1. From ProTEST to Nationwide Implementation
Dr Nono Simelela
Chief Director: HIV/AIDS/TB/STI

2. The Burden of TB and HIV
S.A. is facing one of the worst dual epidemics in the world.
TB cases (424/ ) in 2001.
Based on ANC HIV prevalence of 24.8%, it is estimated that 4.7 million South Africans are HIV-infected.
Approximately 50% of TB patients are infected with HIV.

3. TB/HIV Collaboration 4 TB/HIV Pilot Districts started in 1999
Joint Strategy for HIV/AIDS/STI and TB control in SA endorsed in 2000 including TB/HIV District roll out.
Capacity building workshops with provinces and districts conducted in 2001.
Nine TB/ HIV training districts established in 2001.

4. Lessons Learned.
Consultation with and involvement of community structures is important for success.
Political commitment and ownership is important to mobilize funding and to ensure sustainability.
Improve management of human resources.

5. Lessons Learned.
Active case finding has a role to play in diagnosis of TB in HIV+ clients.
TB control not adversely affected by these interventions.
Variable adherence to INH prophylaxis.
Need to ensure continuum of care.

6. Challenges Certification of lay counselors to perform rapid HIV tests.
Quality assurance for rapid HIV testing.
Standardized prophylaxis and treatment of opportunistic infections.
Ensuring uninterrupted supplies of tests, prophylaxis and treatment.

7. Challenges. Recording and reporting systems Integration with PMTCT.
Robust Health Systems.
Community mobilization.
Insufficient Human Resources.
Lack of uniform policy on volunteers.

8. Criteria for Expansion.
Choose districts with well functioning TB services as demonstrated by:
- Good sputum conversion rates
- High cure rates.
- Low interruption rates.
Sufficient personnel in the districts – lay counselors, healthcare workers, HBC, DOT supporters.

9. Areas of Collaboration.
Formation of TB/HIV collaboration committees at national, provincial and district levels.
Training of healthcare workers on
TB/ HIV management.
Involvement of home based carers in TB case finding, DOT and VCT promotion.

10. Areas of Collaboration.
Involvement of DOT supporters in VCT promotion.
Health education and awareness campaigns should include both TB and HIV.
Training of lay counselors.

11. Roles and responsibilities.
The package of services that can be provided in each training district will vary according to resources available.
Services are largely provided in comprehensive health care facilities.
The same primary healthcare nurse may provide VCT, TB, HIV and STI services.

12. Roles and responsibilities.
At district level there may be one person responsible for TB and HIV or there may be individual coordinators for TB and for HIV.
TB coordinators should take responsibility for ensuring that TB patients have access to VCT, condoms.

13. Roles and responsibilities.
HIV coordinators should take primary responsibility for VCT, condoms, cotrimoxazole, management of opportunistic infections and home based care.

14. Package of care. The key elements of the package will include:
Enhanced district collaboration
between TB and HIV service
providers including both government
and non-governmental organisations.

15. Package of care. Mobilization of communities to assist in
TB/HIV prevention and care.
Increased access to VCT services, with
a focus on self referred clients.
Enhanced case finding for TB among
HIV+ clients.
Diagnosis and treatment of opportunistic infections.

16. Package of care. Provision of Cotrimoxazole prophylaxis.
Improved referral systems between organisations providing services.
Provision of ARV’s for prevention of mother to child transmission.
Provision of post exposure prophylaxis for rape survivors.
Provision of ARV’s for treatment of HIV positive individuals.

17. TB/HIV Training Districts: Targets
Cover all districts by 2006
VCT:
Test 12.5% of adult population and 80% of TB patients by 2005.
Active TB Case Finding:
Screen 90% of HIV+ clients for TB (sputum microscopy if TB symptoms)

18. Targets. Cotrimoxazole prophylaxis: Provide CP to 90% of those who are
eligible including HIV+ TB patients.

19. Expansion Plan 2001 - 4 districts (ProTEST TB/HIV Pilots)
districts (+1 per province)
districts (+3 per province)
districts (+5 per province)
districts (+7 per province)
districts (+3 per province)

20. Coordinating Structures
National TB/HIV Task Team
- Policy recommendations.
- Monitor implementation by provinces.
- Coordinate technical support to provinces.
- Liase with donors.
Meetings: Quarterly

21. Coordinating Structures.
National TB/HIV Working Group
- Monitor implementation in provinces
- Problem solving.
- Sharing best practices.
- Identify further need for support from
national to provinces.
Meetings: Quarterly

22. Coordinating Structures.
Provincial TB/HIV Working Group.
- Monitor implementation at district level.
- Share best practices.
- Problem solving.
- Identify need for further support from
province to district.
Meeting: Quarterly

23. Coordinating Structures.
District Management Teams
- Implementation of TB/ HIV activities.
- Communication and collaboration.
- Improve referral systems
Meetings: Quarterly

24. Monitoring and Evaluation.
Objectively verifiable indicators.
Register.
Data submitted quarterly.
Narrative report on progress quarterly.
Quarterly monitoring visits by national task team to provinces.

25. Conclusion.
Political commitment should be as strong for TB as it is for HIV/AIDS.
Financing at district level for both programmes should be integrated so that resources can be shared.
Health awareness programmes to be conducted jointly.

26. Conclusion. VCT services need to be “marketed”.
There is still a need for separate programmes but what is crucial is to identify areas of collaboration.