PG-10 Implementation of tuberculosis service integration into ANC and PMTCT programs in Northern Nigeria

Background: Tuberculosis (TB) service integration into antenatal care (ANC) and prevention of mother-to-child transmission of HIV (PMTCT) can facilitate prevention and control of TB/HIV co-infection among HIV-positive pregnant women and their HIV-exposed infants. Such integration requires TB intervention roll-out across all Maternal, Newborn and Child Health (MNCH) points of care, and should include the engagement of ANC providers. Objective: To assess the feasibility and impact of TB service integration into ANC and PMTCT, and identify potential gaps. Methods: This retrospective study was conducted at 6 PEPFAR TB-MNCH pilot sites between February and April 2018. Facilities were selected based on monthly ANC attendance, and comprised rural and semi-rural health facilities (5 secondary, one tertiary). A TB integration manual, and TB screening algorithm and data-capturing tools were developed and deployed to facilities, along with healthcare worker engagement and training. TB prophylaxis and treatment services were to be provided to TB-negative and presumptively-infected pregnant women respectively, after universal screening. Data were collected from TB screening registers and cards and ANC general registers. TB-DOT clinic registers were reviewed to determine the number of presumptive cases that accessed GeneXpert testing. A survey was conducted among healthcare workers (HCWs) to explain gaps identified. Results: Out of 5767 ANC attendees presenting in the 3 month period 100% were screened for HIV, and 2993 (51.8%) were screened for TB. A total of 140/5767 (2.4%) women were HIV-positive, with 37/2993 (1.2%) TB-screened women determined active TB-presumptive, all of whom accessed Gene Xpert testing. Ultimately, 36/37 women tested TB-negative and 1 (0.12%) tested positive. One facility had no documentation of ANC-TB screening for the review period. Of the 139 HIV-positive pregnant women confirmed TB-negative, only 3 (2.2%) were placed on isoniazid prophylaxis. The sole TB/HIV+ woman was commenced on TB/HIV treatment, and ultimately, her TB/HIV-exposed infant was provided both isoniazid and HIV prophylaxis. Eleven key HCWs (4 doctors, 6 ANC nurses, and 1 pharmacist) were surveyed across the 6 sites. Only 7/11 (63.6%) HCWs indicated being trained on TB-MNCH integration. Excessive workload was universally reported as the reason for poor TB screening at ANC. Unavailability of Isoniazid was reported as the major reason for non-provision of prophylaxis to eligible HIV-positive pregnant women. Conclusions: Integration of TB services into ANC/PMTCT was inadequate, mainly due to screening and prophylaxis initiation gaps. Closing these gaps will require health systems strengthening to address training/knowledge deficiencies, task-shifting and supervision needs, drug/commodity stock-outs and leadership at the facility and state level. Linkage to confirmatory testing for the TB-presumptive cases was excellent, and maternal treatment initiation and infant prophylaxis were encouraging for the sole mother-infant pair identified. To complement gains and accelerate progress made in both PMTCT and TB program areas, universal TB screening coverage and prophylaxis initiation, confirmatory diagnosis and prompt treatment initiation must be achieved at MNCH facilities in Nigeria.