Who We Are

The Tugela Ferry Care and Research Collaboration (TF CARES) is an international non-governmental organization committed to improving prevention, care, and treatment for adults and children with HIV/AIDS and tuberculosis through clinical care, research and capacity building in Tugela Ferry, South Africa. TF CARES collaborating partners include Yale University, the University of KwaZulu-Natal, Philanjalo, and the South African Department of Health.

Philanjalo, a local South African NGO providing home-based and inpatient HIV and TB, prevention, treatment, and care.  Philanjalo started a comprehensive HIV program, among the first in the country in 1998, offering voluntary counseling and testing, prevention of mother-to-child-transmission, hospice care, an orphans program. Since 2003, this site has provided antiretroviral therapy, and was the first site in which antiretroviral therapy was introduced in the public health care system in South Africa.  During the past decade, with the assistance of TF CARES and our partners, an estimated 20,000 community members have been started on and received antiretroviral therapy.

The KwaZulu-Natal Department of Health 350 bed Church of Scotland District Hospital is the focus of much of the work by TF CARES and our partners . The hospital is comprised of medical, pediatric, surgical and obstetrical and gynecologic services, TB inpatient and outpatient services, and basic laboratory and X-RAY testing. Recently CD4 flowcytometry and GeneExpert TB diagnostics, and an updated HIV treatment clinic have been added.  16 Department of Health (DOH) nurse-managed community primary care clinics, and 1 large Community Health Centre (CHC) are spread widely through the area and refer patients to the hospital.

Yale University School of Medicine, through the AIDS Program, has provided technical assistance and resources for the efforts of TF CARES and our partners defining and confronting the convergent epidemics of HIV, TB and drug resistant TB. This has been accomplished through collaborative development and implementation of research and clinical projects in HIV and TB prevention, care and treatment.

University of KwaZulu-Natal has provided support and laboratory and clinical expertise in combating the combined epidemics.

Our work, and that of our partners, in Tugela Ferry has been supported by the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the National Institutes of Health, US CDC, USAID, Fogarty International Clinical Research CenterKwaZulu-Natal Research Institute for Tuberculosis and HIV (K-RITH), Irene Diamond Fund, Doris Duke Charitable Foundation, Johnson and Johnson Foundation, Gilead Foundation, Patterson Foundation, Burroughs Wellcome Fund and individual donors and volunteers.

With the goal of improving community and patient health through the use of compassionate patient and community oriented research and capacity building TF CARES and our partners have made important contributions in such areas as HIV/TB integration, infection control, accelerated use of new diagnostic tools and community-based screening, prevention and treatment, for both HIV and drug susceptible and drug resistant TB. In addition we have expanded the use and value of community health care workers in all of these endeavors and increase and expanded clinical capacity and training.



Successes to date

April 1993 – The World Health Organization declares TB a global emergency.

1993 – The South African government sponsored TB program, using the World Health Organization (WHO) Directly Observed Treatment, Short course (DOTS) strategy, launches at Church of Scotland Hospital (COSH).

1998 – Community members in the Tugela Ferry community form Philanjalo, a community based organization aimed at increasing quality of life among the Tugela Ferry population.

March 2002 – Physicians from Yale University, Albert Einstein College of Medicine and Philanjalo form Tugela Ferry Care and Research Collaborative (TF CARES) to address the TB and HIV epidemics in Tugela Ferry.

October 2002 – Tugela Ferry’s first patient is started on anti-retroviral therapy (ART) through a Yale/Philanjalo designed program.

March 2004 – Government-funded HIV treatment begins at COSH, the first public sector site in the country, Patients with CD4 counts of less than 200 cells/mm3 are eligible for free anti-retroviral therapy.

2004 – Doctors at COSH notice that some HIV-positive patients are dying from TB despite doing well on ART. They suspect drug-resistant TB.

February 2005 – South African and US doctors at COSH confirm the presence of large number of XDR-TB cases. Ten out of 45 TB patients tested are found to have resistance to almost all anti-TB drugs.

June 2005–March 2006 – TF CARES performs surveillance and testing on 1,428 TB suspects at COSH for drug resistance. MDR-TB is detected in 185 patients, of whom 30 have XDR-TB. In total, 53 XDR-TB patients are diagnosed from January 2005–March 2006, almost all with HIV co-infection; 52 of 53 (98%) die rapidly.

August 2006 –TF CARES presents the XDR-TB epidemic in Msinga at the XVI International AIDS conference in Toronto and publishes findings in The Lancet in October 2006. This receives widespread attention in the lay and medical press and spurs global awareness and mobilization efforts around the drug-resistant TB pandemic.

September–December 2006 – The Italian Cooperation and the Department of Health evaluate Tugela Ferry and surrounding Umzinyathi district’s TB control program. TB indicators are validated and programmatic improvements are made.

September 2006 – At an expert consultation on XDR-TB in Johannesburg, South Africa, WHO and international partners call on South Africa to take urgent action against XDR-TB. The group formulates a plan to control the spread of drug-resistant TB.

October 2006 – The Italian Cooperation and the Department of Health begin household contact tracing. Tracing teams visit, screen and evaluate 725 households with MDR/XDR-TB patients in Msinga, including 3,206 adult and pediatric household contacts.

2006-present Comprehensive multifaceted Program to combat MDR and XDR TB established and implemented including:

1)         Strengthening TB DOTS Program and resources for interventions

2)         Improving inpatient/outpatient airborne infection control

3)         Integrating TB & HIV diagnosis, care and treatment and initiating antiretroviral therapy

4)         Reducing reliance on inpatient care and focusing on patient centered community based early case detection

January 2007 – Airborne infection control program established at COSH, the first in the district, including administrative, environmental and personal control strategies.

February 2007 – TF CARES evaluates a rapid TB diagnostic test strategy using MODS assay in over 900 TB suspects, primarily HIV co-infected. The tests exhibit high sensitivity and specificity with rapid turnaround time.

Dec 2007 – A total of 700 cases of MDR and XDR TB reported from Tugela Ferry and surrounding district

2008-present Johnson  and Johnson  program initiated in collaboration with Yale Deptment  of Medicine Global Health Program. Yale and Stanford residents expand capacity at COSH by providing HIV/AIDs and TB diagnosis, care and treatment for both HIV and TB. >80 residents have participated in 6 moth rotations through June 2017

February 2008 –TF CARES and the KwaZulu-Natal Department of Health establish the first  national decentralized community-based MDR-TB treatment program

July 2009 –TF CARES launches an enhanced pediatric TB diagnosis initiative to improve diagnosis of TB and drug-resistant TB in children

March 2010 – The first 18 MDR-TB patients complete the decentralized community-based treatment program and are cured of MDR-TB.

April 2010- In collaboration with KwaZulu-Natal Department of Health, TF CARES begins expansion of integrated community based TB and HIV intensive case finding (ICF) program to provide earlier diagnosis of TB and HIV, linkage to care and  reduce mortality and transmission. By 2016 over  15,000 community members are screened for TB and HIV at an array of congregate settings in the community.

2012 – TF CARES and partners implement 2-year study of rapid point-of-care (POC) analysis of CD4 in the field by lay persons, with support from NIH.  Similar successful results are obtained from both nursing personnel and lay staff, supporting task shifting to lay health care workers in nursing limited settings.

2012 – TF CARES and partners implement implement 2-year study of Isoniazid Preventive Therapy (IPT) to treat latent TB among eligible HIV positive clients identified in its ICF program, with support from US-CDC.  The clients demonstrate excellent medication adherence and treatment completion rates.

2015 – TF CARES and partners implement program of home based screening for TB, HIV, and multiple other chronic conditions (e.g. diabetes, high blood pressure), by team of specially trained previously unemployed women, as Community Health Workers (CHWs). The results support expanded role for CHWs in resource constrained high prevalence settings.

July 2016-TFCARES reports dramatic and sustained 10 year decline in Tugela Ferry cases of XDR and MDR TB reported at IAS Durban TB International Conference, associated with combined multifaceted intervention strategies initiated in 2006.

2016 – TF CARES and partners begin perform ICF type screenings for HIV, TB, and other chronic diseases at the local bars and taverns (Shebeens) to specifically reach underserved populations of young people, both(males and females, who are at high risk for becoming infected with HIV.

2016 – TF CARES and partners begin implementation of Pre-exposure Prophylaxis (PrEP ) against HIV among teenagers and young women referred by the community-based CHWs.  In a vulnerable population with little opportunity to have a say in matters regarding their health and sexual risks, PrEP gives young girls an opportunity for control and  choice for reducing HIV. risk.

Recent presentations at national and international meetings:

  • Ma M, Moll AP, Guddera V, Andrews L, Friedland G, Shenoi SV. Perceptions of HIV Pre-exposure Prophylaxis (PrEP) in KwaZulu-Natal Province, South Africa. 21st International AIDS Conference, Durban, July 2016.
  • Shenoi SV, Moll AP, Madi J, Guddera V, Madondo T, Turner D, Brooks RP, Kyriakides T, Andrews L, Friedland G. Community-Based Voluntary Counseling and Testing in Rural South Africa.  Oral Presentation. 21st International AIDS Conference, Durban, July 2016.
  • Shenoi SV, Moll AP, Vranken P, Andrews L, Dokubo K, Brooks RP, Friedland GH. Improving Implementation of Isoniazid Preventive Therapy through Community-based Referral in Rural South Africa. Presented at International Union Against TB & Lung Disease, Cape Town, 2015.