South Africa: Integrate TB-HIV Services! 6/6/10
Seven out of 10 South Africans with TB also have HIV, yet they have to get their TB and HIV treatment in different clinics.
By Kerry Cullinan
6 June 2010
Seven out of 10 South Africans with TB also have HIV, yet they have to get their TB and HIV treatment in different clinics.
The buzzword at this week's national TB conference in Durban was "integration" of TB and HIV services. But despite support from Health Minister Dr Aaron Motsoaledi who said the "dual epidemic is a public health emergency", this integration isn't happening on the ground.
Dr Nono Simelela, CEO of the SA National AIDS Council, described the separation of TB and HIV services as "an accident of history not a design for best practice".
"We are disorganising the response to a co-mingled and indivisible problem. We are the immediate problem, not TB-HIV. But we can solve this problem if we want to," Simelela told the conference opening.
Most HIV positive people die from TB, so early detection and treatment is vital. People with HIV but not active TB can also be given medicine called Isoniazid which protects them against TB bacteria that might be latent in their bodies.
People with HIV have a 10 percent chance of getting TB every year while HIV negative people have a 10 percent chance over their entire lifetime.
But former Health Minister Manto Tshabalala-Msimang always favoured a separation of the two diseases, claiming that she wanted to spare those with TB from the stigma of AIDS.
What this has meant in reality is that many HIV clinics are not picking up their patient's TB, HIV patients are not getting Isoniad, TB clinics are not testing their patients for HIV and there are life-threatening delays in patients getting either TB treatment or ARVs, depending on which clinic they start from.
In fact, the World Health Organisation's Dr Haileyesus Getahun said only seven percent of HIV positive people were screened for TB in South Africa in 2008.
At the close of the TB Conference on Friday, the 1 800 delegates passed a unanimous resolution "to integrate TB and HIV clinical services such that patients receive comprehensive integrated care provided by one clinician at primary healthcare level".
Lesley Odendal from Medecins sans Frontieres (MSF) in Khayelitsha in Cape Town says all 11 clinics in the township have offered integrated TB-HIV care since 2008.
"This has improved efficiency and clinical care," said Odendal. "Previously, patients were referred from TB clinics to distant antiretroviral service points, resulting in long waiting times and a duplication of clinical and laboratory tests and medical records."
In 2007, only one in five TB patients were on ARVs. But with integrated services, this number has jumped to around 68 percent in some clinics. Instead of waiting 42 days for ARVs once being diagnosed, TB-HIV patients now wait around 27 days.
Tired of the lip-service paid to integration, an alliance of organisations including the MSF, Treatment Action Campaign, Southern African HIV Clinicians Society (SAHCS) the AIDS Rights Alliance (ARASA) and iTeach have given the health department three months in which to come up with practical guidelines on how to integrate TB and HIV services.
"Whole rainforests have been sacrificed in the World Health Organisation's library on the question of TB-HIV integration. We don't want a policy document. We want a short, simple practical guide for clinics," said ARASA's Paula Akugizibwe.
SAHCS's Dr Francois Venter said to start with, TB nurses could screen patients for HIV and start ARV treatment for those who needed it.
"The TB nurses are going to see the patient for six months while they are on TB treatment. If they initiated and monitored their patients' ARVs, this would save a huge number of lives in a short time," said Venter.
Dr Krista Dong, who runs a TB-HIV programme called iTeach at Edendale Hospital, said only one in five patients suspected of having TB were actually tested.
To address this, iTeach had employed two "treatment warriors" in 2007 to help identify TB patients in Edendale's wards. Now about 95 percent of patients suspected of TB are tested for TB and HIV. The warriors have reached 7000 people and 1000 of these have also been put onto ARVs.
Dong warned against the business-as-usual approach of holding training workshops for healthworkers without monitoring those trained to ensure that they improved their performance
Research has shown that three-quarters of nurses wanted refresher courses on TB, but that there was "no difference in performance between those who had been trained and those who hadn't," said Dong.
"Integration of services needs a few staff who are empowered and held accountable for their performance," said Dong.