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

2. Overview of the Zambian Situation
Population: over 10,000,000
National HIV prevalence: 15.6% (22 % in the capital, Lusaka)
MTCT rates: %
TB notification rates: 510/100,000 population (>800/100,000 in Lusaka)
% 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.

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

4. 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

5. 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

6. Chawama VCT

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

8. Age Distribution

9. 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”

10. 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

11. 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

12. 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

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

14. VCT Matero

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

16. 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-

17. TB Diagnostic algorithm

18. 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

19. 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

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

21. IPT cohort analysis
Adherence 23.5%

22. 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)

23. Outcome after 6/12 IPT

24. 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)

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

26. 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

27. 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

28. 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

29. 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

30. Chipata VCT Outputs

31. Age Distribution

32. Sex Distribution

33. 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

34. 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

35. TB Screening and IPT

36. 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)

37. 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
Positive
Treated
Partner

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

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

40. 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

41. 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

42. 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

43. 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

44. 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?

45. 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