Perspectives on Integrating TB and HIV Programs into General Health Services in Cape Town

1. 16th Conference of The Union North America Region Perspectives onIntegrating TB and HIV Programs into General Health Services in Cape Town Pren Naidoo 23 February 2012

2. Greetings from Cape Town

3. Local Government: 100 clinics Nurse service providers; some medical officer support Historic focus on preventive care, child curative and TB services. Provincial Government 43 community health centres, obstetric units, District, 20 and 30 hospitals. Medical officer and clinical nurse practitioner service providers Historic focus on adult curative services and obstetric services Population: 3.54 M 23.6 % - private medical aid coverage1 Primary health expenditure public sector: R842 per capita1 District health system Health services jointly provided by Local and Provincial Government Health Services in Cape Town

4. Famous Pairing

5. TB and HIV Burden TB Incidence (Reported Cases) HIV Antenatal Prevalence Source Data: WHO Global Reports, City Health Directorate Source Data: National and Provincial Antenatal Survey Reports HIV Antenatal Prevalence Cape Town: 20.2% in 2010 (Sub-district Ranges: 8.8 – 33.2%2) Estimated 233,578 HIV-infected (R. Dorrington, Centre for Actuarial Research) Source Data: City Health Directorate

6. Co-existing Health Challenges • Weak primary health infrastructure • Centralised, focus on hospitals • Apartheid legacy with poorly developed infrastructure in black areas • Incongruity between private and public sector3 • 46% of total national health expenditure and 50% of human resources in private sector • Caters for 15% of the population with medical insurance and 20% who pay out of pocket • Shortage of nurses and doctors3 • 149 nurses per 100,000 population in 1998 • 110 nurses per 100,000 population in 2007 • Stagnant per capita expenditure in the public health sector

7. Baseline TB and HIV Services • HIV: • HIV testing limited pre-2000 • Few infectious disease clinics • Care not standardized • PMTCT pilot project 1999 • TB • Vertical program • DOTS strategy in 1996 • Limited treatment options • Electronic reporting 2003 NSP TB Treatment Outcomes

8. TB diagnosis/treatment TB preventive therapy Screen for TB Cotrimoxazole prophylaxis STI treatment Condoms Safer sex ART / PMTCT Psychosocial care HCT: Entry point to HIV / TB care and prevention  HIV-related infections  HIV  TB ProTest Model (2000) Y  uptake VCT

9. HCT Record HCT Record HCT Register Implementation Approaches • Task shifting and employment of new cadres of health staff • Lay counsellors, adherence counsellors, community treatment supporters, TB assistants • Adoption of new technology • HIV rapid tests • New tools • Integrated M&E • Performance management HCT Record

10. Integration Approach - HCT • Routine: • Pre and post-test counselling • Risk reduction strategies • Condom promotion and distribution • Facilitate access to HIV care if HIV+ • Integration emphasis • Educate on STI’s and TB and the link with HIV • Symptomatic screen for TB and STI and referral • Assess contraception needs and referral

11. Integration Approach - HIV • Educate about HIV and TB / HIV link • Promote risk reduction behaviour • Promote condom use; distribute condoms • Provide clinical care: • WHO staging, CD4, RPR, PAP for women • Cotrimoxazole preventive therapy • Intensified case finding for TB • INH prophylactic therapy • Management of OI’s • Referral / provision of ART if required • Provide syndromic management of STI’s • Address reproductive health needs

12. Integration Approach - TB • Educate about HIV and TB / HIV link • Offer HCT as standard of care • Advise about HIV prevention, promote reduced risk behaviour, promote condom use; provide condoms • Provide clinical care to HIV+ • WHO staging, CD4, RPR, PAP for women • Cotrimoxazole preventive therapy • Management of OI’s • Referral / provision of ART • Referral for HIV care on completion of TB treatment • Provide syndromic management of STI’s • Address reproductive health needs

13. Implementation Approach • New HIV services (HCT, PMTCT, ART) introduced as vertical programs • Additional staff • Separate reporting mechanisms to “Routine Monthly Reports” • Ring-fenced financing • Benefits of approach • Expedient; rapid implementation; less disruptive • Greater acceptability to staff • Greater management control • Disadvantage of approach • Entrenches fragmentation e.g. PMTCT • Requires additional interventions / change processes to expand access to services e.g. ART

14. HCT Achievements and Challenges • Successes • Standard of care in TB, PMTCT and STI services with high uptake • New Approaches e.g. ACTS model (Advise, Consent, Test, Support); non-medical testing sites • Political leadership • Challenges • Improving early access to HIV care

15. HIV Achievements and Challenges • PMTCT Successes • Coverage:>90% • Transmission: 3% (94% babies tested at 6 weeks) • PMTCT Challenges • Integrated HIV and TB care (antenatal and postnatal) • ART Successes • Number on ART: 80,546 (2011) • ART Challenges: • Access, especially for TB patients • Capacity to provide services (move to nurse providers; “chronic clubs” for stable patients)

16. TB Achievements and Challenges • Successes: • Improved outcomes • Performance management targets • Use of routine data to drive improvement • Health system strengthening interventions • Challenges • Access to ART for TB patients • DOT and integrated community health workers Source Data: City Health Directorate

17. TB Achievements and Challenges TB Case Finding • Use of electronic National Health Laboratory Services data to assess positive smears and cultures amongst TB suspects • Multiple sites for screening help increase TB case-finding • Separate diagnostic and treatment facilities contribute to TB initial treatment default Source Data: Desmond Tutu TB Centre

18. Key Success Factors • Good local leadership • Teams of strong, competent managers • Effective planning and implementation • Accountability; performance management • Strong support processes • Financial management • Procurement • Laboratory services etc • Good monitoring and evaluation • Use of routine data • Partnerships

19. Challenges • Funding and human resources in the public health sector • Personal accountability of service providers • What is the ideal model? • Integration vs. harmonisation of services • Process for adding new services • Vertical vs. integrated • Change management “No matter how much you push the envelope, it will still remain stationery”

20. Thank you for your attention!Acknowledgements • Karen Jennings, Judy Caldwell, Virginia Azevedo, Bryan Chute - City Health Directorate • Juanita Arendse - Western Cape Provincial Department of Health • Rory Dunbar - Desmond Tutu TB Centre References • District Health Barometer 2008/09, Health Systems Trust • Western Cape Antenatal HIV survey 2010, Preliminary Report • The health and health systems of South Africa: historical roots of current public health challenges, Coovadia et al, Lancet, Vol 374, 2009