February 2002 Insights Health Issue #2

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Providing care in South Africa
Lessons from TB/HIV pilot districts

South Africa is facing a dual epidemic of tuberculosis (TB) and HIV. An estimated 4.7 million South Africans are infected with HIV; 1.6 million of these will develop TB. How can the country tackle this enormous problem?

The country's Department of Health is participating in the WHO/UNAIDS ProTest Initiative that seeks to increase access to voluntary HIV counselling and testing (VCT) and improve TB/HIV care. The Department established four 'TB/HIV Pilot Districts' in 1999 in collaboration with the Initiative and the London School of Hygiene and Tropical Medicine. Two are urban/periurban districts (East London, Eastern Cape; Central District, Western Cape) and two are rural (Ugu South, KwaZulu-Natal; Bushbuck Ridge, Northern Province). The goal is to implement and evaluate a comprehensive package of prevention, care and support (see box). This package does not yet include access to antiretroviral drugs (ARVs) for HIV.

Each district established a TB/HIV Committee to strengthen collaboration and communication between key stakeholders including: district health officials, social services, public healthcare workers, private practitioners and non-governmental/community-based organisations. This helped to improve referral between health and community services and ensure continuity of care.

The programme trained 109 people to provide HIV counselling and 141 nurses to deliver clinical services including rapid HIV testing, prophylaxis and management of HIV-related infections. As a result, the number of people tested for HIV increased from 1703 in the third quarter of 1999 to 4073 in the third quarter of 2001.

In the four Pilot Districts:

• 26,554 people have been tested for HIV; 8855 are infected.
• VCT has averted an estimated 2700 HIV infections and 900 TB cases.
• The proportion of screened HIV-positive people who started TB prophylaxis (isoniazid) varied from 23 percent in Central District to 52 percent in Ugu South.
• Adherence (defined as the proportion of people receiving isoniazid who picked up six monthly pill packs over a period of eight months) ranged from 13 percent in Ugu South to 63 percent in Central District.

In Bushbuck Ridge, researchers conducted in-depth interviews with six clients who completed a course of isoniazid, six who interrupted treatment and six entering the screening process. They identified barriers to adherence including:

• lack of money for transport to the clinic
• insufficient money for food
• perceived and real side-effects
• beliefs that medicines should only be taken with food and when ill
• views that 'western' drugs should not be taken with traditional medicines.

The researchers suggest that adherence could be improved by:

• alleviating poverty
• improving access to health facilities
• addressing clients' concerns about side-effects
• counselling patients about the risks and benefits of treatment
• implementing reliable drug supply systems
• involving traditional healers
• establishing and sustaining support groups for people living with HIV
• monitoring and reporting adherence, by integrating a simple recording and reporting system into existing health information systems.

The pilot programmes have shown that with adequate training and support it is possible to provide ongoing care to people living with HIV in resource-poor settings. Does this programme offer a framework for delivering ARVs? First, further research is required to determine what interventions and support systems would best improve adherence. Health services might then consider a phased implementation of interventions, starting with improved VCT services, then adding isoniazid preventive therapy and cotrimoxazole prophylaxis, and finally adding ARVs.

Harry Hausler and Peter Godfrey-Faussett
PO Box 51093
Waterfront 8002
Cape Town
South Africa

T: +2721 439 5364
F: +2721 439 5363

Harkeith@netactive.co.za

Co-authors: K. Rowe, B. Makhubele, P. Pronyk, J. Kim, P. Naidoo, B. Karpakis, J. Sallet, C. Sheard, L. Campbell and M. Colvin

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