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Lessons Learned from ProTEST TB/HIV Pilot Districts in South Africa

This workshop discusses the lessons learned from the ProTEST TB/HIV pilot districts in South Africa, including improved collaboration, increased testing and prevention measures, and adherence to treatment.

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Lessons Learned from ProTEST TB/HIV Pilot Districts in South Africa

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  1. Lessons Learned from ProTEST TB/HIV Pilot Districtsin South Africa ProTEST Lessons Learned Workshop 3February 2003 Dr Harry Hausler, WHO TB/HIV Advisor Chief Directorate: HIV/AIDS&TB, DOH

  2. The Beginning of TB/HIV Collaboration in SA • Reviews of national TB and HIV/AIDS/STI programmes in 1996 and 1997 recommended improved collaboration • Consultations with provinces on key district activities for TB/HIV collaboration in 1998 • 4 TB/HIV Pilot Districts established in 1999 and participate in ProTEST Initiative • Rural: • Bohlabela (formerly Bushbuck Ridge), Limpopo • Ugu, KwaZulu-Natal • Urban/Peri-Urban: • East London, Eastern Cape • Central District, Western Cape

  3. Goal of TB/HIV Pilot Districts • To implement and evaluate a comprehensive package of TB/HIV/STI prevention, care and support at district level

  4. Components of package • District TB/HIV collaboration and community involvement • VCT with rapid HIV testing (offered in morning health talks and to all TB, STI and antenatal clients) • Isoniazid Preventive Therapy (IPT) (isoniazid 300 mg daily for 6 months) for HIV+ with no TB symptoms • Cotrimoxazole prophylaxis (CP) (480-960 mg daily for life) to symptomatic HIV+ • Improved management of OIs

  5. Results: April 1999 - September 2002 • 211 trained to provide HIV counselling • 207 nurses trained on package • District TB/HIV collaboration improved • 61,132 people were tested for HIV (10% of adult population) of whom 21,206 (35%) were HIV+ • Research suggests that for every 10 people tested 1 HIV infection is averted • Testing 61,132 people estimated to have prevented 6100 HIV infections and 1830 TB cases

  6. Results: April 1999 - September 2002 • Number tested for HIV increased from 825 in Q4 1999 to 8,946 in Q3 2002 (10 fold increase) • >70% self-refer for VCT in 2 sites • 99% of people receive test results (up from as low as 10% in one rural site) • 7% (147/1991) of HIV+ people screened were found to have active TB in Central District and 3% (10/363) in Bohlabela • 2,878 started on IPT and 2,366 started on cotrimoxazole prophylaxis • 25% of HIV-positive started on prophylactic regimen

  7. Adherence to IPT • Central: 58% (169/290) – screening included tuberculin testing, sputum smear and culture, CXR • Bohlabela: 48% (41/86) in outpatient clinic of district hospital • Ugu: 24% (131/548) – started at first visit

  8. Adherence: IPT in Bohlabela • Interviews with 15 HIV+ clients • Barriers: • Lack of money for transport and food • Belief that meds must be taken with food • Belief that meds should only be taken if ill • Belief that should not mix meds with trad’l • Reasons for better adherence: • Support group and support of family members • Caring non-discriminatory clinic systems • Acceptance of HIV status Rowe, Makhubele, Pronyk 2001

  9. Lessons Learned: District Collaboration • District TB/HIV committee involving key role players strengthens delivery of both programmes and improves continuity of care • Consultation with and involvement of community structures is important for ownership, mobilisation of volunteers and increasing utilisation of services • Cooperation improves if roles and responsibilities are clearly defined • Capacity development of all stakeholders is required • Political commitment and ownership is important to mobilise funding and to ensure sustainability (eg for counsellors, counselling space, rapid HIV tests, prophylactic drugs)

  10. Lessons Learned: VCT with Rapid HIV Testing • VCT with rapid testing is feasible as part of PHC • Promoting VCT, hiring lay counsellors, training existing staff and using rapid tests increases the number of people tested for HIV (10 fold) • The proportion receiving results increases with rapid testing • VCT with rapid testing is acceptable as seen by increasing proportion of self referred • Nurses prefer rapid testing, feel satisfied, confident and enjoy VCT • Accuracy and uninterrupted supplies of rapid HIV tests and buffer are essential

  11. Lessons Learned: Counselling • Good quality counselling may be provided by health staff or lay counsellors • Hiring lay counsellors accelerates increase in VCT but must be sustained • Mentorship programmes help address stress and burnout of counsellors • Need to invest in space for counselling

  12. Lessons Learned: IPT & CP • Proportion of screened who start IPT is lower if tuberculin testing and CXR used (23%) than if only clinical screen is used (36-68%) • Adherence to IPT was better in Central District (58%) than in other districts (24%-48%): (longer screening, nutritional support, PWA support groups,easier access, more patient-centred care?) • IPT and CP do not adversely affect TB control and staff enjoy providing it • It may be better not to start prophylaxis at the time of HIV+ diagnosis but wait until client has demonstrated interest by attending regularly

  13. Lessons Learned: IPT and CP • Patient management is facilitated through simple clinical charts • Programme evaluation of clinical interventions is resource intensive and difficult to sustain without additional resources (computers and data entry clerks) • Active case finding identifies a large number of TB cases

  14. Should IPT be rolled out? • Pros: • Decreases risk of developing TB by 40% in those who take it, inexpensive, screening detects TB, low risk of resistance if effective screening, intervention for HIV+ in stage 1 • Cons: • Variable adherence, risk of resistance if poor screening or drug sharing, cost-effectiveness questionable • What is needed? • screen for good adherence, simple recording tools for clinical management, PWA support, systems for TB screening and isoniazid delivery

  15. Challenges for Health Systems • Political commitment and funding - employing district clinical coordinators, lay counsellors, stipends vs volunteers in DOTS and home based care, space for counselling, training, rapid tests and drugs • Certification of lay counsellors to perform rapids • Quality assurance for counsellors and rapid HIV testing • Standardised prophylaxis and treatment of opportunistic infections • Logistics: supplies of tests, prophylaxis, treatment - add to essential drugs list • Recording and reporting systems – simple, use at facility • Integration with other programmes: PMTCT, HBC

  16. Human Resources • A long term human resource plan is required • District: to manage the programme and provide mentorship and supervision • Facility: to provide clinical care and counselling - incentives to work in underserviced areas? • Community: to provide DOT, HBC, promote VCT, distribute condoms

  17. Capacity Building • Build on existing structures, services and organizations • One off’s are not enough – require training updates and ongoing supervision • Train both senior and junior staff who are motivated to provide the service

  18. Further Research • Effectiveness of interventions to improve adherence (prolonged screening, PWA support groups, nutritional support) • Behavioural survey to determine the impact of VCT on risk behaviours • Cost-effectiveness of VCT (nurse vs lay counsellor) • Cost-effectiveness of IPT (active case finding alone vs ACF and IPT)

  19. Impact of ProTEST in SA • Based on experience in Pilots, a Joint District TB/HIV Strategy with proposed indicators was developed which was endorsed by provinces and senior management in 2000 • Provinces agreed to implement lessons learned in TB/HIV Training Districts • TB/HIV Training Districts trained in 2000/1 and business plans developed for 2002-2003 • Roll out plan developed to cover all districts in the country by 2007 – funding secured from Belgian government and Global Fund

  20. Impact of ProTEST in SA • Improved collaboration at national level – formation of Chief Directorate: HIV/AIDS&TB, joint planning, joint training • VCT strategy that includes rapid testing in all health facilities with targets for testing 20% of adult population • TBHIV strategy that includes VCT for TB patients, active TB case finding in HIV+, cotrimoxazole prophylaxis

  21. Way Forward: TB/HIV Training Districts • All 9 provinces established TB/HIV Training Districts in 2001 – 9019 HIV tests Q1-3 2002 • Key activities: district TB/HIV committees, VCT with rapid HIV testing, active TB case finding in HIV+, cotrimoxazole, recording and reporting for VCT and prophylaxis, DOTS supporters trained on HIV, HBC trained on DOTS, better management of OIs

  22. Phased Approach • Start with DOTS and STI syndromic management • Add VCT with rapid HIV testing, active TB case finding and cotrimoxazole prophyalxis +/- IPT • Add ARVs for prevention of mother child transmission and rape survivors • Consider ARVs for treatment of HIV+

  23. Thanks to our Collaborators • South African Department of Health • TB/HIV Pilot District Coordinators • WHO, UNAIDS, USAID, DFID-SA, CIHR, BTC • Medical Research Council • London School of Hygiene and Tropical Medicine • RADAR, HSDU, U of Witwatersrand • City of Cape Town • University of Cape Town • Equity Project • South Coast Hospice • University of Natal

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