On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.7 Cape Town Jul. 2011
Success of an integrated tuberculosis and HIV/AIDS project in 2009 in Uthukela District, KwaZulu-Natal
S MahomedI; M HolstIII; M UysIV; M van der WaltV; S E KnightII
IMB ChB, FCPHM, MMed (PHM) . Department of Public Health Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
IIMB BCh, FCCH. Department of Public Health Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
IIIBSc (Agr). World Vision South Africa, Johannesburg
IVMB BCh, BA Hons (Mus), HED. Foundation for Professional Development, Pretoria
VMSc (Agric), MBA, PhD (Microbiol). Tuberculosis Epidemiology and Intervention Research Unit, South African Medical Research Council, Pretoria
To the Editor: In South Africa, more than two-thirds of patients newly infected with tuberculosis (TB) are co-infected with HIV.1 Since 1989, international organisations have urged countries to align their national TB and HIV/AIDS control efforts so as to reduce the burden of these diseases.2 In 2010, the National Department of Health (DoH) called for the integration of TB and HIV/AIDS services to effectively manage these dual epidemics. Without a national policy or guideline on how to integrate these services, many districts have developed innovative activities to co-ordinate improved patient care. Initiatives by non-governmental organisations (NGOs) have resulted in an increased uptake of HIV counselling and testing (HCT) for TB patients, improved clinical outcomes, and enhanced community participation in the care of patients living with TB and HIV/AIDS.3
In 2006, the Medical Research Council (MRC) initiated a comprehensive integrated project to expand the delivery of antiretroviral therapy (ART) for TB patients, called 'that'sit' (TB, HIV/AIDS, Adherence Support and Integrated Therapy).4 That'sit is funded by PEPFAR through the United States Centers for Disease Control and Prevention and was initiated in Okhahlamba Municipality in Uthukela District in July 2007 as a partnership between the MRC, World Vision South Africa (WVSA) and World Vision United States, the Foundation for Professional Development (FPD) and the Uthukela Health District. Its aims are to:
increase HIV testing in TB patients
enhance ART uptake in co-infected patients
rationalise patient flow at clinics to facilitate integration of TB and HIV/AIDS services
promote sustained and active community involvement in TB and HIV/AIDS care.
In June and July 2009, an evaluation of the first 24 months of the Uthukela that'sit project was undertaken at the request of WVSA, and with permission from the MRC. A health systems approach was used. Data sources included routinely collected data by that'sit, key informant interviews and observations from field visits. We report some of the successes and challenges of that'sit in Okhahlamba, with permission from stakeholders.
The project employed a co-ordinator who regularly visited clinics, liaised with nursing staff to determine their training needs, and assessed additional resource requirements to improve patient flow and facilitate comprehensive management of patients infected with TB and HIV/AIDS. These consultations promoted communication between that'sit, district management and clinic staff. The integrated patient records introduced at clinics were generally well-received, but did not facilitate data collection for the clinic staff as the DoH required submission of separate TB and HIV/AIDS statistics. Through the FPD, that'sit provided training on HIV/AIDS, sexually transmitted infections and TB to nurses throughout the district, and provided counsellors and data capturers at some clinics.
That'sit trained and employed a team of community field facilitators (CFFs) who engaged with community health workers, home-based carers, youth ambassadors, traditional healers and other active community members. Following a two-day information-sharing workshop, those interested in community-based care of TB and HIV/AIDS patients were invited to a five-day training workshop by the CFF, covering a range of TB and HIV/AIDS topics. More than 500 community members, including 60 traditional healers, received such training in Okhahlamba and Emnambithi municipalities. Collaboration between traditional healers and the formal health sector was fostered and, after being trained, traditional healers began referring patients to clinics.
A referral network comprising the trained community members was established for each clinic catchment area. The functions of the referral network included tracing patients who had defaulted clinic appointments, collection and delivery of patients' medication, and encouraging HCT and TB screening in communities (Fig. 1). Homebased collection of sputum specimens was done on completion of TB treatment to reduce clinic visits. The referral network facilitated referral of patients for other services such as those provided by the Department of Home Affairs and the Department of Social Welfare. There were numerous reports, by patients, of referral network members providing patients with food and assisting with cooking, cleaning and personal hygiene.
The referral network members worked voluntarily. Monthly meetings at clinics were used as a platform for interaction between clinic staff, that'sit and the referral network. Referral network members were reimbursed for transport costs and provided with meals at meetings. A challenge expressed by the referral network members was that they often had to use their own resources to assist patients, including airtime to call patients, and providing food to patients. Clinic staff valued the referral network, as they strengthened communication between the clinics, patients and communities.
That'sit also initiated other community-based activities such as training and assisting patients to establish household gardens, and TB education in schools and to taxi commuters, all of which were well-received.
The combination of facility-based and community-based activities by that'sit led to an increase in HCT of TB patients from 78% to 87% in the first 18 months of the project's activities. The co-infection rate ranged from 68% to 90%. Initiation of patients on ART increased from 22% in 2007 to 33% in 2009.
Early TB treatment outcome data showed a reduction in treatment interruption in smear-positive patients from 8.6% to 6.9%, although there was no measurable improvement in treatment success (cure or completion).
Access to basic health care services in Okhahlamba is challenging owing to the mountainous terrain and the poverty in many of the communities. Within this context, the main focus of that'sit has been on skills development and capacity building in communities. The successes of the project, particularly the referral networks, are remarkable, and many lessons can be shared with other districts.
Management at Uthukela Health District are very supportive of the project's activities, and its sustainability is being addressed. A local NGO has taken over the community activities of the referral network in Okhahlamba. That'sit has expanded some activities to Emnambithi and Indaka municipalities.
Many NGOs operate in Uthukela District, and it is important that there is a forum where their activities can be discussed to provide greater coverage, avoid duplication of services offered, and optimise support to the district.
1. World Health Organization. Global Tuberculosis Control: Epidemiology, Strategy, Financing: WHO Report 2009. Geneva: World Health Organization, 2009. [ Links ]
2. Tuberculosis and AIDS. Statement on AIDS and Tuberculosis. Geneva, March 1989. Global Programme on AIDS and Tuberculosis Programme, World Health Organization, in collaboration with the International Union Against Tuberculosis and Lung Disease. Bulletin of the International Union against Tuberculosis and Lung Disease 1989;64(1):8-11. [ Links ]
3. Friedland G, Harries A, Coetzee D. Implementation issues in tuberculosis/HIV program collaboration and integration: 3 case studies. J Infect Dis [serial online] 2007 [cited 15 August 2009]; 196 Suppl 1: 114-23. Available at: http://www.journals.uchicago.edu/doi/pdf/10.1086/518664 [ Links ]
4. South African Medical Research Council, World Vision South Africa. Project Plan: Expanding Access to HIV Care for TB Patients in South Africa. Johannesburg: World Vision South Africa, 2006. [ Links ]
Accepted 25 May 2011.
Corresponding author: S Mahomed (firstname.lastname@example.org)