Recommendations for policy in the Western Cape Province regarding the prevention of Major Infectious Diseases including hiv/AI
A patient’s journey through the system
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- Programme problems identified in interviews with staff
- Coverage
- Intensity
- Figure 3: HIV Prevalence by 15-24 Age Group: Western Cape 2000-2005
A patient’s journey through the system1. Drainage. People are meant to attend clinics according to where they live. A person who attends a particular clinic but gives an address that does not fall in that clinic’s drainage area will be advised to attend the clinic appropriate to their address. 2. Suspect. An important point to bear in mind in relation to the high burden of disease is that the TB programme relies on individual health-seeking behaviour. Patients who present to a clinic or CHC with a history of cough will be sent by the facility clerk, without opening a folder, to the ‘TB suspect’ room, where they are given two sputum specimen containers to provide specimens. Names and addresses are recorded in a ‘suspect register’ and people are supposed to return for results in 2-3 days. 3. Confirm. A confirmed diagnosis is based on a positive sputum or culture result. There are obvious problems here for smear negative TB. What happens fairly commonly is a person will be told they don’t have TB because their sputum is negative, yet they will continue to deteriorate clinically. These people often need repeated visits before TB is reconsidered 4. Tracing and registering. If a result returns positive and the person has not returned for it, the clinics have the help of recently recruited ‘TB supporters’ (not DOTS supporters) for tracing. Of late the ZAMSTAR research project has also been assisting in this area. Once a patient begins treatment they are entered into the clinic’s treatment register, which tracks outcomes. 5. Decision on treatment delivery method This is determined by whether it is a new or a re-treatment case as well as the particular circumstances of the individual. Re-treatment cases require 40 doses of injected streptomycin, meaning 40 daily clinic visits. Otherwise, the decision is whether community or clinic DOTS is used. As mentioned above, if the person is full-time employed, or a full-time scholar, they are more likely to use the community DOTS system6. Educate and treat. Although patients are informed of the need to complete treatment, the education system is not as comprehensive or systematic as that for ART 7. Monitor outcomes. All patients require a 2-month and 5-month sputum specimen, looking for evidence of conversion from sputum positive to negative. Again there are obvious problems when the initial (pre-treatment) sputum is negative. According to staff high defaulter rates also contribute to these outcomes being poor. 8. Discharge After completion of treatment, the register is filled in with the appropriate categorization: cure, completed, died, transferred, lost to follow up Programme problems identified in interviews with staffTB supporters and DOTS supporters:
Nurses:
Doctors:
Area coordinators:
Appendix 5: Rural health service for HIV/AIDS & TB ART provision in the Western Coast district of the Western Cape: A Case study O
klahoma Clinic, situated in the old doctor’s quarter’s in Malmesbury, started providing ART in February 2005. Community members contributed to decorating the clinic and the hidden talents of some of the clinicians are revealed in the creative posters on the walls. At first glance, a poster on the wall appears to be the artwork for a box of Ouma rusks, turns out, on closer reading to include: “OUMA se geheim is uit… Sy drink haar ARV pille…d4T, 3TC, EFV… Oklahoma, die kliniek wat jy altyd kan vertrou”. Another, done in the style of a tin of pilchards, reads: “Pasïente, in warm hande”. The clinic draws HIV positive patients from Malmesbury as well as surrounding towns. All pregnant women are offered VCT as are TB and STI patients, and uptake is high. VCT uptake is strongly influenced by the relative enthusiasm of nursing staff working in the various communities promoting the service, and partner testing is common in some sites. In some areas the ‘voluntary’ aspect of VCT is less prominent, with many patients being referred by clinics. Rural areas offer less anonymity, and this influences VCT and ARV uptake. In Malmesbury and other towns to the north, the HIV risk environment is strongly influenced by migrancy as a product of seasonal agricultural work, and shifting family units. Migrants are involved in wine and orange harvesting, and migrant patients need to transfer to other sites to sustain their drug access. Farm workers also have difficulty accessing transport to receive drug supplies. Dr Nellis Grobbelaar, who leads the antiretroviral roll out in this district, speaks of the ‘Lazarus’ phenomenon that accompanies the provision of ART to severely ill AIDS patients. Impacts are immediate and tangible. In this way, a positive diagnosis in VCT can be discussed in the context of a ‘bad’ diagnosis, but ‘good news’ in terms of treatment and care. Awareness programmes are run in the communities including in schools and patients receive counseling and condoms. One patient told how she was infected by her husband who was a long distance truck driver. She has come to terms with her infection. After he died she became sick with diarrhoea and mouth infections. She had memory problems and couldn’t walk. “Ek was in a toestand”, she says. Taking ARVs resulted in major changes to her health. She finds it difficult for people who aren’t infected to understand what it’s like to live with HIV, and ignores ‘poisonous talk’ about her. She worries about her son, and finds it difficult to talk to him about HIV, although was pleased to find that he had condoms in his room. Interviews conducted with the HIV/TB co-ordinators in the South Karoo, Eden, Boland and Overberg districts, September – October 2006 HIV / AIDS Management of HIV positive patients needing treatment is being well managed in the rural regions. The challenges of HIV/AIDS in these districts include keeping people who have been diagnosed HIV positive in a good state of health, and delaying the time when they will need to go on to ARV treatment. In most districts there are no waiting lists for ARVs, except moderate access in Boland / Overberg where there is steady progress of the ARV programme. Other programmes that are working very well everywhere are VCT and PMTCT. It has been noted that there has been increased uptake of HIV testing subsequent to the ARV roll out, and increased initiatives for VCT testing drives in businesses and on farms. This has further encouraged those who have tested positive to invest in mutual support and encouragement while attending ARV services. TB It is evident that there is a large burden of non-HIV TB in all rural areas, and it should not be assumed that most TB cases are HIV positive, but that TB should be seen as a disease burden with its own unique challenges. The challenge is that statistics are only available on the cohort of diagnosed TB cases. It would be safe to assume that this represents only 70% of the total TB burden and that the other 30% remain a pool of infection that encourages the extensive spread especially among those who are at risk from other concomitant factors. This situation is further challenged by the disproportionate number of health care personnel who are deployed for TB care within the primary health care system. Risk for disease The sector of the population in all districts who present with HIV are young black females. The other risk that is repeatedly mentioned is the migration of people from other provinces and from the Cape Metropole, that appears to be on a steady increase and among whom there is a high prevalence of HIV infection. This is markedly evident in settlements in areas near the main national highways that traverse the rural areas. However, it is felt that there are still remotely rural areas where people are denied access to testing and treatment for HIV and/or TB, and it is possible that these disease events and deaths are not accurately recorded. The upstream risks for TB are clearly identified as unemployment, poverty, inadequate housing and alcohol abuse. There is increasing unemployment in the rural areas, and much of the available work is casual labour that is seasonally transient. Migration is a very real problem, consisting of large numbers of people of different lifestyles, languages and culture groups moving into rural communities and thereby causing division to arise in communities. There are groups of people from other provinces who are transported to the Western Cape with promises of accommodation and employment. These promises are false, and with no means to return home, the result is settlements of informal housing springing up where there is extreme overcrowding and poverty, for example Grabouw, Plettenburg Bay and Knysna. People are transported to holding places where they hang around waiting for jobs. These places are usually overcrowded and inadequately serviced, which encourages the spread of TB. There are also those settlements along train routes from Cape Town where people have left the city in the hope of employment in the rural regions. The problem of poverty is vast, both in residents and migrants, with extreme lack of food security and lack of support systems to address this. Housing is overcrowded, inadequate and poorly ventilated both in squatter areas as well as on farms. The intake of alcohol is enormous, including the consumption of wine and beer in all populations in the rural regions. Other risk factors named were transport systems which affect those who are far from services, and the functionality of the local municipalities. It must be asked whether the Integrated Development Plans of municipalities are functioning as intended. “If we are succeeding with coverage with antiretrovirals for HIV patients, why do we appear to not be succeeding in curbing the TB epidemic?” The ARV programme is receiving a great deal of attention and resources. It is observed that more attention is paid to HIV positive people and in particular those on ARVs. HIV/AIDS is a doctor-driven vertical programme with designated counsellors. Overall there is greater commitment to the ARV programme than to the treatment of TB. It is observed that ARV patients are almost over-catered for compared to others seeking health care, in terms of medical care, NGO involvement and social grants. TB is a nurse-driven service that forms part of the Primary Health Care service. The shortcomings of the TB service can best be identified by viewing the success of the Overberg district that recently achieved an 85% cure rate and were awarded by National government as the top district in South Africa for achievement in TB care. Initiatives in the Overberg TB programme to achieve an 85% cure rate in 2004
Appendix F: Audit of interventions for HIV/AIDS & TB
Provincial Aids Council (PAC) Accelerated HIV-Prevention Strategy A Multi-Sectoral Framework for Action in the Western Cape - 2006 To 2011 October 2006 
Contents Acknowledgements …………………………………….……………………………3 Executive summary …………………………………………………………………4
Acknowledgements This document was compiled by the members of the Western Cape Provincial HIV Prevention Task Team: Dr Keith Cloete (chairperson) Dr Najma Shaikh Mr Msokoli Qotole Ms Brenda Smuts Dr Mickey Chopra Dr Ivan Toms Dr Andrew Boulle Mr Leigh Johnson Mr Dominique Johnson Ms Anne Herling Ms Cathy Matthews Mr Mark Tomlinson Dr Virginia Azevedo Dr Eric Goemaere Dr Marta Dardar
A. The Communication strategy suggests four key behaviours should be prioritized:
2. Reduce the exploitation of younger women by older men:
B. Behaviour change programmes – focussing on prioritised behaviour changes in key at risk groups; C. Counselling and testing – scaling up access to counselling and testing services; D. Condoms – scaling up distribution of male and female condoms; E. STI management – maximising detection and effective management of STIs; F. pMTCT – maximising access to and continuity of care of mother-infant pairs;
The strategy further recommends the following in terms of improved intervention strategies: Coverage:The extensive ANC surveillance system along with other community based HIV surveys allow us to identify key risk groups that should be targeted for full coverage:
IntensityThe key challenge across all sectors of society is to better understand what interventions are likely to lead to an internalization of the real risk of HIV transmission at an individual level that will result in sustained behaviour change to continually minimize the risk. There are multiple societal factors that influence this. The key is to engage influential opinion leaders that are likely to shape societal behavioural norms. The messages must be uniform and reinforced across a range of natural social networks. These networks include religious institutions, sports clubs, social circles, workplaces, etc. The interventions seek to engage young people in small groups through dynamic interactions, in positive networks. It is vital to provide young people positive alternatives that will provide them hopeful futures. It is important to understand and to lock into the existing regulatory mechanisms in the various communities in the Western Cape. Introduction In the absence of a cure for AIDS, prevention remains the cornerstone of the response to HIV and AIDS. Modeling the impact of increasing access to treatment shows that without an effective prevention programme the impact of the HIV epidemic will be minimal. Figure 1 shows the importance of combining access to treatment and care with prevention. Figure 1: Global New Infections (Millions)  Source: Salomon et al, 2005 A recent review of evidence for prevention interventions, that also considered issues of cost-effectiveness and affordability, recommended that in a generalized high-level epidemic, such as in the Western Cape, prevention efforts should: “Focus on broadly based, population-level interventions that can mobilize an entire society so as to address prevention and care at all levels. Prevention should include the following:
In particular the review emphasised: “The status of women, an important factor in all epidemics, becomes an overriding concern in this setting, requiring priority action to radically alter gender norms and reduce the economic, social, legal, and physical vulnerability of girls and women”.
Much of our understanding of the HIV epidemic in South Africa (SA) and in the Western Cape (WC) is based on the HIV antenatal surveys, mortality data from the vital registration system and the various population level and local level surveys such as the HSRC population survey, MRC Youth Risk Behavior Survey and RHRU household youth survey. 2.1. HIV Prevalence Traditionally, countries experiencing a generalised epidemic have been tracking the epidemic with cross-sectional surveys of women attending antenatal clinics. In SA, the Department of Health (DoH) has been conducting serial national level HIV antenatal surveys for the past 16 years. This entails the annual cross-sectional surveys, carried out in each of the nine provinces of SA. These surveys primarily estimate the magnitude and trends of HIV infection among pregnant women attending public health clinics in order to reflect HIV prevalence among young, sexually active heterosexual adults. The HIV epidemic in SA is characterised as being a generalised form, affecting young sexually active adults and disproportionately young women. While the epidemic is said to be levelling off at the country level, the levels of infection remain high, with a reported 30.5% HIV prevalence among women attending HIV antenatal clinics in 2005. Temporal trend data from these surveys show that the epidemic is heterogeneous both at the country and provincial level (Shaikh et al. 2006). There is wide variation in the HIV prevalence at the provincial level, with KwaZulu-Natal reporting the highest HIV prevalence at 40.2% and the Western Cape the lowest at 15.7% in 2005. The HIV epidemic in the Western Cape province is relatively less mature than epidemics in the other provinces of SA and this implies that this province has an opportunity to halt the epidemic through intensive preventative strategies.
According to the results of the 2005 HIV antenatal surveys within province, the highest HIV prevalence was reported among women aged 25-29 years (Figure 2). This translates to one in every five women attending the public sector antenatal clinics in the Western Cape tested HIV positive. Temporal trends of HIV infection among the youth (aged 15 –24 years), which is considered a proxy of new infections, have shown a significant increase in HIV prevalence for the period 2000 to 2005, although most of the increase took place between 2001 and 2004. Figure 3 demonstrates the HIV prevalence observed in pregnant women aged 15-24 years in 2002 (12%) closely correlates with the 2002 HSRC survey at 11.2%, although the latter included both men and non-pregnant women. These findings clearly support the need to strengthen the prevention programmes.
2.1.1. Heterogeneity of the EpidemicSince 2001, the Western Cape DoH has been conducting local-level anonymous HIV antenatal surveys in all the public health facilities that offer antenatal care. These surveys provide useful insight on the wide heterogeneity of the epidemic within the province and have provided useful local level information for the planning and prioritising targeted responses at the provincial level (Shaikh et al. 2006). F  igure 4: HIV prevalence by area 2005 In 2005, the HIV prevalence ranged from 33.3% in the Khayelitsha to 4.5% in the Bredasdorp/Swellendam area. Trend data demonstrates that even at the local level, the epidemic has progressed differentially both in absolute terms and in the rate of growth. There is evidence of sub-epidemics within the province, at various stages of development and these can be classified as early, emerging and mature epidemics. For example, the HIV prevalence in Khayelitsha and Gugulethu health areas remain consistently high in absolute and growth terms, while Knysna/ Plettenberg Bay and the Stellenbosch areas show very high growth rates over the 2001-2005 period – the latter suggestive of an emerging sub-epidemics. This clearly highlights the need to tailor interventions and programmes to the local situation, focussing on the local context in terms of locally relevant groups, new infections, sexual networks and risk behaviours. The reasons for the heterogeneity may be attributed to a combination of individual, socio-economic and demographic factors such as age of sexual debut, practise of unprotected sex, and presence of Sexually Transmitted Infections(STI), rapid urbanisation, migration, high population density, unemployment, sexual networks and proximity to national roads. In the case of the Western Cape, there has been rapid urbanization and migration from rural areas to towns or from other province. It is estimated that 48 000 new residents migrate to this province annually, and the reasons cited are mainly for employment, education and access to services. While the impact of migration may influence the growth of the epidemic, the growth and spread of the epidemic cannot be ascribed to migrancy alone. It is globally recognised, that underlying factors such as socio-demographic and economic factors associated with migrancy and rapid urbanisation influence the spread of the epidemic. Individuals and families associated with migrancy are often faced with poverty, discrimination, alienation, the separation from the family and the breakdown of established community and social networks makes individuals vulnerable. The heterogeneity in distribution of the epidemic in this province is not unique to the HIV, as it reflects the wide disparities within the province with regard to a range of factors such as the socio economic status, unemployment rates, poverty levels and health outcomes (iKapa Elihlumayo 2006). It is also evident that spatial distribution of the epidemic follows the Southern Eastern corridor of the Cape Metropole along the N2 highway extending to coastal towns such as Knysna, Plettenberg Bay and George.
Tracking incidence is critical measure of assessing the growth of an epidemic and for planning, monitoring or implementing prevention interventions. Since laboratory-based incidence testing is expensive and not feasible for resource constrained environments, the United Nations General Assembly Special Session (UNGASS) group recommended that HIV prevalence in the 15-24 year age group should be used as a proxy indicator for incidence. Figure 3 highlights the Western Cape HIV prevalence trends among the youth who participated in the HIV antenatal surveys in contrast to the findings of the HSRC national household survey results for the province. 2.2. HIV/AIDS Second Generation Surveillance: In SA, second-generation surveillance surveys have been carried out among the youth and at the household level (HSRC household survey, MRC Youth Risk Behaviour Study, High School study of Grade 8 learners of a peri-urban area in Cape Town, SADHS and the RHRU/loveLife youth household survey). There is strong evidence from these surveys that younger women show higher levels of infection compared to males of the same age group (Pettifor et al. 2004, Shisana 2002, Shisana 2005). There is also mounting evidence at the regional and local level that young women who partner older men are at greater risk for HIV infection (Shisana et al. 2005). One of the key elements needed to turn the epidemic is modifying sexual behaviour. Numerous studies have consistently shown that having adequate and appropriate knowledge does not translate to behaviour change. According to the 2002 SADHS findings, the high levels of knowledge were reported in the WC with regard to safe sexual behaviour (SADHS 2003). A study of adolescents living in peri-urban areas of the Western Cape province revealed that almost a third (32%) of the adolescents reported to be sexually active, with the average age of sexual debut at 14.6 years and ranging from 7years to 19 years)(Flisher 2005). A quarter of the sexually active group reported to have sex with partners who were on average 5 years or older, and women formed the majority of this group (Flisher et al. 2005). Condom use is reported to vary by gender among adolescents in this province, with an estimated 49% of males and 33% of females reported to have used a condom at the last sexual intercourse (Reddy et al. 2002). However, it is evident that for the period 1997 to 2004, there has been a decline in condom usage among adolescents, particularly among males. In 1997, 67% of grade 8 males, had used condoms at their last sexual encounter and this significantly decreased to 44% in 2004 (Flisher 2005). More encouraging however, is that trends on age of sexual debut among learners in peri- urban areas of this province showed a delay in the age of sexual debut for about one year (Flisher 2005). These findings emphasize the huge prevention challenges that face this province, particularly among the youth. Exposure to mass media in SA is high with radio being the primary source of information particularly for HIV/IADS information (Shisana2005). However, community perceptions on political leaders commitment to the epidemic are not optimal, particularly in this province. The 2005 HSRC study showed that in the Western Cape, only 57% of the survey participants reported that they perceived political leaders to be committed to responding to the HIV epidemic compared to 66% at the national level (Shisana et al. 2005). Almost half of the sample (49%) in this province believed that the government allocated sufficient resources to manage the epidemic and only 39.4% believed that there are enough community based organizations helping with HIV/AIDS in the community (Shisana et al. 2005). The 2002 HSRC population study highlighted that the major sources of condoms were in places outside health facilities and only 40% condom uptake took place through health facility level in the WC. This findings support the need to strengthen relationship between the DoH and other sectors in response to the epidemic. These perceptions reinforce the need to improve communication between the community and the government departments with respect to the epidemic in this province. Countries that have managed to turn the epidemic have demonstrated that strong leadership to be a key element. For example, the Ugandan response to the epidemic showed how the political leadership and community mobilization could turn the epidemic. Figure 5. Top 10 causes of premature mortality (YLLs) for Cape Town, and 2004 S  ource: Cause of death and Premature Mortality, MRC and City of Cape Town
Trends in HIV related mortality for the Cape Metropole for the 2001-2004 period has shown a marked increase in HIV related mortality, particularly among younger women. In addition, there is evidence of wide variation in HIV related mortality levels in the districts of the Cape Metro. The mortality data showed the impact of a maturing epidemic, particularly among young women. These findings also reflect the demands placed on the health and social service platforms, particularly with respect to the provision of antiretroviral treatment to HIV positive persons and the increased resources needed for home based care, the care of orphans and vulnerable children. There is global consensus that prevention and treatment are not mutually exclusive, and that prevention and treatment are interdependant. Prevention is critical for the sustainability of treatment, but in the context of care, there are a range of prevention options.  Figure 5. Age standardised death rate for TB, HIV+TB and HIV for persons by Areas, Cape Town 2004 Source: Cause of death and Premature Mortality, MRC and City of Cape Town
2.4.1. VCT VCT is an important gateway towards prevention, treatment and care. One of the challenges that remain is, striking the balance between scaling-up and respecting the rights of individuals to make informed choices about testing. For the period April 2005 to March 2006, 262 792 people were tested through the VCT programme in the WC and this translates to an uptake of 8.1% of population aged 15 years and older. However, approximately more than two thirds of these tests were medically referred, highlighting the need to upscale self-referred testing as a prevention strategy. Innovative approaches will have to be explored, where communities have greater access to these services. For example, the Ugandan Home-based Care Programme showed that in a period of 15 months, VCT uptake increased from 10 to 84 percent. 2.4.2. pMTCT One of the successes of the HIV programme in this province is the PMTCT programme. For the period April 2005 to March 2006, the testing rate among pregnant women was 94,8%; AZT administration rate in antenatal period was 73,4%; AZT administration rate in labour ward was 68,3%; NVP administration rate in labour ward was 75,4%; NVP administration rate to babies was 97,1%. 78,4% of registered babies were tested with a PCR test at 14 weeks, of which 6.1% was positive. The transmission rate from mother to baby has decreased from 10% in 2004/05 to 6,1% in 2005/06.PMTCT should however be integrated with the broader comprehensive HIV strategy as evidence shows that the stage of mother both in terms of high viral load and reduction of CD4 counts can impact on transmission to the infant. It is also evident that the mortality in both infected and uninfected infants is very much dependent on survival of mothers. Infants who have lost mothers will experience 50 percent higher mortality rates. The challenges around reducing transmission through breastfeeding and combination treatment to further reduce transmission during the interim period need to be explored. 2.4.3.Condoms For the period April 2005 to March 2006, 33 186 974 male condoms were distributed in the Western Cape, which only represent 22 male condoms per adult male >15yrs of age per year. The distribution was also very uneven from area to area. Over the same period only 131 987 female condoms were distributed at limited service delivery points across the province.
In order to plan appropriate strategies it is also important to be able to anticipate how the epidemic would unfold with or without interventions. We draw on demographic projections derived from the ASSA 2003 model, which models the epidemic based on assumptions derived from retrospective data. The tables below provide insight of the scale of the epidemic in the years to come.
Source: Adapted from ASSA2003 model Yüklə 1,26 Mb. Dostları ilə paylaş:
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