ACTIVITY DESCRIPTION:

Tuberculosis (TB) is a serious public health problem in Nigeria with an estimated prevalence of 684,000

cases. This data places Nigeria as the highest TB disease burden country in Africa and 4th among 22 high

TB burden countries in the world, after India, China and Indonesia. WHO estimates that 371,642 new TB

cases (all forms) and 162.163 smear positive cases occurred in 2005 and that the incidence is increasing.

The case detection rate is around 27% at the end 2006. In 2006, DOTS services were available in all 36

states and Federal Capital Territory (FCT) and 595 of 774 LGAs had at least on facility providing DOTS

services. The burden of HIV/AIDS is also significant. The HIV prevalence as tested among ANC attendees

is on average 4-5%. There are however, significant differences between, and probably within, states. The

average HIV prevalence among TB patients has increased to almost 30%. Based on an evaluation visit by

TB CAP in January 2007, the following three intervention areas are proposed for FY08/ Nigeria.

1) Strengthening TB/HIV management and leadership capacity ($200,000). Nigeria has been implementing

TB/HIV collaborative activities and has identified a need for an increased level of management which

cannot be met by the existing pool of technically knowledgeable and competent staff. The first step to

addressing this issue is to ensure better coordination and implementation of TB/HIV activities through

training a cadre of staff on TB/HIV collaborative activities. The second step is to have these managers roll

out this knowledge and these skills into the rest of the country through a rollout training plan. In order to

improve human and institutional capacity, TBCAP proposes an integrated TOT on TB/HIV in collaboration

with WHO; the Instituto Scientifico di Tradate, Italy; NTLTC in Zaria; and trainers from the NTBLCP and

NASCP to achieve this two step objective. The overall goal of the course is to develop skills and to guide

States and LGAs in planning, implementation and evaluation of TB/HIV collaborative activities, based on

current policy and guidelines. As part of the institutional capacity building, two or three Zaria trainers will be

identified and work with WHO trainers as master trainers for the TOT. This will ensure the availability of

skilled TOT staff to roll-out the training to finally ensure country-wide coverage of good TB/HIV services.

The newly trained staff will have the knowledge and skills to provide the necessary assistance for the

implementation of the TB/HIV collaborative activities in Nigeria. Newly trained trainers in collaboration with

WHO consultants, the UMD ACTION project, and representatives of the target group will adapt each

module with relevant data and information from Nigeria and roll out subsequent trainings to the LGA level. A

series of State level 2-3 day training courses will be conducted. During each session managerial health staff

from 3-4 LGAs from the selected states will be invited. Through these trainings 300 LGAs will be covered in

17 USG-supported states in 3 zones: North-East, North-West and North-Central, and extended nationwide.

In each LGA these trainings will bring together the district TB/Leprosy coordinators, communicable disease

team members and HIV coordinators. Local trainers will be mentored by WHO, UMD-ACTION and Zaria

trainers during their first LGA training session. An estimated 200 health workers will be reached to

implement TB/HIV collaborative activities.

2) Strengthening of TB, TB/HIV drug, and commodity logistics ($300,000): This activity is linked to ensuring

uninterrupted drug availability at TB and HIV treatment sites, and to strengthen pharmaceutical

management systems for the delivery of TB/HIV services in Nigeria specifically focusing on the functioning

of the TB GDF. Activities which began in COP07 and will be expanded and strengthened in COP08.

TBCAP in collaboration with the National TB control program will conduct an assessment on all aspects of

TB pharmaceutical management including; policy and legal framework, selection, procurement, distribution,

rational use and pharmacy MIS to inform the development of strategies that will ensure secure availability

and rational use of TB medicines. Fixed-dose combination (FDC) and TB medicine kits will be introduced to

improve adherence to treatment. Standard operational procedures (SOP) and guidelines will be updated

and reviewed and adapted for use even at the lowest level of health care delivery. The local capacity for TB

pharmaceutical management of the TB GDF commodities in Nigeria will be strengthened by training TB and

HIV program managers and pharmaceutical officers, nurses and community based health workers in

relevant aspects of pharmaceutical management related to TB/HIV. Technical assistance and support will

be provided to National and State TB control programs to develop a functional commodity logistics

management system. Test systems for forecasting, procurement, distribution and tracking of anti-TB drugs

and commodities will be designed and piloted. TB CAP will collaborate with FMOH, WHO, GD, and the

SCMS project to leverage resources and ensure sustainability.

3) Scaling up of TB/HIV collaborative activities in 179 LGAs ($1,400,000): Currently the USG, through

PEPFAR is the major donor supporting and providing technical assistance to TB/HIV activities in Nigeria.

The goal of this activity is to increase coverage of TB treatment and TB/HIV services in 179 LGAs in 23

states across the country that do not have DOTS services or TB/HIV services. In collaboration with the

NTBLCP and in line with the DOTS expansion plan, TBCAP will provide technical assistance and support to

NGOs active in Nigeria to establish DOTS services and integrate TB/HIV services in these previously

uncovered LGAs. TB/HIV services will be established in a phased manner beginning with the 6 - 8 states

with the greatest need. Using this phased approach, it is anticipated that with the first year of funding,

TB/HIV services will be established in at least one DOT Site in 60 LGAs, a total of 120 TB/HIV outlets.

The International Federation of anti-Leprosy Associations (ILEP), namely German Leprosy and TB Relief

Association (GLRA), Damien Foundation of Belgium, and Netherlands Leprosy Relief (NLR) are NGOs that

have supported DOTS expansion efforts in Nigeria for over 2 decades. TBCAP will provide technical

assistance and sub-grants to the ILEP partners to expand TB/HIV collaborative activities. TB CAP will also

support the establishment and operations of State TB/HIV working groups to improve the policy and

coordination environment. TBCAP will strengthen state capacity for supervision, monitoring and evaluation

and for ensuring the implementation of the revised reporting and recording system, and the follow up of HIV

patients on TB treatment with a special focus on support for defaulter tracing. TB CAP will assist LGAs to

improve the referral systems between TB and HIV services. TB CAP will build the capacity of health

workers in TB/HIV through a series of trainings which will be conducted in collaboration with the Zaria

training center while building the capacity of Zaria to roll out such trainings subsequently. Collaborative

activities will ensure adequate treatment to eligible patients with CXT, IPT, ARV, among others. TB CAP will

assist in upgrading and improving the quality of laboratory services including basic renovation of

infrastructure, procurement of microscopes and other commodities as necessary, and training of laboratory

staff on TB smear microscopy and medical officers on x-ray diagnosis. TB CAP will assist with implementing

TB-Infection control measures at various levels. TB CAP will work with State TB/HIV working groups to

develop and disseminate facility level IC plans and monitor the routine implementation of administrative and

environmental control measures, and will conduct training for service providers and laboratory staff on

Infection control.

Activity Narrative:

By implementing these three components during the first year TB CAP expects to establish TB/HIV services

in 120 DOTS sites. With 30% case detection rate as a target for the first year in 60 LGAs, a total of 10,188

TB cases will be detected. For each confirmed case around 10 suspects will be screened. A total of 20,376

(20%) TB clientele (TB patients and suspects) will receive HIV counselling and testing. A total of 4,075

registered TB patients (40%) will receive HIV counselling and testing. Among those, it is expected that

1,426 TB patients (35% co-infection rate) will be referred for HIV care and treatment. A total of 300 health

workers will be trained to provide clinical prophylaxis and/or treatment for TB to HIV infected individuals.

In order to maximize coordination with all partners and effectively implement activities, TB CAP will

establish an office in Nigeria. That office will employ technical and administrative staff. The operations of the

office will be directly supported and supervised by TB CAP Project Management Unit in The Hague.

EMPHASIS AREAS:

Local Organization Capacity Development is the primary aim of this project, with emphasis also placed on

building logistics systems and capacity as well as training in all areas.

TARGET POPULATIONS:

All TB suspects (male, female, children and adults) and most at risk populations like PLWHA, people

affected by TB and their household members are the key beneficiaries of this project. To reach them,

pharmacists, policy makers, host country government workers and other MOH staff, public sector health

care workers, and ILEP implementing organizations will be targeted.

Activity Description: Funding for this activity will fall under the TB/HIV program area while targets are

reflected in the policy and systems strengthening program area.

Tuberculosis (TB) is a serious public health problem in Nigeria with an estimated prevalence of 684,000

cases. This data places Nigeria as the highest TB disease burden country in Africa and 4th among 22 high

TB burden countries in the world, after India, China and Indonesia. WHO estimates that 371,642 new TB

cases (all forms) and 162.163 smear positive cases occurred in 2005 and that the incidence is increasing.

The case detection rate is around 27% at the end 2006. By 2006, DOTS services were available in all 36

states and Federal Capital Territory (FCT) and 650 of 774 LGAs had at least on facility providing DOTS

services. The burden of HIV/AIDS is also significant. The HIV prevalence as tested among ANC attendees

is on average 4-5%. There are however, significant differences between states and probably within states.

The average HIV prevalence among TB patients has increased to almost 30%. Based on an evaluation visit

by TB CAP in January 2007 and referring to the APA2 workplan (OP07) the following two intervention areas

are proposed for FY08/ Nigeria.

1Strengthening the TB/HIV management and leadership capacity

2Strengthening of TB, TBHIV drug and commodity logistics

Part 1: $200,000- Strengthening the TB/HIV management and leadership capacity

Nigeria has been implementing TB/HIV collaborative activities and the request for better management

cannot be met by existing pool of technically knowledgeable and competent staff. The first step to

addressing this issue is to ensure better coordination and implementation of TB/HIV activities through

training a cadre of staff on TB/HIV collaborative activities. The second step is to have these managers roll

out this knowledge and these skills into the rest of the country through a rollout training plan. In order to

develop Improved human and institutional capacity, this COP08 for TBCAP proposes the following three

activities to achieve this two step objective;

1. TOT on TB/HIV in collaboration with WHO training Institute in Sondalo, Italy

Following the development of the basic package of policy and guidelines on TB/HIV, WHO (as the TB CAP

implementing partner on this activity), jointly with the Italian WHO Collaborating Centre for Tuberculosis and

Lung Diseases developed and conducted successfully two TB/HIV courses for consultants in 2004 and

2006. From the gained experience with these two courses, a TOT for Nigeria will be designed and

conducted by WHO and the Instituto Scientifico di Tradate, Italy in collaboration with NTBLTC in Zaria and

trainers from the NTLCP as well as the AIDS and Sexually transmitted infections Control Program

(NASCP). The overall goal of the course is to develop skills and to guide States and LGAs in planning,

implementation and evaluation of TB/HIV collaborative activities, based on current policy and guidelines. As

part of the institutional capacity building two or three Zaria trainers will be identified and work with WHO

trainers as master trainers for the TOT. This will ensure the availability of skilled TOT staff to roll-out the

training to finally ensure country-wide coverage of good TB/HIV services. The newly trained staff will have

the knowledge and skills to provide the necessary assistance for the implementation of the TB/HIV

collaborative activities in Nigeria. By the end of the Course the participants will have further developed their

skills to review data on the key components of Tuberculosis and HIV/AIDS national programs and analyze

and synthesize the main findings, identify priorities, propose solutions and develop recommendations.

Based on experience and due to the methodological participatory approach, the maximum number of

participants will be 16 and be selected among the Zaria and NTBLCP and NASCP staff.

2. Work with NTBLTC in Zaria and USG partners including UMD/IHV/ACTION (#3254.08) who currently

provides support to adapt TB/HIV modules for Nigeria

In order to rollout the training TB/HIV modules need to be adapted to Nigerian setting. Newly trained

trainers in collaboration with WHO consultants and representatives of the target group will adapt each

module with relevant data and information from Nigeria. Selected Zaria and NTBLCP trainers will also

develop a detailed rollout training plan to replicate the trainings at the LGA level. The target group for the

training courses is the LGA managerial health staff responsible for the NTBLCP and NASCP.

3. Mentored roll out of subsequent trainings in country

Based on the rollout training plan, a series of State level 2-3 day training courses will be conducted. During

each session managerial health staff from 3-4 LGAs from the selected states will be invited. Through these

trainings 300 LGAs will be covered in 17 USG-supported states in 3 zones: North-East, North-West and

North-Central., and extended nationwide. From each LGA these trainings will bring together the district

TB/Leprosy coordinators, communicable disease team members and HIV coordinators. The main purpose

of the LGA level training is to update the knowledge and skills of staff on TB/HIV collaborative activities as

well as facilitate the development of district level TB/HIV collaborative activity implementation plans. LGA

level training sessions will be conducted by pairs of newly trained TB/HIV trainers. Each pair of trainers will

be mentored by WHO and Zaria trainers during their first LGA training session.

Part 2: $300,000 - Strengthening of TB, TB/HIV drug and commodity logistics

The activity is linked to ensuring uninterrupted drug availability at TB and HIV treatment sites. Overall

objective of the project is to strengthen pharmaceutical management systems for the delivery of TB/HIV

services in Nigeria specifically focusing on the functioning of the TB GDF. This objective will allow for the

identification through assessment and the provision of support for more functional elements of the

pharmaceutical management cycle including Selection, Procurement, Distribution, Rational use, adequate

Policy and Regulatory framework and Management support systems. The objective of a strengthened

commodity management will be achieved through the implementation of the following activities which began

in COP07 and will be expanded and strengthened in COP08;

Conduct an assessment to measure the strengths of pharmaceutical management systems: The objective

is to collect data on all aspects of TB pharmaceutical management including; policy and legal framework,

selection, procurement, distribution, rational use and pharmacy MIS to inform the development of strategies

that will ensure secure availability and rational use of TB medicines.

Introduce Fixed-dose combination (FDC) and TB medicines kits to improve adherence to treatment: The

objective is to ensure that multi-source (generic) FDC TB medicines are registered and that the ones

currently in the system are of assured quality.

Update and review standard operational procedures (SOP) and guidelines to include FDCs and TB PK

medicines: The objective is to review all related guidelines and SOPs to ensure that FDCs and TB PK are

listed for use even at the lowest level of health care delivery.

Provide training to improve local capacity for TB pharmaceutical management of the TB GDF commodities

in Nigeria : The objective is to provide trainings to cover all aspects of pharmaceutical management in view

of the introduction of FDCs and TB PK and the development of new SOPs and guidelines. To reflect the

strategy of TB/HIV/AIDS mainstreaming, HIV/AIDS program managers and pharmaceutical officers will

Activity Narrative: surely benefit from this training. In COP08 the following follow-up activities will be implemented:

Assessment of the program implementation: Collect data on the implementation of COP07 activities

including MIS, use of FDC and dissemination and use of SOP.

Follow-up training: Ensure that program managers, pharmaceutical officers, Nurses, HBC & CBO providers

and expert patients have been trained. These trainings will only focus on key persons due to limited funding.

Continuous technical assistance (TA): Provide periodic TA to NTBLCP, MOH and the National Agency for

Food, Drug Administration and Control (NAFDAC) on program implementation. Specific TA would include

working with facilities and providers to make sure that IPT is available in health centers meeting appropriate

diagnostic criteria and that guidelines are implemented to make sure that every patient who qualifies for IPT

receives it.

Assist National and state TB control programs to develop a functional commodity logistics management

system. Design and pilot test systems for forecasting, procurement, distribution and tracking of anti-TB

drugs and commodities. Inventory management systems will also be designed and pilot tested and key staff

trainings in their use will be initiated. TB CAP will collaborate with FMOH, WHO GDF and the SCMS project

to leverage resources and ensure sustainability. Expansion and full implementation of these systems will

require additional funding in following years.