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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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)

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

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

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

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+

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