SUMMARY:

The Desmond Tutu TB Centre project aims to improve access to prevention of mother-to-child-transmission

(PMTCT) services, address comprehensive care of antenatal women and promote family centered postnatal

care of mothers and babies at well baby clinics. The PMTCT program will be evaluated at facility level to

identify gaps in services and quality improvement initiatives will be developed in response to these gaps.

The emphasis areas include human capacity development through in-service training and ongoing

supervision. The project aims to improve pre- and post-natal PMTCT care and to improve maternal and

infant health outcomes. The primary target populations includes all women in their reproductive years, with

a focus on those who are HIV-infected, and all HIV-exposed babies, whether registered with the PMTCT

program or not.

BACKGROUND:

The Provincial Government initiated the PMTCT Program in the Western Cape in 1999 in the Khayelitsha

Sub-District. The program offered HIV testing to women booking at antenatal services in Khayelitsha, dual

therapy (AZT/NVP) in pregnancy and labor and advocated formula feeding of infants. The Provincial rollout

of the program commenced in 2001 and was completed within two years. This rollout followed national

protocols and offered nevirapine monotherapy. The Western Cape PMTCT protocol was modified in 2004 to

include a dual therapy regimen. Emphasis was placed on exclusive feeding options and early infant

diagnosis using PCR tests at 14 weeks. Reporting was simplified with single registers at antenatal sites, in

labor wards and at well baby clinics with reporting done on a cohort basis. The Western Cape PMTCT

program has been extremely successful and serves as a best practice model for the country. During 2006,

54,211 women accessed opt-out counseling at antenatal services in Cape Town with 93% accepting HIV

testing. This is substantially higher than the rest of the country. However, a substantial number of pregnant

women never access antenatal care and they and their babies thus fall outside the PMTCT program - these

may be the women and babies with a high risk of being HIV infected. Of the 3389 HIV-exposed babies who

came through the PMTCT program and were registered at well baby clinics in 2006, 79% had PCR tests

done at 14 weeks and transmission rates were 5%. There are, however, several gaps in the program that

make a thorough evaluation of PMTCT difficult. These include: inconsistent collection of booking data;

fragmented TB and HIV care in antenatal settings; poor quality of labor ward data; loss of clients between

obstetric units and well baby clinics; mixed infant feeding; delays in testing of infants; low index of suspicion

of HIV among exposed babies whose mothers did not access the PMTCT intervention. This project aims to

address these challenges and facilitate the implementation of quality PMTCT services. 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) and will be embedded within the services offered

by these health departments. Project staff will work closely with line and program managers to support

facility staff in implementing quality improvement initiatives that increase access to quality PMTCT

interventions. Lessons learned will be used to inform the program throughout the province. This project will

be implemented within existing health facilities. The integration of postnatal maternal and infant care will

take place in the six clinics which form part of the Zamstar project and which are also associated with these

flexi-hour VCT centers. The Zamstar project is part of the CREATE consortium and is funded by the Bill

and Melinda Gates Foundation through a grant to the Johns Hopkins University. Zamstar works to reduce

the prevalence of TB by improving integration of HIV and TB services. This project will complement Zamstar

through insuring that PMTCT services are also fully integrated into TB and general HIV services.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Increase Access and Improve Quality PMTCT Services at Antenatal and Delivery sites through

improvement of health systems

The PMTCT program is clouded by inconsistent information from antenatal and delivery sites. Inconsistent

collection of antenatal booking data makes it impossible to assess the true reach and impact of the PMTCT

program. Poor recording of information, high staff turnover and the use of untrained locum staff all present

problems to the implementation of a quality program. Formal training courses are difficult to arrange due to

staff shortages. Using FY 2008 PEPFAR funding, project staff will work on site at six Midwife Obstetric Units

in Cape Town. Systems will be evaluated and the overall program will be improved by various interventions,

including the collection of quality data to allow a better assessment of the PMTCT outcomes. Simple flow

charts will be developed and made available to serve as prompts to locum staff that may be unfamiliar with

the program protocols. Once good baseline data is available, quality improvement initiatives will be

implemented to address deficits in the local program. The role of project staff will be to assist with program

evaluation and to support the facility manager in implementing quality improvement initiatives. This will be

done in a way that will ensure sustainability by building capacity within the health services.

ACTIVITY 2: Provision of Adequate HIV and TB Care Antenatally

The provision of antenatal services to women in Cape Town is fragmented: in general, women receive

obstetric specific care at Midwife Obstetric Units, TB care at Local Authority Clinics and HAART at

Provincial Community Health Centers. While it is outside of the scope of this project to address the

structural issues contributing to this fragmentation, this project will ensure that women who access antenatal

care are appropriately screened for STIs, TB and HIV and receive the necessary services through

improving services at the Midwife Obstetric Units as well as referral links to other health facilities.

Community health workers, PMTCT counselors and clinic nurses will be trained to do symptomatic

screening for TB. Nurses at the six Midwife Obstetric Units will be trained on TB screening algorithms.

Once clients are diagnosed with TB, they will be referred to the local clinic for treatment. Further antenatal

visits will be used to reinforce key messages and to motivate TB clients to complete the full course of

treatment. Staff will also be trained on the basic package of HIV care to enable them to deliver this at the

Midwife Obstetric Units. The components of HIV care will include WHO staging, CD4 counts, PAP and

RPR, cotrimoxazole prophylaxis, management of concurrent OIs, TB screening at every clinical visit,

including the use of sputum culture in symptomatic clients who are smear negative and referral for HAART if

required. The responsibility of project staff will be to train and supervise staff, to transfer skills and build

capacity, and to conduct regular folder reviews to ensure that established protocols are being followed.

Project staff will work with facility staff and managers to improve the quality of all aspects of PMTCT

services as described above.

Activity Narrative:

ACTIVITY 3: Family-Centered Care to Mothers and Infants at Well Baby Clinics

At present, when mothers present with their infants at well baby clinic, the focus is on the care of the infant

whose mother accessed PMTCT. Little effort is made to ensure that the mothers receive general HIV care

at the same visit or that babies of mothers who did not access the PMTCT program are screened for HIV.

There is also little reinforcement of exclusive feeding options. A significant number of babies are lost to

follow-up by the time of the PCR test at 14 weeks. Systems will be established at the six clinics attached to

the PEPFAR-funded flexi-hour VCT sites to ensure that the care of babies and mothers is linked. Staff will

be trained on the basic package of HV care to be provided to mothers and infants and on simple algorithms

to screen for HIV among infants not registered on the PMTCT program. Ongoing counseling of mothers will

improve the retention of babies so that a higher percentage pf babies are tested at 14 weeks and retained

on the program for the full six-month duration. The role of project staff will be to evaluate services,

undertake in-service training, transfer skills, build capacity and plan quality improvements with facility staff

and managers. Improvements will be evaluated through ongoing supervision on-site, audit of clinical folders

and evaluation of routine program data.

These activities support an integrated approach for TB and HIV services in a PMTCT setting that is a key

strategy for both PEPFAR South Africa and the South African Government. The project contributes to the 2-

7-10 PEPFAR goals by ensuring early identification of HIV-infected pregnant women and ensuring that they

are enrolled into the PMTCT program and reducing vertical transmission of HIV.

SUMMARY:

The Desmond Tutu TB Center has developed a project focused on improving the integration of TB and HIV

services by expanding access to HIV-related services to large numbers of TB clients in the Western Cape

(WC) and intensifying case finding for TB among HIV-infected clients. The major emphasis area is human

capacity development through training of staff and managers, development of networks, linkages and

appropriate referral systems. The target populations include policy makers, program managers and the

general population with specific focus on HIV-infected and TB-infected and diseased adults and children.

The project addresses the dual challenges of reducing HIV transmission in communities and minimizing the

impact of HIV on individuals and of reducing the TB burden by increasing case-finding and ensuring

appropriate TB care.

BACKGROUND:

The extremely high TB rates in the Western Cape, and the increasing prevalence of HIV have led to the

health system being put under extreme pressure resulting in a failure to cope with the dual epidemics.

Therefore it is necessary to develop effective and feasible strategies that can be adopted by health services

to increase access to services and improve the quality of care for people with HIV and TB. This project,

implemented in existing government health services, aims to complement, enhance and support these

services. It is nested in six Western Cape communities that form part of the Zamstar project (part of the

CREATE consortium funded by the Bill and Melinda Gates Foundation through a grant to the Johns

Hopkins University) that works to reduce the prevalence of TB by improving integration of HIV and TB

services. This project has already established community advisory boards and stakeholder support. The

PEPFAR funded project links with the Zamstar project by implementing complementary activities focused

on HIV and TB such as routine screening for TB at CT, improved access to TB and HIV care, improved

quality of services and collaboration between HIV and TB services at facility level. The project scope has

been revised from that submitted in COP07 to address evolving community and health service needs. All

activities of the Desmond Tutu TB Centre, including the present project, are implemented in close

collaboration with the Western Cape Department of Health, Cape Town City Health Department and non-

governmental organizations (NGOs).

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Routine Screening for TB through CT services

Symptomatic screening for TB during CT is current policy. If clients are symptomatic, they are sent to the

nurse for investigation. There is no routine data at present to show whether symptomatic clients had sputum

samples taken, whether a TB diagnosis was made and TB treatment commenced. An operational

evaluation of routine data has been undertaken to assess the efficacy of TB screening at CT as a possible

means of increasing TB case-finding. This evaluation has shown that symptomatic screening does take

place at CT but that gaps exist in the follow up, particularly with clients having the appropriate sputa taken.

Based on the outcome of the evaluation, appropriate training for lay-counselors is being undertaken to help

improve the quality of counseling provided to TB and HIV clients at health facilities throughout the City of

Cape Town and West Coast-Winelands Districts. Systems will be strengthened to facilitate sputum testing

for symptomatic clients identified at VCT. These systems will be implemented at the routine CT centers in

clinics and in the 6 PEPFAR-funded Community Flexi-Hour CT Sites. The Audit Tool for evaluation of TB

and HIV services will be used to assess whether clients had a symptomatic screen at CT and if

symptomatic, whether the appropriate TB tests were done.

ACTIVITY 2: Improve TB/HIV Services at Facility Level

This activity focuses on improving health services and care of people infected and affected with HIV and TB

by providing in-service training and ensuring the implementation of current guidelines. For TB clients: that

all are offered CT; that those who test positive undergo a baseline evaluation, including WHO staging, CD4

counts, PAP, RPR; that cotrimoxazole prophylaxis, management of concurrent opportunistic infections and

referral for antiretrovirals are provided as required. For all HIV-infected clients: In addition to being provided

this package of care, that all clients are screened for TB at every clinical visit, including the use of sputum

culture in symptomatic clients who are smear negative. In 2008 particular attention will be paid to HIV

testing among children with TB and appropriate HIV care for those who are positive. TB services for

persons living with HIV and HIV services for TB clients are enhanced and monitored through a system of

quality assessment and improvement. The project uses an audit tool that has been developed by the Cape

Town City Health Department, Provincial Department of Health and the University of the Western Cape,

thus ensuring skills transfer and sustainability. This tool uses the "Conditions for Effectiveness" framework

to evaluate availability, capacity, access, initial use of services, continuity of care, quality and impact of TB,

HIV and STI services. The tool uses regular audit of clinical folders to identify whether the package of TB

and HIV services have been appropriately provided to clients. In-service training and on-site supervision will

be used to improve the delivery of these services. Project staff work closely with the health authorities to

improve the data management system used to evaluate TB services to those with HIV, and HIV services to

those with TB. Project staff advocate for improved monitoring of HIV services to TB clients through the

electronic TB register. The skills of facility managers and staff will be developed to improve their ability to

evaluate routine data and information from the audit. Staff will be taught a participative planning process to

help improve collaboration between the services and to use the data to drive quality improvements in both

TB and HIV services. The transfer of appropriate skills will empower people and build local capacity, and in

turn, this will help ensure sustainability after completion of the proposed project. The lay counselors will also

learn to provide effective counseling to TB suspects and clients, and this 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.

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.

SUMMARY:

The Desmond Tutu TB Center has developed a project in the Western Cape (WC) focused on improving the

integration of TB and HIV services by increasing access to counseling and testing (CT) services,

intensifying case finding for TB among those who are HIV-infected and expanding access to HIV-care for

those diagnosed positive. The major emphasis area is human capacity development through training of staff

and managers, developing the capacity of local organizations to implement and manage community CT

sites; development of networks, linkages and appropriate referral systems and increasing gender equity

through improving male access to CT. The target populations include policy makers, program managers

and the general population with a specific focus on couples, men and youth. The project addresses the dual

challenges of reducing HIV transmission in communities and minimizing the impact of HIV on individuals

and of reducing the TB burden by increasing TB case-finding and ensuring appropriate TB care.

BACKGROUND:

The extremely high TB rates in the WC and the increasing prevalence of HIV have led to the health system

being placed under extreme pressure resulting in a failure to cope with the dual epidemics. Therefore, it is

necessary to develop effective and feasible strategies that can be adopted by health services and

supporting community organizations to increase access to services and improve the quality of care for

people with HIV and TB. This project is closely aligned with existing health services and aims to

complement, enhance and support these services. It will be nested in six Western Cape communities that

form part of the Zamstar project. The Zamstar project is part of the CREATE consortium and is funded by

the Bill and Melinda Gates Foundation through a grant to the Johns Hopkins University. 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 establishing Community Flexi Hour CT Centers, and improving access to and

utilization of CT services through social mobilization and existing household and community activities. It will

implement routine screening for TB at CT at the Community Flexi Hour CT Centers and improved access to

TB and HIV care through strong referral networks. The project scope has been revised from that submitted

in COP FY 2007 to address evolving community and health service needs. All Desmond Tutu TB Centre's

projects are implemented in close collaboration with the Western Cape Department of Health, Cape Town

City Health Department and non-governmental organizations (NGOs).

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Establish Six Community Flexi-Hour CT Centers

Approximately 8% of the adult population of the WC access CT through existing healthcare services

annually. The majority of people accessing CT are women who are exposed to CT through prevention of

mother-to-child transmission (PMTCT) programs, and clients who are tested in health centers for medical

reasons. Only about 30% of people undergo CT through self-referral. Community Flexi-hour CT Centers

aim to 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 services. The target groups include youth, couples, working

people and males and this activity will therefore address the gender inequality in access to CT.

The Community Flexi-hour CT Centers focus on outreach activities in the community (sports clubs, youth

clubs, church organizations, local small businesses) and individual households. The Centers aim to raise

awareness about HIV and to promote CT. Six Community Flexi-hour CT Centers will be established through

contracts with existing NGOs already employing CT counselors deployed to health facilities. NGOs should

have the capacity to manage the service and to sustain the initiative in the long term. Project staff will be

employed to run the CT centers in partnership with the NGO. Each center will be staffed by (a) a

professional nurse who will manage the center, oversee HIV testing and test if required; (b) an enrolled

nurse who will do HIV and TB testing; and (c) three to four CT counselors who will provide pre- and post-

test counseling, symptomatic screening for TB and be responsible for health promotion in the community

and at the center. Staff will be responsible for mobilizing the community to utilize the service, for provision of

the service at the site and on an outreach basis and for routine data collation.

A database will be established at each site to collect and collate routine client information, including

demographics, referral source to the center (from community drama events, school initiatives, household

interventions etc), HIV test results, TB screening and referral to clinics. The Monitoring and Evaluation

(M&E) manager will undertake data validation, quality control, data collation across sites and evaluation of

data. A mentor will provide support to staff at these sites through case discussions, debriefing, stress

management and team building. The mentor will visit sites every two weeks.

Symptomatic screening for TB will be undertaken during CT at the Community Flexi-hour CT Centers.

Counselors will be trained to implement a simple screening tool that is used in health facilities in the

Western Cape. Symptomatic clients will have sputa collected and the nurses at centers will use standard

national diagnostic algorithms to diagnose TB. Those diagnosed positive will be referred to local clinics to

commence TB treatment. Feedback loops from clinics will be used to minimize primary TB treatment default

rates. Project staff will monitor the referral process to ensure timely visits and back-referral. Approximately

15% of clients with newly detected HIV infection will have active TB disease. Community Flexi-hour CT

Centers will be regarded as a "ward" of the established health facility. Although Community Flexi-hour CT

Centers will not be situated on the grounds of a health facility, they will be linked to formal structures,

ensuring appropriate patient referrals to treatment, care and support, and ultimately, helping to ensure

sustainability. Close links will be maintained between the Community Flexi-hour CT Centers and the Sub-

District Management Team to ensure good communication and feedback and to address referral issues.