SUMMARY:

The Desmond Tutu TB Center (DTTC) has developed a project focused on integrating TB and HIV services by expanding access to HIV-related services to large numbers of TB-infected inhabitants of the Western Cape (WC). The major emphasis area is development of networks and linkages and minor areas will focus on information, education and communication, community mobilization and linkages with other sectors. The project addresses challenges of reducing HIV transmission in communities and minimizing the impact of HIV on individuals. This project will be implemented in close collaboration with the Western Cape Department of Health, Cape Town City Health Department and non-governmental organizations (NGOs).

BACKGROUND:

Due to the record breaking TB rates in the WC, and the prevalence of HIV, and because both TB and HIV are increasing in sub-Saharan Africa, health system are failing to cope with this dual epidemic. Therefore it is necessary to develop effective and feasible strategies that can be adopted by health services to increase access to voluntary counseling and testing (VCT), provider-initiated counseling and testing (DCT) and care for people co-affected with HIV and TB.

This project addresses access to VCT and DCT by using existing household and community activities and will be a pathfinder in developing services to address access to counseling and testing (CT) for TB clients. It will be nested in six WC communities that form part of the Zamstar project. Zamstar works to reduce the prevalence of TB by improving integration of HIV and TB services, and through these efforts, have established community advisory boards and stakeholder support. The PEPFAR funded project will benefit the Zamstar project by implementing complementary activities focused on HIV and TB, by establishing off-clinic flexi-time VCT centers, and improving access to and utilization of VCT services through social mobilization.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Outside-Health-Facility Flexi-Hour VCT Centers

Approximately 6-7% of the adult population of the WC access VCT through existing healthcare services. The majority of the population who access VCT are women who are exposed to VCT through PMTCT programs, and clients who are referred from health centers. Few people undergo VCT through self-referral. The establishment of outside-health-facility, flexi-hour CT centers will expand the reach of CT to settings outside health facilities, making CT more accessible to those who do not access routine health facility-based CT centers. Males are a target group, and this activity will address the gender inequality in access to CT.

Individuals found to be HIV-infected through the flexi-hour centers will be screened for TB signs and symptoms. Counselors will be trained to implement a simple screening tool. Individuals with symptoms will be referred for diagnostic evaluation in the PHC clinics. Project staff will monitor the referral process to ensure timely visits and back-referral. It is estimated that 15% of clients with newly detected HIV infection will have active TB disease. All clients testing positive in the flexi-hour centers will be screened. This outside-health-facility flexi-hour CT centers will be regarded as a "ward" of the established health facility. They will be linked to formal structures, ensuring appropriate patient referrals to treatment, care and support, and ultimately, helping to ensure sustainability.

ACTIVITY 2: Household and Couple Counseling

The DTTC will implement a household model for addressing TB/HIV. The DTTC will use a model that was developed in Zambia with proven results that demonstrate an increase in community's utilization of CT. The model could also help to reduce stigmatization of HIV and TB through exposure to counseling. Finally, the household TB model will identify higher risk households through the identification of index TB cases. Community members will be trained as counselors and specifically on household and couple counseling. This training will augment the number of skilled people in the communities and also add new

skills to communities. Counselors will visits homes of the index TB patients and will provide a package of counseling on HIV and TB, HIV testing, behavioral and psychosocial counseling, tuberculosis adherence support, active tuberculosis case-finding and linkage to care and support networks. Counselors should reach all the household contacts of TB patients. Furthermore, household members will be motivated to access prophylactic treatment for TB.

ACTIVITY 3: Raising Community Awareness of HIV and TB

Drama groups consisting of local youth will create and perform plays aimed a communities and schools. These dramas will be developed to deliver messages about HIV and TB through the life skills program. Street performances will also take place in areas such as taxi ranks, market places and other areas where people tend to congregate. This activity will evaluate alternative ways of preventing HIV transmission and increasing VCT by targeting the youth through drama groups, and by using simple, repetitive messages to create awareness of TB and HIV co-infection and HIV prevention. In addition to the drama performances in communities, all schools (primary and secondary schools) will be visited three times per year. Messages will be delivered in a modality coupled to activities appropriately linked to the culture and age group.

ACTIVITY 4: Promote Program Collaboration between HIV and TB Services

This activity will focus on improving health services and care of people infected and affected with HIV and TB. Providers will be trained to screen all persons offered HIV counseling for TB and that all TB patients are referred by providers for HIV testing. The activity will be promoted in established health facilities as well as in the outside-health-facility flexi-hour VCT centers. The number of HIV-infected people who are tested for TB will be monitored, and those who test positive for TB will be referred for appropriate treatment at TB clinics. The number of HIV-infected people on TB treatment and the number of TB patients tested for HIV will be monitored. TB services for persons living with HIV will be enhanced and monitored through a system of quality assessment and improvement based on enhancing management information. The project will use monitoring tools that have been developed by the Cape Town City Health Department, thus ensuring skills transfer and sustainability.

The transference of appropriate skills will empower people and build local capacity, and in turn, this will help sustainability after completion of the proposed project. The lay counselors will learn to counsel in an innovative manner, and will help alleviate time pressures on the nursing staff and allow them to concentrate on professional tasks. It is anticipated that this activity will result in improved job satisfaction among nurses and have a positive influence on the morale of staff thereby motivating nurses not to leave the services.

ACTIVITY 5: Assess current HIV screening and referral activities in community health care centers caring for pediatric (<15 yr) TB patients and improve proximity, availability, and accessibility of HIV counseling and testing facilities for pediatric TB patients. Earlier identification and treatment of HIV in children with TB leads to improved outcomes.

This project contributes to the PEPFAR goals by strengthening linkages between HIV and TB, by encouraging TB patients to undergo HIV testing, by identifying those who are co-infected and, by ensuring treatment, care and support. In addition, the project contributes to PEPFAR goals by providing messages on HIV transmission to schools and communities at large.