB and Lung Diseases in France during the quarter. TB CARE II chaired one of the sessions at the conference in addition to a poster presentation.

• TB CARE II supported the NTP in distributing 20 Bio Safety Cabinets to selected hospitals in all five Health Zones in Malawi.

• TB CARE II supported the NTP to hold a workshop where a draft Xpert/MTB Implementation Plan was developed including a section on recording, reporting and documentation.

• TB CARE II provided technical and financial support to improve decentralization of TB registration and initiation in Malawi. Eleven new TB initiation and registration sites were opened: two sites each in Neno, Nsanje, Zomba and and three sites in Balaka.

• TB CARE II provided technical support to NTP on Global Fund Round 7 phase II implementation. During the quarter the senior TB Advisor worked closely with NTP and other stakeholders on requests for disbursement of funds, quarterly reports and supported effective implementation of planned activities.

• TB CARE II rolled out renovation projects in selected facilities. Kasinje Health Centre's renovation improved implementation of integrated TB/HIV services. There are five more sites that will be renovated during the PY 4 to improve laboratory services as well as TB/HIV integrated services.

• District TB review meetings were conducted in all 12 districts to assess progress made on TB control and address emerging challenges. The findings were discussed and recommendation included in the Q2 work plan that focuses on TB/HIV integration.

3.2 Challenges:

• Slow process in utilization of the disbursed funds from Global Fund resources for NTP programmatic activities.

• Slow decentralization of TB/HIV initiation services at the national level affecting the quality of integrated TB/HIV services.

• Limited, or in some cases, no funding for TB control activities at the district level.

• Inadequate human resources for TB delivery services due to attrition and redeployments of staff at district and health centre levels.

• Inadequate collaboration between TB and HIV stakeholders at national and district levels.

October- December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 7 • Key programmatic issues:

– Low TB diagnosis in HIV care settings and among children

– High mortality among TB patients in some districts

• Staff changes: during this quarter, TB CARE II experienced several personnel changes, including a change in the Country Director. With support from the project's overall management team and USAID, the transition was handled smoothly and Dr. Limbikani Kanyenda took over as Country Team Leader.

4 ACCOMPLISHMENTS BY RESULTS 4.1 Result Area 1: DOTS Expansion and Enhancement

Quality and Performance Review Meetings & Distribution of Enablers to Community Sputum Collection Points and Their Volunteers

The project continued to strengthen community-based TB service delivery systems. The number of presumptive TB identified through CSCPs in PY4 Q1 is 1286, out of which 73 tested smear positive and were started on TB treatment. During the quarter, 12 new CBOs were linked to NTP control activities bringing the total to 31 CBOs, Nsanje (4), Mulanje (3), Mzimba (1) Neno (10), Phalombe (4) and Zomba (9) to promote TB screening among people living with HIV and AIDS. This is a reflection of the growing access to TB diagnosis and treatment support made possible by TB CARE II presence and support in the communities.

A total of 55 (24 male and 31 female) CBO volunteers in Phalombe, Zomba and Neno districts were orientated. The volunteers were drawn from the following CBOs:

District Health facility CBOs Zomba Thondwe Chikapa and Msamba Matawale Chigwirizano Neno Magareta Chiyanjano Ligowe Liwoni Phalombe Phalombe health centre Phalombe

Community Sensitization and Mobilization

Volunteers conducted community awareness meetings in their respective catchment areas as part of routine activities. Over 3,000 community members, 74% women, were reached. During these meetings data verification was also done. Challenges with time of recording, sample transportation and turn-around time were identified and sorted at Kambale CSCP in Neno district. TB CARE II supported community programmes in Neno with enablers (Gum-boots, T-shirts, and cups) at Chawe, Kambale and Nsambe.

October- December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 8 Improve Facility-Based TB Case Finding and Management

The project continued to support the NTP decentralization policy to improve access to TB diagnosis and treatment. In PY4 Q1, the number of TB cases (all forms) notified was 1,773, up by 64% from Q2 PY3. Of the total cases, 752(42%) were bacteriologically positive, 590(33%) were bacteriologically negative, 387(22%) were extra-pulmonary and 17(1%) were relapse cases.

Trend TB Cases Notified All forms 2000 1800 1600 1400 1200 1000 TB Cases Notified All 800 forms 600 400 200 0 Q2 PY3 Q3 PY3 Q4 PY3 Q1 PY4

Eleven new TB initiation and registration sites were established in the quarter as follows: two each in Neno, Nsanje, Nkhotakota and Zomba districts and 3 sites in Balaka. A total of 55 (24M & 31F) health care workers (clinicians, nurses, head of heath centres) were trained on TB and TB/HIV integrated case finding and management. TB screening was encouraged in all HIV pre- ART & ART clinics, PMTCT & ANC clinics.

Cough corners represent one facet of TB CARE II Malawi’s approach to strengthening district- wide implementation of comprehensive TB/HIV integration. In Q1, five cough corners were established at Dzunje, Nsipe, Champiti, Ntonda and Kapeni (in ) where 28 HCWs (20M & 8F) were oriented on how to man the cough corners. In addition, five cough officers, one per site, were appointed. Other activities and strategies include the establishment of “one-stop- shop” centers for TB/HIV services; orientation of HIV service providers on TB, and TB service providers on HIV; integrating systems for intensive TB case finding in HIV service settings (HTC, ART, PMTCT and ANC clinics) as well as in OPD and diabetic clinics in impact districts.

District TB review meetings were conducted in all twelve impact districts. The review meetings provided forums for the districts to review progress made on TB and TB/HIV control and address emerging challenges such as shortage of reagents, registers, or staff attrition.

Supportive supervision was conducted to support HCWs across the 12 districts. Staff members were trained in paediatric TB, TB classification, categories, treatment regimens, presumptive TB identification, contact tracing and IPT in children and adults.

October – December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 2

4.2 Result Area 2: Strengthening the Laboratory Network for TB

National TB Reference Laboratory (NTRL) and Peripheral Laboratories

The project continues to provide support to the National TB Reference Laboratory (NTRL). In Q1 FY14, financial support has been provided to the NTRL to manage the cold storage for huge amount of samples processed from the TB prevalence survey that is currently underway. In addition to the technical support provided by TB CARE II laboratory officers, the project has purchased additional eggs for LJ culture media preparation.

Orientation on the use of GeneXpert testing was conducted for 11 HCWs (8m, 7F) at Nsanje District Hospital, Tengani, Sorgini, Phokera and Kalemba health facilities in Nsanje district. Following the orientation, TB CARE II collaborated with Riders for Health for the transportation of sputum samples from the health centers for GeneXpert testing at the district laboratory in Machinga.

TB CARE II supported the participation of Mangochi, Machinga and Neno districts Xpert platforms in round 2 of the CDC-Atlanta Xpert EQA panel testing program being implemented by the National TB Reference Laboratory. Proficiency samples were examined and results sent back to the NTRL.

In Zomba, 10 Microscopists underwent refresher training on ZN microscopy from 4 Microscopy sites namely Matawale, St. Luke's, Cobe Barracks and Zomba Central Hospital; and 22 microscopists, ten (7M & 3F) in Nsanje at Nsanje District Hospital, Tengani, Sorgini, and Kalemba health centres and 12 (10M, 2F) from Balaka districts. In addition, ten other male laboratory technicians from had refresher training on iLED microscopy. In all TB CARE II supported districts, reagents are being distributed to peripheral microscopy sites. Where Riders for Health are operational, TB CARE II coordinates to have these reagents distributed through this service with Machinga as a good example. TB CARE II also supported NTP in the distribution of 20 new biosafety cabinets (BSC) to district hospitals throughout the country.

TB CARE II conducted EQA activities at seven microscopy sites in Zomba and provided on-the- job training in QA in Nsanje.

Laboratory joint supportive supervision and monitoring visits were conducted at 41 laboratory sites (eight sites each in Nsanje, Phalombe, Ntcheu, and Zomba; five sites in Mulanje; and four sites in Chikhwawa). During the supervision in Nsanje, TB CARE II facilitated the identification and allocation of a room for smear preparation at Lulwe Health Centre. This room, with minor renovation can be used as the laboratory for Lulwe. Chikweo microscopy site was reopened after two months of no operation, and two microscopy centers (Mayaka and Makwapala) in Zomba district were also revived.

GeneXpert Roll out and Examinations for TB Suspects

October – December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 10 The project has been instrumental in supporting the rollout of GeneXpert machines. In this quarter, TB CARE II conducted laboratory assessments at Nkhata Bay, Kasungu, Mchinji, Kamuzu Central Hospital, Kawale, St. Gabriel and Limbe sites in collaboration with NTP in preparation for the installation of the seven Xpert machines to be procured through PEPFAR funding. In addition, five technicians, all males from Ntcheu and Neno districts were provided refresher training. TB CARE II also supported the Xpert implementation planning meeting organized by NTP in Mangochi. A total of 2,172 people with presumptive TB were tested with Xpert MTB/RIF in nine districts (Machinga, Neno, Mulanje, Phalombe, Mangochi, Chikhwawa, Nsanje, Zomba, and Balaka). Of this, 450 were MTB positive and five Rif resistant. The Xpert platform in Ntcheu was out of service due to the breakdown of the machine. TB CARE II had negotiated a replacement and the new machine arrived in the country in December 2013 and it is being cleared through customs. All the patients identified with Rifampicin resistance are currently on standard MDR-TB regimen pending culture and drug sensitivity testing (DST) results.

Representatives from various implementing partners working on the Malawi Gene Xpert implementation guide-line in Mangochi

4.3 Result Area 3: TB/HIV

TB CARE II conducted a joint TB/HIV implementation review of activities in six facilities, two each in Machinga, Neno and Ntcheu where critical gaps requiring attention in the control of TB and HIV in Malawi were identified and have been included in a three-month TB/HIV accelerated implementation plan that will run from January to March 2014.

In order to enhance TB/HIV collaboration and integration, TB CARE II supported the establishment of TB/HIV Coordinating Committees (THCC) in Neno, Mzimba, Zomba, Mangochi, Phalombe, Nsanje, Machinga and Balaka (eight districts). Each THCC is expected to conduct joint TB/HIV planning, implementation, monitoring and evaluation. The THCC is also expected to prepare health facilities in each district for integrated TB/HIV control activities and advocate for adequate funding of TB/HIV services.

October – December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 11 In addition, TB CARE II supported the commencement of intensified TB case finding among PLHIV through screening at all HIV service units in all target district high volume health facilities and TB registration sites. TB CARE II supported the training of 62 (41 M & 21 F) HCWs of different cadres working in HIV service settings on intensive TB case finding among PLHIV attending HTC, ART, PMTCT and ANC clinics in all target districts.

In PY4 Q1, among 32,179 PLHIV attending HIV services, 30,287 (94%) were screened for TB down from 99% in Q2 due to some staff problems in Chikwawa and Nsanje districts. The CPT uptake at TB CARE II impact health facilities increased from 90% in Q2 PY3 to 99% in PY4 Q1, while ART uptake among HIV positive TB patients also remained unchanged at 89% in the same period. The proportion of health facilities implementing the TB infection control plan by instituting administrative, environmental and personal controls) increased from 57% in Q2 PY3 to 92% in Q1 PY4.

Trend TB/HIV key indicators

89% 94% 84% 89% 90% 96% 96% 99% 86% 92% 92% 88%

99% 99% 100% 94% Q2 PY3 Q3 PY3 Q4 PY3 Q1 PY4

Intensified TB screening PLHIV Known HIV Status Reg TB cases CPT uptake ART Uptake

4.4 Result Area 4: MDR-TB Management

TB CARE II distributed 5,000 N95 masks to all 28 districts in the country. In addition, TB CARE II has also taken the lead in initiating an electronic MDR-TB recording and reporting system and the setting up of a steering committee that will start operating in Q2.

Only two new MDR-TB patients were enrolled in Q1 FY14. Of the 14 patients whose 6th month cultures were examined during the quarter, 12 (86%) converted. Among the 30 patients registered 24 months earlier, 25 (83.3%) completed treatment, 4 (13.3%) died and 1 (3.3%) was lost to follow-up.The 6-month culture conversion increased from 12% in 2011 to 86% in Q1, 2014.

October – December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 12 4.5 Result Area 5: Health System Strengthening

TB CARE II continued to promote, strengthen and support partnership and coordination efforts at the district level.

TB CARE II supported DHMTs to organize and conduct TB review meetings and, in collaboration with NTP, TB CARE II finalized the development of District Implementation Plans (DIPs) in all 12 districts. TB CARE II also supported and participated in joint quarterly zonal and district review meetings at the central level in the South West and South East Zones.

TB CARE II discussed and advocated for more government support and funding from the Executive Committee (DEC) members for TB & TB/HIV control activities in the district.

Additional support was provided to NTP that paved way for the release of funds from Global Fund for selected approved activities and for a no extension waiver to obligate funds until end of Q1, 2014. The remaining funds will be channelled through the Transitional Funding Mechanism to be signed later in Q1, 2014.

M&E

TB CARE II supported review meetings that were conducted in all target districts at end of Q1. The results were discussed at the TB CARE II quarterly review and planning meeting held from 16 - 20th December, 2013. Action points from the meeting have been incorporated into the implementation plans of impact districts. In addition, TB CARE II provided support for the printing and distribution of revised recording and reporting materials nation-wide.

5 CONCLUSION

The PY4 work plan was revised to accommodate TB/HIV activities in four selected districts of Neno, Machinga, Balaka and Ntcheu. TB CARE II also finalized the FY14 budget in which additional NTP activities requiring financial and technical support were included.

6 ACTIVITIES FOR NEXT QUARTER

The following are some of the activities planned for Q2, PY4:

• Continue with decentralization of TB registration and treatment initiation centres

• Intensify TB/HIV planned activities in the four selected districts of Balaka, Neno, Machinga and Ntcheu as well as other districts

October – December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 13 • Support the implementation of the Three I’s including TB screening for ALL Patients Attending Pre-ART, PMTCT & ART Clinics as well as in HIV Positive Infants in MCH Clinics

• Conduct District-level TB/HIV Training (HCWs) and establishment of District TB/HIV Coordinating Committees in the remaining districts

• Train IC Focal points from selected high volume facilities & develop IC implementation plan per selected district

• Training of two additional District MDR-TB Management teams on MDR-TB patient care and management

• Support Joint Supervision and Mentoring of District TB Staff (TB CARE II and DHMT staff)

• Support NTP national TB supervision

• Support the Quality Improvement Review Meeting and Data collection

• Support Laboratory Proficiency Testing and CDC-Atlanta GeneXpert EQA program panel testing

• Initiate renovations of new sites and finish works at Kasinje and Chonde health centers

• Conduct TB CARE II Quarterly Review Meeting

October – December 2013 Quarterly Report, USAID/Malawi TB CARE II Project; University Research Co., LLC 14