A majority of randomly surveyed South
Africa health facilities have started implementing the
recent National TB screening and IPT Guidelines according to a cross-sectional
study by the US Centers for Disease Control (CDC) and the SA Department of
Health presented as a poster at the 5th South African AIDS
Conference in Durban
7-10 June, 2010.1
If the study is indeed representative of the country as a
whole, it suggests there’s been a dramatic increase in the number of people
living with HIV receiving IPT compared to the past. However, policy
implementation was markedly uneven — with little to no action at all in some
provinces, and concerns abou the quality of the service at some sites.
Two other reports at the conference, however
focusing on IPT implementation in specfic districts or subdistricts, may
provide models for the Health Department in how to do IPT right.
Background
The current guidelines, updated in June last year,
recommended TB screening in all people living with HIV. All those with TB
symptoms should be referred for TB diagnosis, while everyone else should be
given IPT. The guidelines no longer require mandatory chest X-rays or a
tuberculin skin test (TST) before starting HIV-positive patients on IPT, and
its coadministration with antiretrovirals is longer discouraged.
“There is no excuse for health workers to withhold this
inexpensive and effective intervention to prevent TB,” said Minister of Health
Aaron Motsoaledi — and the department of health set ambitious targets for the
first year of its roll-out (around 450,000 people).
But there has been a longstanding reluctance to scale up IPT
among many in the healthcare establishment and some concerns that the health department was rushing to
roll out the policy, without adequate preparation — with local authorities left
to translate the policy into practice, develop training and operating procedures
for staff based upon the guidance. Given these issues, what
progress has been made in South
Africa since the guidelines change?
To assess how the policy was being put into effect in the
country, researchers from the US Centers for Disease Control (CDC) and the SA
Department of Health performed a cross-sectional study in 49 randomly selected
clinics in South Africa’s
nine provinces. These included one clinic drawn from the district with the
highest antenatal HIV prevalence in each province (except for KZN where two
were chosen), public health clinics, community health centre and district
hospitals. Teams were trained to interview supervisors of TB and HIV services
using standardised questionnaires to assess clinic policy, service delivery,
supply, recording and reporting and barriers to implementation.
As of February 2011, 71.4% of the clinics were implementing
IPT — with about 56% of the eligible patients in the sample receiving IPT.
Among the clinics not providing IPT, the most commonly offered excuses were
that they hadn’t had clear guidance or commitment from local authorities on the
policy (29%), while about a fifth said they were concerned it would lead to
resistance (though a number of studies have shown this is unlikely to occur).
There was a high rate of implementation at PHC and district hospitals, but
community health centres didn’t do as well.
Among the 35 clinics providing IPT, coverage varied markedly
by province. Sampled clinics in some provinces reported that they had put more
clients on IPT than the total number eligible (all those who had screened
negative for active TB). So something was not quite right with these figures.
There was little implementation at the sampled clinics in Limpopo or the Eastern Cape, and oddly, no implementation at all in the Western Cape. Likewise,
although most clinics had at least some staff who had been trained in HIV/TB,
this also varied significantly across the provinces.
Some form of IPT counselling was also being provided by all
of the clinics providing IPT in each of the provinces except Limpopo,
where only half of them were. However, the quality of the counselling was
uneven. The researchers had identified four essential components for IPT
counselling including adherence, reporting symptoms, reporting side effects and
reducing alcohol intake — but only 17.3% of the IPT dispensing facilities got all these messages into their counselling.
All the facilities providing IPT were recording and
reporting IPT data — all but one facility that counselled on IPT also recorded
IPT data in their registers.
The researchers recommended continuing efforts to make IPT a
priority intervention, especially in the Western Cape,
the Eastern Cape and Limpopo,
and called on PEPFAR to support the Department of Health’s efforts to increase
monitoring of IPT. They added that the quality of IPT counselling should also
be improved by mentorship at the facility level.
Regardless, these findings suggest that IPT is being scaled up at a much greater pace than before the recent guidelines were released — and although
uneven — it represents a good start.
However, as the study’s author’s noted “while counselling of
IPT is common, quality and comprehensive counselling is rare.” This raises the
spectre that nurses and patients might not understand the intervention well
enough for it to be given safely.
Another issue is that the study said nothing
about intensified case finding itself — how widely and routinely TB screening
was being performed, and how many active cases were being identified.
Finding
and treating active TB cases in people living with HIV is a crucial part of the
ICF/IPT strategy to prevent TB spread and acquisition, especially in health
facilities. A focus just on the performance of IPT is not only incomplete, but
potentially dangerous — continued screening of patients put on IPT is
recommended to make certain that cases weren’t missed the previous time, and to
quickly detect breakthough cases.
The study also left some other very important questions
unasked —most notably, how many of the people being given IPT are adhering to
treatment, being retained in care, and completing their course of treatment? Does
the programme know? As the example of the IPT programme in Botswana has
shown, it's easy enough to start handing out IPT to patients — it is another
matter entirely to keep track of what happens to them. Given this well-known
experience in a neighbouring country, why was this assessment mum on the topic?
It would also be useful to have more information on the ways in which performances at health
facilities differed — and what factors were associated with success or failure
to implement.
While the lack of clear guidance from local authorities
might be business as usual for the clinics that aren’t scaling up IPT — the CDC
study gave little insight on how IPT was being operationalised at the other clinics.
Why are some clinics and districts scaling up so much better
than others, and how are they doing it? Is it due to the kinds of support that they are receiving?
As already noted, quality improvement, mentoring, community-based outreach
teams and peer-based adherence support were recurring themes at the 5th
South African AIDS Conference. Along with training and technical support
provided by NGOs these measures have
improved the quality and reach of health services in a number of now model
districts, contributing to the improvement of PPTCT services and helping
support nurses to initiate ART.
These methods are now also being employed in the scale up of
IPT (as well as the other Three Is for HIV/TB, intensified case finding and TB
infection control) — while some districts have benefited considerably from
technical expertise of some of the smartest NGOs.