South Africa: From ProTest to Nationwide Implementation 15 June 2002 Dr Nono Simelela Chief Director: HIV/AIDS&TB

The Burden of TB and HIV S.A. is facing one of the worst dual epidemics in the world. 150,696 TB cases (346/100,000) in 2000 - 250% increase since 1989 It is estimated that 4.7 million South Africans HIV-infected. Approximately 50% of TB patients are infected with HIV. TB is the most common opportunistic infection and leading cause of death in people living with HIV/AIDS.

TB/HIV Collaboration Reviews of SA TB and HIV/AIDS&STI Programmes in 1996 and 1997 recommended improved collaboration. 4 TB/HIV Pilot Districts started in 1999 Joint Strategy for HIV/AIDS/STI and TB control in SA endorsed in 2000 including TB/HIV District roll out. Capacity building workshops with provinces and districts conducted in 2001.

Lessons Learned. Consultation with and involvement of community structures is important for success. Political commitment and ownership is important to mobilise funding and to ensure sustainability. Improve management of human resources. Active case finding has a role to play in diagnosis of TB in HIV+ clients. TB control not affected by these interventions. Poor adherence to INH prophylaxis. Need to ensure continuum of care.

Challenges Certification of lay counsellors to perform rapid HIV tests. Quality assurance for 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 Integration with PMTCT.

Challenges. Robust Health Systems. Community mobilisation. Insufficient Human Resources.

Criteria for Expansion. The districts chosen should be DTDs with well functioning TB services as demonstrated by: -Good sputum conversion rates - High cure rates. - Low interruption rates. Sufficient personnel in the districts – lay counsellors, healthcare workers, HBC, DOT supporters.

Areas of Collaboration. Formation of TB/HIV collaboration committees at national , provincial and district levels. Training of healthcare workers and doctors on TB /HIV management. Involvement of home based carers in TB case finding, DOT and VCT promotion.

Areas of Collaboration. Involvement of DOT supporters in VCT promotion. Health education and awareness campaigns should include both TB and HIV. Training of HBC, DOT supporters, lay counsellors.

Activities. The package of services that can be provided in each training district will vary according to resources available. Services are largely provided in comprehensive health care facilities. The same primary healthcare nurse may provide VCT, TB, HIV and STI services. At district level there may be one person responsible for TB and HIV or there may be individual coordinators for TB and for HIV.

Activities. TB coordinators should take responsibility for ensuring that TB patients have access to VCT, condoms. HIV coordinators should take primary responsibility for VCT, condoms, cotrimoxazole, management of opportunistic infections and home based care.

Package of care. The key elements of the package will include: - Enhanced district collaboration between TB and HIV service providers including both government and non-governmental organisations. - Mobilisation of communities to assist in TB/HIV prevention and care. - Increased access to VCT services, with a focus on self referred clients.

Package of care (cont’d) - Enhanced case finding for TB among HIV+ clients. - Better diagnosis and treatment of opportunistic infections. - Provision of Cotrimoxazole prophylaxis. - Improved referral networks between existing organisations providing services or support.

TB/HIV Training Districts: Targets Cover all districts by 2006 VCT: Test 12.5% of adult population and 80% of TB patients by 2005. Active TB Case Finding: Screen 90% of HIV+ clients for TB (sputum microscopy if TB symptoms) Cotrimoxazole prophylaxis: Provide CP to 90% of those who are eligible including HIV+ TB patients

Expansion Plan 2001 - 4 districts (ProTest TB/HIV Pilots) 2002 - 13 districts (+1 per province) 2003 - 40 districts (+3 per province) 2004 - 85 districts (+5 per province) 2005 - 148 districts (+7 per province) 2006 - 174 districts (+3 per province)

Coordinating Structures National TB/HIV Task Team Involves key national staff. Policy, monitors progress and technical support to provinces, liaises with donors National TB/HIV Working Group Involves ProTest site reps, provincial HIV and TB coordinators. Monitors implementation in provinces, problem solving, sharing best practices 9 Provincial TB/HIV Working Groups Involving TB/ HIV coordinators district and provincial, logistics. Monitor implementation at district level.

Coordinating Structures. District Management Teams Involves district coordinators, managers, laboratory, pharmacists, NGOs/ CBOs. Implementation of TB/ HIV activities.

Monitoring and Evaluation. Objectively verifiable indicators. Register. Data submitted quarterly. Narrative report on progress quarterly. Quarterly monitoring visits by national task team to provinces.

Conclusion. Political commitment should be as strong for TB as it is for HIV/AIDS. Financing at district level for both programmes should be integrated so that resources can be shared. Health awareness programmes to be conducted jointly. VCT services need to be “marketed”. There is still a need for separate programmes but what is crucial is to identify areas of collaboration.