HIV and TB in Practice

Studies report challenges and successes in the roll-out out of intensified case finding and IPT

This regular feature on TB/HIV integration is kindly supported by the Stop TB programme of the World Health Organization.

By Lois Eldred and Theo Smart

Two large urban HIV clinics in Windhoek, Namibia have been able to scale up the provision of isoniazid preventive therapy (IPT) (after screening for active TB) to about half of their patients with HIV in less than a year, through the use of a ‘quality improvement’ programme, according to presentations at the 40^st Union World Conference on Lung Health held in Cancun in December. Furthermore, they have been able to achieve better than average treatment completion rates of between 56% and 67% for a 9-month course of IPT — with results growing better with each successive round of quality improvement (see below).^{1, 2}

“Integrating isoniazid preventive therapy into HIV care is feasible as part of routine care if all staff are engaged in planning and implementing it, ” said Dr. Sandya Wellwood, a clinical mentor with the ITECH (International Training and Education Center for Health) in Namibia, who gave one of the presentations.

“Well structured quality improvement programs can be used to accelerate implementation of all the 3 I’s,” said Dr Tehetena Zarou of Katutura Health Center. “And I would like to stress that no additional staff was added to the clinic, or no additional financial resources were allocated. It was basically done with minimum resources.”

Other presentations at the conference from Sao Paolo, Brazil and Kenya also addressed some of the challenges in connecting TB screening with putting people onto IPT in a programmatic setting— sharing some of their lessons learned and practical recommendations.

Background

Namibia has a fairly small population of around 2 million people, but a very high HIV prevalence — 17.8% in antenatal clinics, with a total population of about 196,000 people living with HIV.

TB is considered a national health priority in Namibia. It has one of the highest TB case notification rates in the world, at 665/100,000 in 2008. TB is the leading cause of death among those with HIV. Fifty-four percent of TB patients have been tested for HIV and 59% of those are HIV-infected.

Namibia has rapidly rolled out antiretroviral therapy, achieving coverage of around 80% for those with CD4 counts below 200, and enrolling over 70,000 people. But a 2007 study revealed only about 6% of the HIV-infected were receiving IPT, even though it is recommended by WHO as one of the essential activities to reduce the burden of TB in people with HIV — and is national policy in Namibia.

HIVQUAL Namibia 

IPT provision was also found to be quite low at sites involved in HIVQUAL Namibia.

HIVQUAL Namibia is a national quality improvement programme to improve the quality of care for people living with HIV/AIDS led by the Ministry of Health and Social Services, and launched in 2007 in collaboration with the US Centers for Disease Control and HIVQUAL International USA.

“It’s an internal process which allows facilities to access, plan and implement strategies timeously and in a manner which is uniquely applicable to that facility,” said Dr Zarou.

HIVQUAL has three basic programme components:

• Performance measurement: this is based on the (core set) of performance indicators. Eleven indicators have been selected at national level in Namibia – these include TB screening and IPT provision. Reviews are performed every six months. The review period is from January till June and then again from July until December and reports are generated after the end of each review period.
• Quality improvement projects based and selected on performance data and the priorities of the facility. Different facilities can have different priorities and can therefore select different quality improvement projects.
• Programme infrastructure and capacity development, which involves putting structured, facility-specific quality management plans in place, setting goals and establishing committees tasked with meeting these goals.

“Clinicians involved in HIVQUAL and the ITECH clinical mentors selected TB-IPT and TB screening as an important priority area for intervention,” said Dr Zarou.

The barriers to IPT in Namibia

Two clinics were selected to participate in the study:  Katutura Health Centre, a large urban health centre in a low income district of Windhoek, and Windhoek Central Hospital ARV clinic, a smaller HIV clinic within a tertiary national referral hospital.  The two clinics have over 7,000 HIV-infected registered patients.  At the start of the study in September 2008, most of the clients with HIV were reportedly screened for TB, but only 2% were receiving IPT.

A baseline survey was conducted asking about reasons for using or not using IPT, and three root causes were identified:

• Clinician reluctance: Clinics noted that there was no “habit” of prescribing IPT. Furthermore, clinicians were concerned about missing (and under-treating) subclinical TB in the screening process. There was also no on-site pharmacy stock of isoniazid, so patients would need to travel to obtain IPT, unlike other medications.
• Language barriers between the clinicians and the patients: Clinicians in Namibia often could not speak the local dialects, which hindered communication during the screening process to rule out TB.
• Poor record keeping: In Namibia, health information is documented in a ‘health passport’ that the patient takes with them. Often this was the only place where things were documented — the information was not being transferred to the patient booklet retained by the clinic. In the case of IPT, the prescription was written in the health passport. Particularly when patients went from one facility to another, the staff had no way to be sure whether a script had been written, let alone whether the patient had completed their course of treatment.

According to Dr Zarou the decision of whether to provide IPT essentially came down to a few simple yes no questions:

• Has this patient been screened for tuberculosis?
• Does the patient have tuberculosis?
• If the patient does not have TB, are they on IPT?

“It became pretty evident that even though we had ruled out or excluded tuberculosis, the next logical step was to put that patient on INH prophylaxis. And we could see that we weren’t actually doing that in the majority of cases,” she said

Quality improvement project: i nterventions

A few interventions were put in place to address some of these barriers. In order to convince the facility physicians on the safety and efficacy of IPT, sensitisation sessions were held reviewing the evidence base of the WHO guidelines on the use of IPT in patients living with HIV.

An IPT Stamp was developed to help locate that initial script for IPT (and its initiation date) in the patient’s health passport, make it more visible and to make it easier to prescribe.

Lay counsellors were put on the frontline of TB screening and reporting.

“Lay counsellors communicate in the patient’s language,” said Dr Zarou, “overcoming the language barrier faced by clinicians, so they were given the responsibility for actually screening the patients for TB.”

A checklist was prepared and displayed in each counsellor’s room, and after screening, counsellors recorded their findings both in the patient’s health passport and in the clinic’s patient file.

A quality improvement plan was developed to put these interventions into practice.

“We had multi-disciplinary staff meetings every two weeks, to discuss performance data and and sensitise staff to the quality improvement work plan” said Dr Zarou.

The plan included having the clinicians train counsellors on IPT (the duration of treatment and the need for monthly screening for side effects and TB), “who then were to empower the patients with the knowledge of why they were actually being put on IPT,” said Dr Zarou.

The TB screening check-list was developed and distributed to the lay counsellors. TB suspects would then be referred to the nurses for sputum requests, after which they were booked for review by doctors, who were to initiate IPT. Then the pharmacy was to dispense, register and monitor the INH.

“This final step was found to be the most labour-intensive of the whole project,” said Dr Zarou. “The process of screening, registering, recording and dispensing of TB-IPT was found to be time- consuming for a pharmacy staff that is already burdened with dispensing of ARVs.”

Results

Despite the initial barriers and low uptake, by August 2009, over 3000 patients were prescribed IPT (49% of all patients). This success actually presented something of a challenge, according to Dr Zarou, because of the high growth rate and a very high daily clinic patient load. But with each round of quality improvement (every quarter), a higher percentage of patients are being put on IPT — and completing the regimen.

According to Dr Wellwood, there was a low default rate primarily due to health systems issues rather than patient default. The prescription of IPT became, and remains, the standard of care, and the problems that arose were primarily facility specific,” said Dr Wellwood who recommends developing facility-specific operating procedures, orienting all staff, and addressing systems flow issues early.

Dr Zarou pointed out that the quality improvement tools and programmes empower the staff to come up with innovative solutions to problems that arise — and that solutions also come from regional meetings where they can learn from the experience of other facilities.

Ongoing monitoring is also key to the programmes success

“Well structured monitoring and evaluation tools (e.g. electronic data bases) are essential to track the use and outcomes of TB-IPT. This can also be done without electronic databases, but it becomes more labour intensive work,” said Dr Zarou.

Barriers and successes in other studies: in Kenya

These two clinics have very quickly scaled up IPT — to a much larger percentage of patients than reached by some of the first programmes to pilot IPT.

For instance, the Eastern Deanery AIDS Relief Programme (EDARP) in Kenya has been much praised for its early adoption of IPT for people with HIV, and the programme reports the highest treatment adherence/completion rates ever recorded for IPT in a clinical setting (84.9%). It helps assure high treatment adherence by excluding patients with known adherence or substance abuse issues, and by providing weekly community health worker visits, random nurse home visits for pill counts and other unscheduled visit to check for side effects and other illnesses.

But what usually goes unnoticed is that the programme only puts about 10% of its patients on IPT because it only targets the ‘well’ patient. It excludes pregnant women, people with a prior TB history or because of monitoring or adherence concerns — but the vast majority do not qualify simply because they have symptomatic stage III/IV HIV disease.

One of the problems with people with symptomatic HIV is that the symptoms often overlap with the key symptoms used in TB screening: cough, fever, recent weight loss. According to a presentation by Dr Lucy Wanjiku Nganga, of the US CDC in Kenya, EDARP does a very thorough job at screening for TB —the challenge is in getting the TB diagnosis.³  Checklists for TB screening are integrated into routine patient visit forms. Nurses perform TB screening before the patient sees the clinical officer or doctor. In addition, all new patients have sputum collected and sent for smear microscopy regardless of symptoms, and if they are smear-negative but symptomatic they also receive a chest x-ray. Any returning patient is put through this same process if they are symptomatic.

Dr Nganga reported that TB screening has identified about 12,071 (58%) of EDARP 20,707 HIV patients as TB suspects. Although most are not found to have TB, 31% of the patients are eventually diagnosed with active TB. However, only 63% are diagnosed as a result of the screening process at enrolment. Thirty-seven per cent are diagnosed in follow-up — with the majority of these only recognised after they have started antiretroviral therapy.

Although there are concerns about missing ‘subclinical TB’, much of the problem is that it is very difficult to diagnose extrapulmonary or smear-negative TB, partly because TB culture in this setting is only available for retreatment cases — not to investigate suspected TB in people with HIV.  As a result, the majority of the people who are most at risk of TB in this programme remain in sort of a therapeutic limbo, either waiting for a diagnosis or to go on and develop TB. One potentially more humane option, suggested by Dr Stephen Lawn of Cape Town, to be discussed in a future HIV and TB in Practice column, would be to simply put such patients on empiric TB treatment.

Barriers in São Paolo

In Brazil, people with HIV also face a number of decision points after entering care that will determine whether they get IPT — and each offers an opportunity for something to go wrong, according to Dr Mariangela Resende, of the University of Campinas in São Paolo.

Brazil has a much-admired ART programme and the Brazilian National AIDS and TB programmes also recommend IPT for people with HIV who screen positive on tuberculin skin tests (TST) (and who do not have active TB).

“However, this recommendation has not been instituted regularly among individuals with HIV, even in settings with organised programmes like metropolitan Brazilian areas,” said Dr Resende.

So Dr Resende and colleagues performed a review of medical records to evaluate missed opportunities for treatment of latent tuberculosis among HIV-infected patients at the Brazilian University Hospital, a general, tertiary care facility in São Paolo, where in-patients have a TB incidence rate of about 38/100 000 inhabitants. The study included 271 people with HIV without previous active TB.⁴

As in other studies, they found that tuberculin skin tests (TST) make an IPT programme much more complicated.

Of the 271 subjects, the TST was solicited from 219 (80.8%). Results were only available for 155 (70.8%) — and health care workers interviewed by Dr Resende stressed that the TST takes two clinic visits; the application of the test and the reading schedule for the skin reaction make it difficult to get patients to come in to have their test results read on the right day.

Of those for whom TST results were available, 37 (16.9%) had a reaction greater than/equal to 5 mm (which was the cut-off for latent TB in this study). Twenty-two (59.5 percent) patients received full isoniazid treatment.

Fifteen others clearly should have been put on IPT, but Dr Resende pointed out that overall, after tallying up all the missing tests and results, as many as 131 of 271 (48.4%) patients ‘may’ have qualified for IPT. While not all would ultimately have qualified for IPT, this does suggest that a fair number of people with HIV and latent TB would be missed by this process.

A chart review like this doesn’t tell one everything, and in follow-up interviews with health care workers involved in the facility, it was noted that some of these subjects could have been TB suspects, and that there is often a delay in getting TB investigated.

However, the challenges posed by requiring TSTs should serve as a cautionary tale to any programme considering introducing TST in response to the findings of the Botswana IPT study (see December 18 2009 edition of HATIP).

Even so, the healthcare workers interviewed by Dr Resende and her colleagues recommended a number of operational measures and interventions to improve IPT uptake. These included putting the TST protocol in all charts of HIV-infected patients and making sure that the TST status was checked and updated during the follow-up visits for every HIV patient. Patients with a positive TST results, but who had never received isoniazid treatment should be evaluated immediately for IPT.

There was also a call to evaluate the cost-effectiveness of IGRAs (interferon gamma release assays) compared to TST among HIV patients — an advantage of the IGRA is that it doesn’t require a repeat visit to read. However, they are much more expensive

Finally, the health care workers called for stronger linkages with the local TB programme, not only to optimise the TST process at primary health care facility but to guarantee early diagnosis of both TB and HIV in patients.

Accelerating efforts to control TB

By Theo Smart

The world is still a long way off meeting some of the TB control targets linked to the UN Millennium Development Goals (MDGs). At the Union World Conference on Lung Health in December, several experts proposed taking more aggressive action to reach targets to reduce the global burden of TB and TB-related mortality.

Recommendations ranging from adopting more proactive strategies to detect cases sooner and shorten diagnostic delays, to rolling out HIV treatment earlier in order to prevent TB, and offering TB treatment to all people with advanced HIV (even without a confirmed diagnosis). This article reviews some of the proposals for more aggressive action.

Targets

Technically, the world has already met the 2015 MDG goal of halting and reversing the increasing incidence of TB, because it peaked at a very high level in 2004. But the World Health Assembly and the Stop TB Partnership set the bar a bit higher by linking this goal to several other targets or milestones to be achieved by 2005 including:

• Detecting 70% of new smear-positive patients arising each year, and successfully treating 85% of these cases;
• Cutting TB prevalence and death rates to half the 1990 level by 2015;
• Cutting the global incidence of active TB to less than 1 case per million people per year by 2050 (thus eliminating the TB as a health threat of global significance).

But of these other milestones, only the 85% treatment success target has been reached — and that has only happened very recently, in 2008 — though not in every important region, such as sub-Saharan Africa, according to the recent update to the 2009 Global Tuberculosis Report).¹

Even so, the epidemiological impact of this achievement may be limited because programmes only seem to be diagnosing or at least reporting about 62% of the estimated number of smear-positive TB cases. That means that close to 40% of smear-positive (infectious) TB cases could remain undiagnosed and capable of spreading the disease in the community and sometimes (see below) in health facilities.

“Many DOTS countries are achieving 85% cure rates, which is reassuring, but the minimum of 70% case detection is not yet achieved in many settings,” said Dr Léopold Blanc of the World Health Organisation’s Stop TB Department, during a session on TB case finding among vulnerable populations.²  “And I just want to stress that 70% case detection was a target for 2005 — we are in 2009. Four years later, we have to get out of this 70%. We have to aim for 100%.”

Likewise, even though TB prevalence and mortality rates are falling in most settings, the 2015 targets are unlikely to be met globally, according to the update to the Global Tuberculosis Report, because of the continuing high rates in Africa. Rather disturbingly, the reported death rates don’t even include the deaths of HIV-positive people with TB, so the actual mortality rates have to be much higher. Nevertheless, because of the impact of HIV on the TB epidemic during the 1990s and 2000s — and the large population of people with HIV and at increased risk of TB, it will be impossible to achieve the TB prevalence and mortality targets in Africa without tackling HIV.

Of course, recommended activities including collaborative TB/HIV activities such as the Three I’s, health systems strengthening, developing new tools for diagnosis, treatment and prevention, and empowering and educating people with TB and in the affected communities (Advocacy, Communication and Social Mobilisation or ACSM) could have a great impact on TB control. But Dr Blanc stressed that these interventions have not been widely implemented. (Encouragingly, this Union World Conference contained a large number of symposia on the Three I’s, often running concurrently). 

Improving case detection

Nevertheless, a way forward is needed to more rapidly achieve the MDGs according to Dr Blanc: “we need to accelerate efforts in TB control by aiming at 100% case detection — universal access — and by shortening diagnostic delays.”

He described a framework WHO has developed to identify bottlenecks and constraints that limit identification of TB in vulnerable populations; and to indicate actions to reduce delays (whether due to the patient or health sector) and improve case detection and notification. The framework considers the steps between the time of infection and starting treatment, including the development of active disease, the recognition of symptoms, approaching the health services, getting a diagnosis from the health system, to case notification. Each step provides an opportunity for intervention.

For instance, delays in patient health seeking behaviour could be reduced by more effective ACSM programmes that educate people to recognise the symptoms of TB and seek a diagnosis, and by minimising barriers to accessing a diagnosis, perhaps by decentralising diagnostic services.

Delays on the part of the health service could be addressed by making sure effective TB screening is implemented with broader indications for who should be screened, and by taking actions to improve the quality and efficiency of diagnostic services.

Developing effective collaboration between the public health sector and private providers (including non-governmental organisations, faith-based organisations, traditional and informal health care providers) referred to as a public-private mix (or PPM) could also help alert the health system to TB cases that have been identified but not yet notified, making certain that they receive appropriate referrals and care.

“But there is a short cut for some targeted groups through this path and around the many obstacles to diagnosis— active case finding,” said Dr Blanc. Active case finding can avoid both patient and health system delays entirely through early identification and diagnosis of active disease before an individual seeks medical attention.

Dr Blanc stressed that active case finding “is not about screening the entire population, but should be focused at the populations and groups most at risk” such as prisoners, the poor, people living in congested urban settlements, refugees, migrants, women, household contacts and in particular children. Analysis of local epidemiological data should guide the selection of which groups to target first.

However, some audience members stressed that active case finding among the general population might be justified in settings where the burden of TB is particularly high. Indeed, this approach paid off in Dr Corbett’s DetecTB study in Harare — though the yield was greater in some communities than others.

Meanwhile, an active case finding study performed in a rural district of Ethiopia had a very high yield of smear-positive TB.³  The study used health extension officers to provide door-to-door active case finding which identified 2.5 times the number of cases identified by passive case finding during the same period. In other words, for every smear-positive TB case in treatment, there were at least 2.5 undetected smear positive TB cases. The survey also identified a higher proportion of female patients than were being diagnosed by passive case finding.

A similar finding was made by another study that compared the gender of people diagnosed by passive case finding verses active case finding (screening of household contacts) in Peru.⁴  Over a period of five years, 60% of the 1259 TB cases identified by passive case finding were men, while active case finding identified TB in an approximately equal proportion of men and women (51%). “Furthermore, active case finding in household contacts diagnosed TB after a significantly shorter cough duration than passive case finding (median 15 days (IQR 7-30) vs. 30 days (IQR 15-60) respectively, p<0.001),” the authors wrote.

A number of other presentations and posters at the conference explored some of these other community-based approaches to increasing case detection in more depth. 

Public-private mix: engaging more providers in case finding and notification

Dr Noor Ahmad Baloch, the National TB Control Programme Manager in Pakistan described how diverse types of formal and informal providers can be engaged in TB case finding and management.⁵

TB is a major public health problem in Pakistan. In a population of 170 million there are about new 300,000 cases (75% among people of reproductive age) and 15,000 new MDR TB cases each year. DOTS was introduced in 2001 and fully implemented at all public facilities by 2005. But around 40% of the total population lives in peri-urban low-income communities, with poor housing, inadequate water, sanitation and little or no access public health services.

Most of this population is dependent upon “a huge and diverse private sector providing health care to the population,” said Dr Baloch. “There are general practitioners, hospitals, for-profit, not-for-profits and non-governmental organizations — and one NGO has 108 outlets that exclusively provide TB services. There are also informal practitioners, many of whom are not qualified, not registered, not licensed, illegally practicing.”

A systematic approach was adopted to research and prepare for implementing the PPM. This started with a study assessing the knowledge of providers, conducted at sample sites in two large cities with 600 doctors providing TB services. Out of all of these doctors, only one knew that the first and the priority diagnostic tool for TB is sputum smear microscopy — most were instead relying on chest x-rays.

Once these doctors were trained and provided with free TB medications, an evaluation found that they readily adopted the DOTS strategy.

Next, a country-wide institutional analysis was conducted among all the stakeholders, assessing the capacity, gaps and needs of hospitals, NGOs and others providing TB care.

Based on this analysis, a national strategic framework was developed with six different models for delivery of TB services working with the different types of providers available in different areas (rural and urban). Operational guidelines and a mechanism for monitoring and evaluation were also developed.

The presentation focused on two models: social franchise marketing targeted to peri-urban low-income communities in very large cities; and a district led model, serving low income populations with poor access to TB services in both urban and rural areas.

In social franchising models, the private sector providers are trained and empowered to delivery branded and quality assured health services: in this case, TB diagnosis and treatment services.

In Pakistan, the social franchise marketing model provides active case finding through media marketing, ‘chest camps’ and interpersonal communication with community advocates who identify and refer suspects for diagnosis, with smear microscopy provided by a private laboratory.

The district-led model strengthens passive case finding — with diagnostic services being provided after the patient presents for care and smear microscopy is performed by either a public lab or NGO/ CBO supported lab.

In both models, the department of health provides free treatment, which is prescribed to the patient by a trained GP — though directly observed therapy may be provided by the practitioner, an outreach worker or lay healthworker. The social franchisee is responsible for default tracing, reporting and quality assurance in the franchise social marketing model, while the district health sector provides these services for the district-led model.

Of course, before launching, materials, including the ACSM strategy and reporting and recording tools, were developed and resources mobilised (the Global Fund initially supported the Social Franchise Marketing). The target population had to be identified, surveyed and mapped. A training programme was developed and implemented and supply logistics worked out.

But in the space of just a few years, the social franchise marketing model engaged about one thousand GPs, large numbers of community workers and 54 private labs in five very large cities in Pakistan — covering a total population of 40 million. After 2005, the number of TB cases (smear-positive and all types) diagnosed and notified by GPs jumped dramatically (by around 12-20 fold). In the last couple years, the private sector has contributed 18-26% of the cases to national case notification.

While the model is feasible to provide TB services to the vulnerable population, “it needs evidence-based refinement for scale-up, keeping in mind sustainability,” said Dr Baloch, because there have recently been concerns about the sustainability of the project as Global Fund support for staff salaries has dried up.

In Myanmar, TB services are also being provided by the private sector via social franchising.⁶  Population Services International (PSI) presented a poster at the conference reporting that TB services — free to the patient but made available through the private sector — could be scaled up very rapidly (to over 600 clinics within five years), and reach significant numbers of cases (the programme is responsible for 10% of case notifications nationally). As time goes on, and new, more remote clinics join the franchise, the programme has became more effective at reaching the poor.

The TB service is branded as ‘Family DOT’ using the same logo as the National TB Programme, and in addition to TB diagnosis and care, participants receive free nutritional and adherence support. Community health workers are paid both to perform active case finding and provide treatment support. The National TB Programme provides treatment for free and franchisees are not paid to delivery TB services (though they can charge for other services they may provide the patients).

PSI currently pays for many of the services that are provided but argues that the model would be sustainable with public funding — though the cost effectiveness of some services might be a concern. (A paper on the earlier days of the programme by Lönnroth et al in Health Policy and Planning Advance Access is also available online.

Engaging private and informal care providers to reduce diagnostic delay

Several posters from Africa emphasised another important reason to engage healthcare providers (formal or informal) — to reduce diagnostic delay. A study in Kampala found that the mean delay between symptoms and reaching the public health services was 7.4 weeks — during which time people had consulted 4 different healthcare providers outside the public health services, including nurses, midwives, drug shops and private GPs.⁷

Another poster reported that in the slums near Nairobi, 72.6% of TB patients first sought care from one of these providers, and as a result the average patient delay (between recognition of symptoms and diagnosis) was seven weeks.⁸

A pilot programme was launched in one of the settlements (Kawangware). First, a mapping exercise was conducted to identify all the potential providers in the area. They were then invited to a sensitisation/training meeting on TB and on the tasks that the providers would be expected to carry out. Participants were given referral forms and asked to refer all patients with a cough of two weeks or more to the nearest diagnostic centre, and provided with regular supervision.

Out of 106 providers identified, 48 attended the training session and 25 participated in the initiative. In the space of six months 267 TB suspects were referred, though only 26.5% completed the referral. Almost half of these were diagnosed with TB however, and TB case finding at the diagnostic lab increased by 46% during that period. Subsequently, the programme has been expanded to other communities — and a number of new DOTS centres establish to reduce clinic congestion.

With an estimated 200,000 traditional healers (or sangomas) in South Africa, compared to 25,000 doctors, 80% of the black population go to a sangoma as their front-line healthcare provider, according to a poster from Dr Krista Dong and colleagues from iTEACH and Edendale Hospital in KwaZulu Natal.⁹ Despite calls for greater cooperation between the health services and sangomas, there has been no systematic integration of the traditional healers into South Africa’s TB or HIV programmes.

In 2006, iTEACH engaged a network of 300 sangomas interested in improving their knowledge about TB and HIV, but existing certification services were only available in English. iTEACH developed materials, including a patient referral form to document the signs and symptoms of TB, AIDS or drug side effects and in 2009 launched a counselling certification course in the local language (isiZulu). During 2010, traditional healers will be engaged to provide adherence support/defaulter tracking and a pilot study will evaluate the use of healer referral form.

Dong et al note that many doctors and nurse are reluctant to work with traditional healers — particularly because they have observed cases of toxicity due to ingestion of herbal remedies. However, the sangomas engaged in the iTEACH programme “uniformly acknowledge that TB and HIV cannot be cured with traditional or herbal remedies and infection and that patients must be referred to clinics and hospitals for effective treatment and management,” Dong et al reported. Meanwhile, the majority of patients are enthusiastic about being able to receive support from both the formal health services and their local sangoma.

Reducing diagnostic delay at the health facility

Dr Dong also gave an oral presentation on the use of community-based workers to increase the use of bacteriologically confirmed diagnosis, increase diagnosis and reduce diagnostic delay at Edendale Hospital.¹⁰

She first reviewed all the frightening facts related to the HIV and TB epidemics in KwaZulu-Natal, South Africa where Edendale Hospital is situated: the province is the epicentre of the HIV epidemic, and has the highest TB burden in a country with the fifth highest TB burden globally; district cure rates are extremely low, and there are rising rates of multidrug resistant- (MDR) and extensively drug resistant- (XDR) TB. Edendale Hospital serves an area covering about one million people — the antenatal HIV prevalence is 60%, and 50-80% of the beds contain patients with HIV. There is also a high inpatient TB burden with about 200 new cases each month — and an 2007 MRC study found that 40% of coughing patients had culture positive TB.

But despite all this, “there have been no deaths due to TB in three years,” said Dr Dong, pausing for effect, “because they die in OPD, they die on arrival to the ward before receiving TB results — and their deaths are never registered.” However, post-mortem results suggest that at least 40% of deaths in the public sector in KZN are TB culture-positive.

In 2005, bacteriologic coverage was only 23%. Sputum request forms were not filled in, were filled in incorrectly or simply not getting to the lab. Doctors complained that they never got results back anyway, and the average turn-around time did indeed exceed the average length of hospital stay.

HATIP 105 has previously described how Dong and colleagues were able to turn the situation around by hiring and training a couple of community health workers, called `TB warriors`, who were given the responsibility to collect sputum specimens, make sure that sputum request forms are filled out, take specimens to the lab, collect results and get them to the patient.

Bacteriologic coverage at the hospital has now increased to 95% and within a few month of launching the TB warriors, the lab turn around times have shortened dramatically to less than 0.5 days. Dr Dong says that provincial “buy-in has now occurred” and the programme will soon be scaled up by the government.

Quality assurance programmes for laboratories can also improve the confidence of clinicians and decrease the turnaround time (and diagnostic delay). According to a presentation on the FIDELIS initiative, a case finding venture funded by Canada and the International Union Against Tuberculosis and Lung Disease, projects that implemented innovative activities in microscopy laboratories were among the most successful interventions piloted.¹¹ Fidelis supported 52 different case finding projects for patients with limited access to TB care — using strategies such as general health systems strengthening, active or semi-active case finding, IEC/ACSM projects, PPM activities, incentives, and lab improvement. Unfortunately, the initiative was not really designed to establish the relative effectiveness of the strategies.

Improving screening tools and targeting HIV

The effectiveness of active case finding may be limited by the appropriateness of screening tools being used in the target population, and HATIP has previously described efforts to refine TB screening tools in people with HIV.

There were a couple of important presentations at the conference with more recent findings on this matter, including one with the preliminary results on a meta-analysis undertaken by WHO’s STOP TB Department to identify the best constellation of signs and symptoms to confidently exclude active TB disease in people with HIV. We will discuss these findings and their implications in a future issue, since WHO will be holding a meeting in a couple of weeks to discuss the data, and the development of a new policy that will more closely integrate intensified case finding in people with HIV with the delivery of isoniazid preventive therapy (IPT) to those in whom TB is excluded.