Caring for the caregivers in the face of HIV and TB: a clinical review (part one)

Additional reporting by Lance Sherriff.

This clinical review was kindly supported by the Diana Princess of Wales Memorial Fund. Previous clinical reviews can be found here. 

We would like to thank the following reviewers: Dr Linda Gail-Bekker, The Desmond Tutu HIV Centre, Cape Town, South Africa; Dr Liz Corbett, London School of Hygiene and Tropical Medicine, Harare, Zimbabwe; Dr Halima Dawood, Greys Hospital, Pietermaritzburg, South Africa; Dr Krista Dong, i-Teach, Edendale Hospital, Pietermaritzburg, South Africa; Dr Haileyesus Getahun, Stop TB Department, WHO; Chris Green, Spiritia Foundation, Jakarta, Indonesia; Dr Kerrigan McCarthy, Reproductive Health and HIV Research Unit, South Africa; Professor Emmerentia du Plessis, North-West University, Potchefstroom Campus, South Africa; Dr Fabio Scano, Stop TB Department, South Africa; Dr Doug Wilson, Edendale Hospital, Pietermaritzburg, South Africa; Professor Alta Van Dyk, UNISA, Pretoria, South Africa.

Case study

Prudence called in sick to work today.

She has worked as a nurse for a few years in the district hospital serving area where she was born. At first, she was excited about her job and eager to give something back to her community; but it has proved more complicated than she expected. One challenge she has found is that she knows quite a few of the people coming in for care, including several members of her extended family who are HIV-infected - but she has had to keep this information to herself. For instance, she held her tongue when a man living with her cousin started taking antiretroviral therapy (ART). He quit taking it shortly afterwards, and tried to tell her that medicinal herbs from a traditional healer had cured him. He died not long after that. Since then, she has found herself growing increasingly annoyed with patients who are reluctant to start treatment, or who have adherence problems - especially if she knows them or their families.

Each day is an emotional rollercoaster. Although she has seen ART restore health to many patients, she has also seen many who only came for care when they were gravely ill, or who came into the clinic just once or twice and then simply never came back. Many people are still dying - and are never visited by their families. The clinic is always busy, with too few staff to keep up with the workload, and her responsibilities just keep increasing.

At the end of one particularly exhausting day, Prudence pricked herself putting the cap back onto a needle after giving a patient an injection. It seemed minor at the time and so she didn’t report the needle stick injury (NSI) to anyone or try to access post-exposure prophylaxis (PEP). But later it began to worry her and she had some sleepless nights. She began to imagine symptoms of HIV and sometimes she would check to see whether her lymph nodes were swollen. Avoiding the testing facilities at her own hospital, she eventually went to a mobile clinic and tested negative. She still worries about contracting HIV in the workplace, though as a woman living in southern Africa, she is probably at greater risk of acquiring it within the community.

However HIV isn’t the only health danger Prudence should be concerned about: for instance, hepatitis B virus also poses a risk, and many health workers in resource-limited settings have never been vaccinated.  But the greatest threat of all may be TB. Prudence has attended to many patients who have TB, some probably multidrug-resistant, and several of her coworkers have come down with the illness. She’s decided just not to think about it too much.

Prudence could have one of these serious illnesses today - or she could just be exhausted, stressed out and simply sick of her job. Either way, the health system could be in danger of losing one of its most essential resources - one of its healthcare workers.

Why do we need to care for the caregivers?

Last year, HATIP ran two articles, on how programmes need to quickly scale up the production of healthcare workers, and how task shifting can help address some aspects of the healthcare worker shortage in resource-limited settings.

But while much has been written about healthcare workers migrating to settings where they can get better pay, the healthcare staff attrition in resource-limited settings can actually be due to a variety of factors.^1,2,3 Many work in grim and unsafe working conditions for inadequate pay. Eventually some quit their jobs because of overwhelming workloads and responsibilities undertaken for less than a living wage; or they have unsupportive or sometimes abusive management, and a lack of opportunities for further professional development.⁴  

Many healthcare workers are suffering from occupational stress - the feeling of being unable to cope with the demands or expectations of the job. Some feel that they have been inadequately trained or supervised for new tasks, or that they are unable to perform their jobs well when working in inadequate and often deteriorating facilities that are short of staff, necessary equipment and essential supplies (including, notably, gloves and other protective clothing).^5,6,7 Consequently, many are also concerned about workplace safety (occupational exposure to HIV and TB) - and worry about job security especially if they should become HIV-infected.

Finally, many healthcare workers are falling ill and dying from TB or HIV-related illnesses, with morbidity and mortality accounting for over 60% of attrition in some settings.^8,9

“One of the toughest things we face around this issue at Edendale Hospital is that there are notices in the hospital hallways every month - Sister so and so RIP Memorial service.  There are constantly funeral notices from hospital staff,” Dr Krista Dong told HATIP. She described one recent example of a leader of a local NGO working in HIV education, prevention and positive living who died from AIDS a couple of months ago, not on treatment. “He tested, was positive and died two weeks later. There is an epidemic of preventable death not just amongst healthcare workers, but in persons who are leaders in HIV programmes.”

Doctors are affected too. In fact, one study of 77 doctors who graduated in 1984 from Makerere University in Kampala, Uganda found that 11 had died of AIDS by 2004, and that six had committed suicide (at least five of these cases were believed to be related to a known or suspected HIV diagnosis).¹⁰

And even for healthcare workers who stay in the workforce, poor health and stress affect the quality of care that they provide. According to a recent survey of nurses in Swaziland, health workers believed that colleagues missed an average of 10 days per month due to their own or a family member’s HIV disease.¹¹

Clearly much more needs to be done to keep our healthcare workers healthy, happy and productive members of the health system.

This clinical review is devoted to the health and safety of our healthcare workers, exploring the factors that endanger their emotional, psychological and physical wellbeing, potential interventions that could be put in place to help protect them from harm, and how to most effectively provide access to high quality palliative care (including HIV and TB treatment) to healthcare workers where and when they need it.

This should begin with occupational stress and other experiences affecting the mental health of healthcare workers in the workplace - including stigma - because it has direct bearing on how they perceive workplace safety, respond to the interventions designed to protect them, and how they are most likely to access care.

The burden of occupational stress and burnout among healthcare staff

It isn’t necessary to tell the readership of HATIP that the healthcare profession is inherently stressful or that the HIV/AIDS epidemic has exacerbated the demands placed on healthcare workers.

But the severity and intensity of the HIV epidemic is often perceived as overwhelming by healthcare workers, especially since it involves whole families (including children) who are often suffering severe financial hardships and other problems at the same time.¹² According to a research project involving 20 AIDS service organisations in Canada, it is “the relentless complexity of working in HIV/AIDS” that makes it so difficult to retain an effective workforce when staff members have to continually deal with communication problems, fatigue, depression, unresolved grief, high staff turnover and burnout.¹³ Similar observations have been reported in a number of surveys of health workers in Africa.^14,15,16 While some of these reports come from surveys and interviews rather than rigorously controlled studies, the reports nevertheless show consistent trends.

“Occupational burnout and its manifestations (e.g. despondency, lack of capacity to give compassionate care, development of a negative self-image and the belief that it is not possible to make a difference) must be prevented at all costs,” wrote Professor Alta Van Dyk of the University of South Africa (UNISA). She conducted a study in 243 caregivers about to start a counselling course on HIV/AIDS at the school, asking them to fill out a semi-structured questionnaire about the stress factors affecting healthcare workers involved in HIV/AIDS-related care, their symptoms of occupational stress, and what type of employer or organisational support were available to them, and then to write short essays describing their own experiences and personal coping mechanisms. Prof Van Dyk pointed out that the participants were a ‘convenience sample’ of caregivers and since they were motivated enough to take the course and “thus choosing to empower themselves with more knowledge to cope with HIV or AIDS in their workplace” they may not be representative of healthcare workers in general.

Even so the key themes that emerged ring true: healthcare workers “battle with bereavement overload, over-identify with their patients, fear occupational exposure to HIV, and find it difficult to cope with their own and patients' stigmatisation and confidentiality issues. The caregivers generally believed that they had not been adequately trained to offer HIV-related counselling; they largely felt unsupported by their employers, family and friends; and they were frequently angry about slow government processes and misleading health messages." Of note, there was no relationship between the stress factors and any of the socio-demographic variables of the caregivers, “indicating that the experience of stressors in the HIV/AIDS field was inherent in the working context,” she wrote. However, younger caregivers were more likely to report stress-related symptoms (r_s = –0.135, p < 0.05).

Several observations stand out in the study - one is that more than half of the caregivers found it difficult to keep a professional distance from their clients/patients, and about four out of five (especially the nurses) “confessed that they felt the need to ‘rescue’ or save their clients/patients, often expressing their frustration in essay form at not being able to do so.” Prof Van Dyk noted that many studies have reported that caregivers who do not establish an appropriate emotional distance eventually suffered from severe occupational stress and burnout.

According to an UNAIDS report on managing stress in HIV/AIDS caregivers, “burnout is not an ‘event’ but a process in which everyday stresses and anxieties that are not addressed gradually undermine the carer’s mental and physical health, so that eventually caregiving and personal relationships suffer.”¹⁷

Since burnout occurs gradually, caregivers may keep working until their wellbeing and job performance hits rock-bottom.¹⁸ Thus, they may suffer from “compassion fatigue” for a prolonged period, during which time their patients may be neglected, treated in a detached, mechanical fashion; or even subjected to mental/physical abuse.¹⁹ In the UNISA study, about 21% of the healthcare workers said that they no longer cared what happened to their patients.

Even though most of the participants in the UNISA study reported using ‘positive’ mechanisms to cope with stress, many people who are truly burnt-out have not found healthy coping mechanisms. Having worked in the field since the early 1990s, this writer has personally observed many cases of severe stress and/or burnout among caregivers that have led to self-destructive behaviour, including alcoholism and drug dependency and more than a few cases of community-acquired HIV.

Yes, but won’t the ART rollout make everything better?

It should be noted that many of these surveys including the UNISA study were performed before the rollout of ART was in full swing - and it has been suggested that the ability to improve outcomes and save the lives of more patients could go a long way towards tackling the sense of helplessness and feelings of despair confronting HIV/AIDS. Indeed, in one analysis of PALSA Plus (Practical Approach to Lung health and HIV/AIDS in South Africa), nurses who were working in the primary healthcare clinics and responsible for most of the care delivered to AIDS patients, found new hope and motivation in the ART rollout - and shrugged off their increasing clinical responsibilities.²⁰

That’s fantastic, but there’s a chance that the novelty of ART could wear off after a while. It is worth noting that the Canadian survey of AIDS service organisations mentioned earlier took place well after the introduction of ART in that country, but stress and burnout were persistent. Although Prof Van Dyk reported that it was “the intensity rather than the chronicityof HIV/AIDS” that was most stressful to healthcare workers in her study, at the time HIV wasn’t really such a chronic condition in South Africa.

With ART, HIV care is for the long haul, and therefore, so is HIV disease. According to O’Neill and McKinney in A Clinical Guide to Supportive and Palliative Care, in the United States, “the prolongation of the disease course, uncertainty about overall prognosis, and a “roller coaster” pattern of repeated exacerbations and remissions in later stages of HIV disease have intensified the emotional and physical demands of caregiving.”²¹

In these circumstances, O’Neill and McKinney note that caregivers often have “little time or energy for self-care,” and the effects of neglecting nutrition, exercise, socialisation, and sleep are cumulative, potentially leading to very real physical ailments not to mention problems with relationships and family. Furthermore, healthcare workers who experience “work overload and interpersonal conflict over an extended period of time are particularly vulnerable to burnout.”

So despite initial programme successes in the ART rollout, a few years down the road, it may grow increasingly difficult for healthcare workers, who have been working under ‘emergency response conditions,’ to continue delivering quality care for a chronic disease to ever-increasing numbers of patients.

Health systems and programmes must make plans to support the mental health of the health workforce over the long term.

Stigma

Stigma merits special attention since it can have a bearing on how healthcare workers deal with occupational exposure. Healthcare workers not only observe stigma, they experience it first hand and often internalise it.

The healthcare workers in the UNISA cohort observed many patients being rejected by their families: “Some are being isolated”, one wrote, “they are given their own eating utensils and may not watch TV with others, especially when they are coughing’. 

Almost a third of the participants in the UNISA cohort were even afraid that people in their communities would stigmatise them because they worked with AIDS patients.  One home-based care nurse wrote that, in the community where she worked, she was known as ‘the AIDS sister who should be avoided’.  And in another study, one nurse reported trying to keep her profession a secret:

“I can’t dare to wear my nurse’s uniform when I go home. Before leaving the hospital, I remove my epaulettes, so that people can think I work for Pick ’n Pay [a food chain store] or something. It is risky these days to say that you are a nurse. People think because we work with HIV-positive people, that we are contaminated or something.”²²

Fears of contracting HIV caused problems at home.²³ “Some nurses confessed that they did not tell their husbands when they had sustained needlestick injuries because the husbands then refused to have sex with them (and in one case, he would ‘visit girlfriends’). They could also not share their (often irrational) fears with their partners, ‘because they freak out completely’,” Prof Van Dyk wrote.

Some healthcare workers believe that HIV would cause them problems in the workplace as well.

‘If I look at what is happening to my poor patients who disclose their status, I will never ever tell anybody if I am infected - not even my colleagues at the hospital,” said one of the participants in the UNISA study.

Indeed, according to a more recent and even larger survey, more than 40% of 910 healthcare workers interviewed thought that coworkers would laugh behind their back, or think that they were immoral if they knew they were positive.²⁴ Dr Liz Corbett presented findings from the survey, conducted to inform the “Treat” component of Treat, Train and Retain (TTR), WHO’s plan for AIDS and the health workforce, at the Union World Lung Conference in Paris last October. The study involved randomly selected health worker interviews from 50 different facilities (six randomly selected facilities, as well as four selected best practice facilities from each country) in Ethiopia, Kenya, Malawi, Mozambique and Zimbabwe.

Participants anticipated being stigmatised much more if they had HIV than if they had TB - although 63% of health workers said that if they had TB, their coworkers would consider them to be HIV-positive.

Almost 70% of healthcare workers interviewed thought that they would be discriminated against in terms of having fewer training and promotion opportunities if their employer were to learn that they were HIV-positive. Notably, all of these countries have national policies against HIV discrimination at the workplace - but only 36% of facilities had any written guidelines or even memos about it, and only 20% of healthcare workers were aware of the policy. 63% did believe that they would be able to report HIV discrimination without fear of reprisal.

Notably, in the recent survey from Swaziland mentioned earlier in the article, healthcare workers also reported fearing that their patients would not respect them or be willing to be treated by them if they knew that they were HIV-infected.²⁵ They “expressed a sense of failure and embarrassment for contracting an infection that they felt they should have had the knowledge to avoid,” wrote the study’s authors.

This form of internalised stigma is more difficult to assess but is an additional barrier to care, according to a recent paper by Eubel et al in JID. They quote Justice Edwin Cameron who defined internalised stigma as fear, self-disablement, and feelings of contamination, self-rejection and self-loathing that results in inaction, postponement, delay, denial and death.²⁶ In other words, delayed health-seeking behaviour. “The effects of this internal stigma, when added to the burnout experienced by many health care workers, contribute to enormous barriers for health care workers accessing HIV care. The fear of disclosure to colleagues within the small community atmosphere of a hospital, if confidentiality is not protected, can make the barriers seem insurmountable,” they wrote.²⁷

But HIV testing seems to be the first and most significant stumbling block.

“Many caregivers in the study said they preferred to live with the uncertainty of their HIV status than seek counselling or testing,” Prof Van Dyk wrote.

In the TTR survey, 70% of the 910 participants had had at least one HIV test - but most had privately tested themselves.

“Most of them had last tested more than a year ago and not through their own routine services,” said Dr Corbett. “The issue of how to provide regular HIV testing at the workplace in an acceptable fashion, is really the key to unlocking HIV and TB prevention and care in health workers in these countries —concerns around privacy and confidentiality are really paramount.”

The risk and burden of HIV/AIDS among healthcare workers

Possibly because many healthcare workers have been unwilling to get tested for HIV at their workplace or are not open about their results, it is somewhat hard to find reliable figures of how many healthcare workers are HIV-infected.

In the US, the Centers for Disease Control has reported that as of December 31, 2000, 24,844 adults reported with AIDS in that country had a history of employment in healthcare.²⁸ These cases represented 5.1% of the 486,826 AIDS cases reported to CDC for whom occupational information was known.

Notably, in the US, there were only 57 cases where HIV transmission was confirmed to have occurred following an occupational exposure and 139 cases where there was no other reported risk factor for HIV besides a history of occupational exposure to blood, body fluids, or HIV-infected laboratory material.

The average risk of infection due to a single percutaneous injury is estimated to be about 3 in 1000, which is higher than the risk after sexual exposure.²⁹ Globally, it has been estimated that a little over 4% of the HIV infections among healthcare workers are due to occupational exposure related to injuries with sharps.³⁰ Although the majority of HIV transmission due to occupational exposure is believed to occur in sub-Saharan Africa (more on that later), that still means that the vast majority of HIV infections among healthcare workers are community acquired.

But are healthcare workers more or less likely to be HIV-infected than the general population? The data are mixed.

In 2002, the Human Sciences Research Council performed a survey involving 595 respondents from public/private hospitals in four provinces (Mpumalanga, Northwest Province, KwaZulu Natal and the Free State) who were screened for HIV using an OraSure HIV test.³¹ The seroprevalence rate overall was 15.7% (95% (CI): 12.2-19.9%) - virtually the same as the 2002 seroprevalence rate among the general adult population aged between 15 to 49 years old in South Africa (~15.5%).

While the confidence intervals overlapped, there were some trends that could be worth noting. For instance, there was a slightly higher prevalence at primary health facilities and clinics (17.5%) than at hospitals (15.3%). There were differences by province, ranging from a seroprevalence of 9.6% in the Free State to 19.7% in the Northwest Province. The prevalence differed substantially between non-professional (20.3%) and professional health workers (13.7%). And finally, there was a higher seroprevalence in the younger age group (20% among 18 to 35 year olds) versus 16.6% in the 36 to 45 year old age group.

An even larger HIV surveillance study was performed a few years later in 1493 staff at Coronation and Helen Joseph Hospitals in Johannesburg, including medical doctors, allied staff, nurses, student nurses and general assistants.³² The prevalence rate in this cohort was lower, at 11.5%. There were differences by occupation: with a 2% seroprevalence in the doctors, 5.7% in allied staff, 13.7% in nurses, 13.8% in student nurses and 12.3% in general assistants. The highest prevalence by age was in the 25 to 34 year old age group (15.9%).

The study also looked at what percentage of the healthcare workers might need to go on treatment. 74 of 172 HIV-positive participants (43%) in the study provided blood samples for CD4 tests. The median CD4 cell count was 397 (range 69-1359) but 18.9% had CD4 counts less than 200 and (28%) had counts in the 201-350 cells range.

In an accompanying editorial Dr Olive Shisana of the Human Sciences Research Council calculated that if these findings were extrapolated to the nation, the number of nurses with AIDS, or in danger of having opportunistic infections (those with CD4 cell counts 200-350) could outstrip the number of nurses being produced in the next couple of years.³³  “The supply [of nurses] is not meeting the demand. This is even before we consider the question of emigration of nurses, or their exit to other professions.”

While producing more nurses should be encouraged, there is no reason why the HIV-positive nurses and other workers should be given up as ‘lost’. They can be treated, after all. Connelly et al’s data suggest that about 2.2% of all nurses would immediately qualify for treatment under current guidelines. This is a bit higher than the percentage of healthcare workers reported to be participating in ART programmes in the TTR 5-nation survey presented by Dr Corbett in Paris, where 1.9% and 1.6%, respectively, of the staff at randomly selected and best practice facilities were reported to be attending the ART clinic at their own facility.³⁴

“The rate of death among staff for 2006 was almost 1 percent at routine health facilities,” said Dr Corbett. “That’s high for a workplace setting, but it is not the very high rates that some smaller studies were reporting from individual African facilities.” She told HATIP that human resource managers at the facilities were reluctant to make an estimate of how many deaths or retirements were occurring at the facilities. However, in another part of the survey, respondents reported that about 45% (at the routine facilities) and 41% (at the best practice facilities) of the retirements or deaths in the previous year were believed to be due to AIDS.

The risk and burden of TB among healthcare workers

“Healthcare workers are at risk simply because they are part of our population and if our population incidence and prevalence is high, we can expect the same in our healthcare workers - both with HIV and with TB,” said Dr Natalie Beylis, during her talk which was directed to healthcare workers during a skills building session at the first South African TB Conference. “But the risk from TB is obviously higher because they are working in close proximity to infectious TB patients on a day to day basis, and infection control might not be optimised in their healthcare setting. So we know that the rates are much higher in healthcare workers compared to the general population. And of course, they have also got to deal with MDR/XDR-TB.”

That skills building session put together by Dr Beylis, Dr Kerrigan McCarthy and Dr Juno Thomas informs much of this section.

The following studies have looked at latent TB among health staff using either tuberculin skin testing (TST) or newer interferon γ release assays (IGRA) (such as Quantiferon or EliSPOT). Note, most had previously been vaccinated with BCG, which can lead to some false positives in TST (especially with repeated testing). According to a review by Joshi et al, (which goes into much more detail on all of the following) the prevalence of latent TB among healthcare workers in low and middle income countries is, on average, 54% (ranging from 33% to 79%).³⁵

Prevalence of latent TB in HCWs (some selected studies)³⁶

* = BCG vaccinations

Without preventive treatment, healthcare workers with HIV and latent TB have about a 5% annual risk of developing active TB, while those without HIV have about a 10% risk of active TB in their lifetime. However, about half of active TB occurs in the first two years after infection, so it would be useful to know the annual risk of TB infection (ARTi) in healthcare workers.

A few studies have studied that in high TB burden settings. One found an annual incidence of 14.3 infections per 100 person years (95% CI 4-30) among 35 resident interns in Peru.⁴² Another study by Corbett et al reported an ARTi of 19.3 per 100 person years (95% CI 14.2-26) in 159 Zimbabwean nursing students (a rate more than six times as high as experienced by 195 polytechnics students in the study).⁴³

Several retrospective cohort studies have reported high incidences of active disease in TB in healthcare workers, ranging from 1180 cases per 100,00 in the Western Cape of South Africa in 2002⁴⁴ to over 5,700 cases per 100,000 in Malawi in 2003.⁴⁵

In most cases, the incidence of active disease among healthcare workers was many times greater, and in the case of Ethiopia, twenty times greater than that of the general population.⁴⁶

The recent TTR survey reached a similar conclusion.⁴⁷ “The rates of treatment for TB are several times the national case notification rates in each country. And so these would be equivalent to 700 or 800 per 100 000 case notification rates,” said Dr Corbett. “48% of health workers [in the survey] stated that TB was the most serious threat to their health, which was higher than any other condition. 35% and 39% of the healthcare worker deaths in the previous year (in the routine and best practice facilities respectively) were attributed to TB,” she added, stressing that this was clear evidence that infection control practices are not good at most of these facilities.

This is even more worrisome in light of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB. (XDR-TB). As HATIP has previously reported, several of the deaths that occurred at the Church of Scotland Hospital in the Tugela Ferry XDR-TB outbreak were among healthcare staff.⁴⁸ But MDR-TB is a much more common threat.

“We had one of our clinic senior nursing sisters recently diagnosed with MDR-TB and she subsequently died,” said Dr Juno Thomas of Chris Hani Baragwanath Hospital in Soweto at the South African TB Conference. “Following that, I tried to engage with the superintendents and even the CEO of the hospital - firstly - to arrange an Infection Control Committee. We do not have an Infection Control Committee at that large hospital. If you don’t have support from your hospital and from higher up, you really are powerless to make any changes.”

The current practice of institutionalising people with drug-resistant TB in healthcare facilities may be making things much worse because some of the patients seem to be lashing out. A couple of participants at the skills building session at the South African TB Conference were convinced that the patients in the isolation wards were deliberately trying to infect the healthcare workers with their strains of TB. 

“I’ve had to go in there to mediate between the patient and the administration and whoever. In the Eastern Cape, the patients feel they’re locked away… and if you have them in the hall where you are now going to hear all their grievances, 140 patients will cough and cough on you. And they deliberately cough upon all our nursing staff,” said one woman.

This suggests yet another good reason to move towards community-based models of providing treatment to people with MDR-TB. But even that won’t remove the risk entirely.

“If you want to designate a specific ward or side-room for MDR patients, no one will voluntarily work there,” said Dr Thomas. “But they are working with MDR-TB patients all the time, unknowingly, anyway. Education, I think, is one of the biggest barriers to infection control in healthcare workers.”

Although participants in the TTR survey had a good basic knowledge of TB infection and control, the survey identified several areas where even key cadres had low levels of knowledge:

• Only 44% of qualified staff agreed with the fact that patients with negative smears can be considered non-infectious
• Only 62% agreed with the basic principle of cough hygiene that patients with a cough should be given a cloth or mask to cover their mouths until TB has been excluded
• There was poor knowledge (in only 23%) that keeping TB suspects/patients outdoors would keep TB from spreading
• Only 19% of health workers knew that ordinary surgical masks do not protect the wearer from TB
• 63% thought that ART would help protect HIV-positive health workers from TB, but only 39% thought isoniazid preventive treatment (IPT) could do so.

At facility level

• Only 28% practising outpatient triage for cough;
• Only 10% practising cough hygiene (cloths to cover mouth, coughing);
• Only 18% collecting sputum outdoors, as opposed to the toilet which is the most common place; and
• Only 46% of facilities with wards had a separate ward for TB inpatients.

And there was very little in the way of active TB prevention for HIV-positive health workers: mainly reliance on change of duties and early detection. Only Ethiopia had a policy of routine IPT for exposed health workers.

The second part of this article, due to be published next week, focuses on interventions that can protect and support caregivers.