The Zambian ProTEST Experience Lessons learnt workshop Durban 3 – 6 Feb 2003 Dr H Ayles, Dr R Ginwalla

Overview of the Zambian Situation Population: over 10,000,000 National HIV prevalence: 15.6% (22 % in the capital, Lusaka) MTCT rates: 30 - 40% TB notification rates: 510/100,000 population (>800/100,000 in Lusaka) 70 - 80% of TB cases HIV positive (Elliot et al, Lusaka 1990) Overview of Zambian situation: HIV/TB   Zambia is a country of over 10 million people that is one of the hardest hit by the dual TB/HIV epidemics. Recent antenatal surveillance has estimated the HIV prevalence to be 19.6% countrywide and 29.7% in the capital Lusaka. The Mother-to-child transmission rates of HIV are between 30 – 40%. Tuberculosis has been on the increase since 1984 with rates of more than 400/100,000 countrywide and 800/100,000 in Lusaka. Studies in Lusaka have shown that 70 – 80% of tuberculosis patients are also infected with HIV.

Lusaka 800/100,000 HIV Rates: 22% Both clinic based ProTEST sites Chawama 1999 Pop.: 68,515 Matero 2001 Pop: 61,076

Aims of ProTEST To encourage VCT as an entry point to integrated management and prevention of HIV-related TB To enhance collaboration between government health services and community organisations To introduce TB-related issues into HIV-related social mobilisation and activism To act as a model that can be integrated into the essential health package

Interfaith HBC Jon Hospice Catholic HBC Chawama Health Centre TB corner OPD Youth Friendly MCH Outreach Lab Kara Counselling centre NZP+ Mobilisers HIV clinic Stress the importance of situation analysis as a first step in protest Post test club Outreach Outreach Outreach

Chawama VCT

Sex Distribution 1. Limited study 6/12 ? Redo from compilation of data book

Age Distribution

Equity and Penetration Overall assessment: VCT service widely valued Equity - majority clients were young men (15-24 age group) Penetration - services better known by people living nearer the clinic Access - young women had limited access Quality of counselling service IPT - both client and patients positive about IPT STI services - inadequate Young men – easier access to clinic services: >free time, > info through social network, > openness about sexuality, mobilisers found it easier to approach young Young women – Level of literacy, household chores and petty trading, implications of being seen at the clinic/VCT centre by others Older people are busy financial and family responsibilities - TIME, more difficult for young mobilisers to approach, VCT service “full of young people” or “too old to be infected”

Responses Increased counselling capacity: More space, increased counsellors Mobiliser training Sex-worker initiative STI studies and intervention: Training, syndromic guidelines pocket and desk guides, monitoring and evaluation

Situation analysis Matero Baseline Situation analysis outlining: NGO’s in the area (HBC’s, HIV/AIDS prevention programmes) Staffing at the clinic Services (TB,VCT,STI,MCH) Facilities (Lab, X-ray,drugs) Outreach activities/groups Support services

Matero Ref Health Centre 2 HBC Matero Ref Health Centre TB corner OPD Youth Friendly MCH Outreach Lab VCT centre X-ray HIV clinic Stress the importance of situation analysis as a first step in protest Mobilizers Post test club NZP+ Outreach

Matero VCT: NGO/Government Partnership KCTT - NGO Training Supervision Supplies Outreach LDHMT Counsellor Space Laboratory X-ray service

VCT Matero

Sex Differences in Matero New data Age distribution: slightly older than Chawama, male/female equal

TB Case detection Jan 99-May 02 Chawama and Matero All HIV +ve clients screened for TB Symptom screen in VCT centre Symptomatics referred to protest clinic (weekly) Diagnosis made according to algorithm Transferred to usual district TB services 2531 HIV+ 1453 screened 141 TB Number screened those who received ZK number ? Underestimate but all that were recorded. 141 Extra cases of TB represents 7% of district population CHECK ### Sputum Positive TB cases not including those already with TB We have no way of knowing how many TB patients come for testing ? Some would not be screened and therefore not recorded. This was not one of our objectives 55 sm+ 86 sm-

TB Diagnostic algorithm

STI Diagnosis and management: A two pronged attack VCT centre Clients asked about symptoms of STI Referred to ProTEST clinic Syndromic management of STIs Clinic All STI patients treated syndromically All patients referred to VCT centre Drugs made available at clinics

STI’s Clinic STI service: Chawama and Matero (3 month period) – Total of 445 clients seen – Syndromic guidelines followed in 86% – 88% given information on VCT service STI's - VCT service 70 60 50 40 30 20 10 Q1 Q2 Q3 Q4 Chawama Matero

IPT: Chawama and Matero Screening as per TB detection Asymptomatics given IPT Received drugs monthly via VCT centre Adherence poor but recording inaccurate

IPT cohort analysis Adherence 23.5%

Why is adherence so poor? Focus group discussions In-depth interviews with clients and counsellors Case control study Prospective cohort testing a theoretical model of adherence (221 individuals)

Outcome after 6/12 IPT

Reasons for poor adherence Hunger “I was too hungry. I had no food and no support from friends and relatives so I stopped taking PT” (HIV+woman) Lack of disclosure Beliefs about IPT Valued by counsellors and clients Lack of belief in efficacy Concerns about side effects (more than reality)

CPT CPT study in Lusaka ongoing Results of study expected by the end of year and will guide Zambian position on CPT

MTCT Currently 3 districts in Zambia, offering MTCT as part of the National programme MTCT offers a minimum package of care to mothers during pregnancy, labour and delivery to reduce the risk of transmission to baby Criticism of MTCT: Poor partner participation (<1%) and lack of interventions for the mother With the combined intervention these problems are being addressed, with already better partner involvement

MTCT/ ProTEST General Objective Specific Aims To reduce the combined burden of HIV/TB using the MTCT and VCT programmes as entry points to the community Specific Aims Increased access to VCT service by women and their spouses Active TB and STI case finding and treatment Set up a framework for TB preventive therapy Two-way referral system between all services Integration of MTCT / VCT / TB services / IPT Advocacy to reduce stigma

MTCT ProTEST OUTPUT INDICATORS Increased collaboration between partners VCT service TB and STI case finding IPT Referral network INDICATORS Set up of ProTEST PMG Reviewed manual, refresher training of counsellors,# of people counselled,origin of referred clients,Proportion post-test counselled # of TB suspects, # TB notified, TB cure rate, # STI’s detected, # STI’s treated Proportion eligible for IPT, IPT Acceptance rate, IPT completion rate, IPT Toxitiy Design and produce referral cards, # referred who reach referral centre

Chipata clinic Situation analysis 3 HBC NewHBC ProTEST TB Corner VCT Peers VCT C H W’s LAB Y F S MTCT N H C MCH OPD VCT/ProTEST clinic Set up PTC

Chipata VCT Outputs

Age Distribution

Sex Distribution

PMTCT 10,459 New ANC - Group counselled 3,490 Individual counselled 1,783 Women tested (17%) 1,001 Post-test counselled 467 positive women (26.2%) 346 women on PMTCT intervention

Couple counselling VCT Couples 94 couples counselled 15 single mothers referred to MTCT 5 Expectant couples referred to MTCT MTCT Couples 4 at start of ProTEST (~2 years in operation) 22 at end of Year 1 Two way referral exists to facilitate couple counselling

TB Screening and IPT

MTCT TB/IPT Numbers of pregnant women referred for TB screening – 18 Number of pregnant women diagnosed TB – 4 (already on TB from clinic) Post-Natal women with TB – 3 Mothers referred for IPT – 10 (of total clients on IPT not clear how many are post-natal mothers)

STI/CONDOMS VCT- 170 cases of STI MTCT all screened for STI Condom Distribution on average 30,000 condoms distributed monthly Q1 Q2 Q3 Q4 Screened 309 259 276 761 Positive 26 24 63 66 Treated 16 16 60 57 Partner 10 14 25 32

MTCT/ProTEST referrals - 2002 From To Number MTCT ProTEST 128 30 Outreach ProTEST/MTCT 460 HBC 65 32 Support 79 See Macro

Other Indicators TB/HIV collaboration Govt/NGO collaboration Social Mobilisation Knowledge/attitudes/behaviour Equity and Access Capacity building Outreach

Lessons Learnt-1 ProTEST is difficult and time consuming Situation analysis vital in planning and implementing ProTEST Importance of partnership, both at national, district and community levels Single counsellor centres fail to meet demand for VCT Outreach work key in raising community awareness and increasing VCT Monitoring and evaluation helped identify problems, impact on community, benefit, costs and long term sustainability

Lessons Learnt -2 Role of existing health staff in counselling ProTEST clinics for HIV patients are highly in demand- overcoming stigma IPT adherence a challenge DOTS possible with community involvement (more practical than clinic based DOTS) Benefits of continued training resource persons Integrated HIV/TB/STI activities through ProTEST are acceptable feasible and cost-effective - “providing the bridge” Integration with the MTCT programme promises a wider application with the scaling up

Successes Integration of services within AND outside the clinic Integration of government and NGO services Improved referral mechanism Male involvement improved with MTCT/VCT integration and promises better IPT adherence Improved TB case finding Reduction in Stigma associated to HIV with improved access to services Greater government commitment

Failures Adherence to IPT Severe lack of resources in the government clinics Matero - Why did it not work despite government involvment? 1 counsellor only-lack of involvement of other staff Jealousy within clinic Lack of collaboration between clinic staff and NGOs Other constraints on clinic - big research programmes Location of counselling room

The Future for Zambia District sites - LUDHMT - Scaling out with MTCT GFATM component on expansion of ProTEST country wide ? ARV programme in Zambia through ProTEST clinics?

Acknowledgements London School of Hygiene and Tropical Med Zambia Aids related TB project Kara Counselling and Training Trust Lusaka District Health Management Team Network of Zambian People living with HIV Home based care groups Central Board of Health National HIV/AIDS Council