Introduction

Tuberculosis (TB) remains one of the top 10 causes of death worldwide. Globally, 10 million people fall sick from TB each year and about 1.5 million die from it.. In Kenya it is estimated about 140k cases per year with estimated 20,000 deaths half of which are co-morbidities with HIV. It is estimated that one- quarter of the world’s population (an estimated 1.7 billion people) is latently infected with the TB causing bacteria. Of these 5-10% are at risk of progressing to TB disease.

Latent TB infection occurs when a person is infected with the TB bacteria but does not exhibit any symptoms. Apart from being at risk of progressing to TB disease, people with latent TB infection may transmit the disease when they develop lung disease and thus become infectious. TB preventive therapy is offered to individuals who are considered at risk of developing TB disease to reduce the risk of progression to disease.

●    Kenya is listed among the 14 high burden countries for TB,

●    TB is a major public health problem in Kenya

●    4th cause of death among infectious diseases

CHAI approach

The World Health Organization (WHO) has set ambitious targets for reducing Tuberculosis (TB) incidence and mortality with an aim to eliminate TB by 2035 and treatment of Latent TB infection as Key strategy CHAI Kenya from 2018 has supported the MOH to adopt utilization of efficacious shorter TPT regimen. Kenya rolled out use of IPT in 2016 which is a longer duration regimen which affects completion rates and consequently protection to TB infection as well challenges with toxicity rates. CHAI was seeking to establish 3HP as an affordable, quality-assured, less-toxic treatment suitable for wide roll out in the country.

Prior to 2018, only the United States was purchasing 3HP, partially due to its high cost per patient course ($72) relative to the cheaper 6-month daily patient course of Isoniazid Preventive Therapy (IPT). As a further barrier to uptake, there was only a single manufacturer of 3HP.

 The Goals:

• Support the adoption of 3HP into Kenyan MoH’s TPT/LTBI Guidelines for PLHIV and all contacts
• Support the inclusion of 3HP into the national information systems for TB and HIV programs.
• Support community engagement to ensure the public understands and supports 3HP.
• Support data collection and analysis of anonymized patient-level data at? sentinel sites of two Kiambu county in Kenya to understand completion rates.

IMPACT

Service delivery

1.     Lessons from sentinel sites:

Of the 503 PLHIV who initiated 3HP, 94,8% (N=477) completed their 3HP treatment course. Ten individuals (2%) discontinued treatment, 5 were lost to follow up, 1 died, 7 (1,4%) did not have their treatment outcome recorded, 1 individual’s outcome was not evaluated by clinicians, and 2 individuals had ‘other reason’ reported for a treatment outcome. 

Of the 10 individuals that discontinued treatment, 2 reported ‘other toxicity’ as a reason given, 5 individual’s reason for discontinued treatment was listed as ‘missing’ and the remaining 3 did not have any information provided as to the reason for discontinuation.

2.     Roll out in the country:

3HP roll out has been in a phased approach started with one county (Kiambu) based commodity supply. Currently 42 counties have been rolled out targeting PLHIVs, Household contacts, Prisoners, and health care workers.

NB. The data is captured in national reporting systems - KHIS for HIV population and TIBU for HIV-ve population

3HP Supply Chain

Through UNITAID catalytic Procurement of early 3HP implementation in 2020 was supported by the Kenya MoH included 3HP in Global fund NFM 3 to support 100,435 doses in 1st year and 154000 doses in 2nd year. PEPFAR in COP 2020/2021 included 37 418 doses and 2022 /2023 56,000 patient courses.

In support of distribution and management of TB commodities in the country through this grant, CHAI supported development of an order management electronic platform that links with National reporting tool (KHIS) and Kenya medical supplies agency (KEMSA) LMIS tool that seamlessly transfer order quantity from facilities. The platform was rolled out thought the country and adopted by MOH to decentralise TB medicines order management. This has resulted to:

o  Report rate for TB commodities moving from 62% in 2019 to over 95% in 2022

o  Increased proportion of sub-counties sending commodity reports-to 100%

o  Reduced order processing and validation from three weeks to three days

o  Increased proportion of order fill rate at the national and county level to 100%

o  Eliminated frequent emergency orders.

Decentralised order management from National to counties and sub counties

3HP COST

The cost of 3HP patient courses has dropped significantly, from $72 per patient course in 2017 to $14.25 in 2022.