TF CARES initiatives aim to integrate HIV and TB preventive treatment and care, including transmission and diagnosis of HIV and TB and identify disease earlier, and to strengthen TB and HIV care and treatment programs. More recently, services have been expanded to address non-communicable disease, like hypertension and diabetes.
We provide clinical support and technical assistance to the Department of Health and to the physicians, nurses and staff at Church of Scotland Hospital, a 350-bed government district hospital. We also link clinical care and operational research to increase program effectiveness and to inform policy and practice, with a specific focus in community settings throughout our district.
Some of our initiatives include:
Strengthening and Integrating TB and HIV care
TF CARES provides technical assistance to the Department of Health in the areas of infection control, ongoing surveillance of HIV and MDR/XDR-TB, intensive case finding for HIV and TB, and community management of MDR-TB. In 2002 and 2003, TF CARES first demonstrated that TB and HIV care could be integrated with successful outcomes even in rural, low-resource areas. These approaches, which we first demonstrated in Tugela Ferry, are now being adopted throughout the province.
Uncovering the XDR TB epidemic
In 2005, we uncovered the massive XDR TB epidemic in Tugela Ferry, and developed and implemented a comprehensive strategy with the local Department of Health to significantly reduce its impact over the past decade. We worked with the Department of Health to improve 4 factors: strengthening of their TB program, improving hospital infection control measures, developing a program for community management of MDR TB, and improving access to ARVs We have shown how testing, co-treatment, active case finding and community-based treatment are feasible approaches in rural areas.
Improving Diagnosis of MDR- and XDR-TB
TF CARES affiliated researchers are developing and testing multiple strategies for a more rapid diagnosis of MDR/XDR-TB.
- Demonstrated the feasibility and effectiveness of the Microscopic Observation Drug Susceptibility (MODS) test at COSH. MODS is a simple and inexpensive procedure that uses existing lab equipment and yields results in one week
- Studied the efficacy of blood cultures and body fluids as a diagnostic tool for patients with suspected drug-resistant TB
- Identified factors contributing to survival of MDR/XDR TB patients
Intensive case finding (ICF)
TF CARES has established intensive case finding programs in Church of Scotland hospital and other community settings in the Tugela Ferry area. Since 2008, patients entering the hospital and clinics are routinely screened by ‘cough officers’ to identify TB suspects. Since 2010, TF CARES has also launched a TB and HIV screening program at congregate settings throughout the community. These include ‘pension pay points’ where monthly grants are distributed, schools, and taxi ranks. Over 14,000 individuals have been screened to date and 9 percent have been found to be HIV infected and over 50 cases of TB, including drug-resistant TB, have been identified.
Improving infection control
Since the epidemic of MDR/XDR-TB was originally fueled by healthcare-related transmission, TF CARES has taken measures to address airborne infection control at COSH. We have helped to develop and implement infection control policies by working closely with the designated infection control nurses appointed by the Department of Health. This carefully monitored program has been associated with a decrease of MDR/XDR-TB in hospital wards, with a total of only 3 positive cases being detected during annual surveillance ’snapshots’ since 2010.
- Ventilation has been improved in waiting rooms and the TB ward through an ‘open window policy’ and the installation of mechanical extractor fans.
- All patients in the ARV and other clinics and waiting rooms are screened for cough and other TB symptoms and those who are suspected of having TB are separated from others and evaluated.
- Staff risk has been reduced by the provision of N95 respirator masks for all staff, infection control education and training, and encouragement of HIV counseling and testing.
Community-based care of MDR-TB and HIV
TF CARES helped develop and test one of Africa’s first community-based treatment programs for patients who are co-infected with MDR-TB and HIV, with the goal of improving treatment outcomes for MDR-TB and limiting the generation and transmission of XDR-TB.
- In this program, nurses conduct daily home visits to give second-line anti-TB drugs by injection to their patients and observe doses of oral TB medications and ARVs. The nurses use a TF CARES-developed treatment literacy curriculum to teach patients and families the importance of medication adherence and how to prevent MDR-TB and HIV. Home visits provide close monitoring for any treatment-related adverse effects or disease progression.
- We have shown that community-based treatment can yield successful outcomes for patients and have demonstrated that MDR patients can be cured through community-based treatment.
- Our program design and educational materials have been adopted by other districts in the province and were used in the design of a national program by the South African Department of Health.
TF CARES helped demonstrate the feasibility and usability of rapid point-of-care CD4 analysis in field settings by lay people.
- Using the PIMA portable CD4 analyzer, nurses and lay people achieved similar results in the field. CD4 is used to assess severity of disease and (previously) was used to identify persons eligible for treatment using ARVs.
Prevention of TB / Treatment of Latent TB
TF CARES helped demonstrate the successful initiation and use of Isoniazid Prventive Therapy (IPT) for Latent TB among persons identified during ICF screening efforts, with patients demonstrating excellent adherence.