Disease Prevention and Control / Communicable Diseases / Tuberculosis
Report of a "Lessons Learnt" Workshop on the Six ProTEST Pilot Projects in Malawi, South Africa and Zambia(Durban, South Africa, 3–6 February 2003; published by WHO in 2004) | ||
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Full Text (42 pp, PDF) PAHO TB/HIV Workshops: 2004 | 2003 |
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Executive Summary | Summary of Results | ConclusionsThe ProTEST initiative was established in 1997 by WHO to develop a more coherent response to tuberculosis (TB) in settings with high HIV prevalence through collaboration between TB and HIV/AIDS control programs. HIV counseling and testing services were developed as the entry point to a package of prevention, care and support services. Under the overall coordination of WHO, Six ProTEST projects were established in three countries with a high burden of HIV-related TB: Malawi (Lilongwe); South Africa (Bohlabela District, Limpopo Province; Ugu District, KwaZulu Natal Province; East London District, Eastern Cape Province; Cape Town Central District, Western Cape Province); and Zambia (Lusaka). The project results were reviewed during a four-day "Lessons Learnt Workshop" in Durban, South Africa, in February 2003. The interventions included:
Collaboration between TB and HIV/AIDS control programs was feasible at all levels and helped to improve general health services delivery through enhanced and expanded referral networks, better use of resources and improved staff capacity, training and support. The profile of HIV-related TB was raised at all levels (from community to national government and internationally). Collaboration may also have improved staff morale and contributed to reducing the stigma attached to TB and HIV. Situational analysis at the outset of each project informed planning and ensured that improvements in service provision were focused on areas of local need. All projects improved human-resource capacity by providing training in TB and HIV and their interaction, as well as continuous post-training support for staff. Additional staff had to be hired for general project management and for implementation of activities. Different cadres of staff were employed to provide the additional services, including doctors, nurses, lay people trained as counselors, community volunteers, data entry clerks, and support and administrative staff. However, one project managed to achieve its goals with the employment of only one additional part-time project coordinator. (The comprehensive summary table in the Annex includes details of the numbers of project staff involved.) More than 140,000 people accessed voluntary counseling and testing (VCT) for HIV as part of the ProTEST projects. Improved access to high-quality HIV counseling and rapid testing services, in a variety of settings, responded to a large unmet need; the resulting increase in uptake of these services was dramatic—up to 13-fold in South Africa and 6-fold in Lilongwe. In most settings, high uptake was achieved with a minimal communication strategy at community level to promote such services. Increased counseling capacity through training of more counselors, the use of rapid HIV test kits with same-day test results, and social mobilization were also shown to improve uptake. Uptake of VCT by TB patients varied between the projects. Intensified case-finding (screening) for TB was introduced in all projects and proved to be feasible and effective. The proportion of people found to be HIV-positive after VCT who were also found to be new cases of TB on screening for TB symptoms ranged from less than 1% to 10% depending on the setting. The epidemiological impact of detecting these additional cases is unknown, but the cost of their detection is small. IPT was offered to HIV-positive clients who had no evidence of active TB on questioning. Isoniazid preventive therapy was introduced in all sites. Co-trimoxazole preventive therapy was introduced in all projects except Zambia where the results of a randomized controlled trial are awaited. Although the uptake of and adherence to preventive therapy were low among eligible clients, so were the costs. Early analysis suggests that the costs are in line with estimates from elsewhere and that preventive therapies are likely to be cost-effective—the incremental expense of grafting them onto existing services is low. Adherence appeared to be improved by the application of stricter inclusion criteria and by greater support and resource input. All projects introduced HIV prevention activities or enhanced existing activities (such as condom promotion and screening for sexually transmitted infections) in clinics and VCT centers. The impact of these interventions and the direct impact of VCT on HIV prevention were not measured. However, assuming that counseling and testing can prevent HIV through consequent behavioral change, the ProTEST projects are likely to have made a sizeable contribution to HIV prevention. A study is underway in Malawi and another is planned in Zambia to measure the impact of ProTEST activities on sexual risk behavior. Community involvement and post-test support clubs were developed with the aim of strengthening promotion of VCT, and identifying and providing psychosocial support for people living with TB and/or HIV in the community. Data on the cost-effectiveness and behavioral impacts of ProTEST collaborative interventions are still being collected. All projects made significant progress towards their original goals. The governments of the three countries involved are now formulating and approving plans for national expansion of TB/HIV joint activities, based on the achievements and evidence from the ProTEST pilots. Monitoring and evaluation of the six pilot projects were developed locally and therefore not in a standardized manner. This has often made it difficult to directly compare results (e.g. the need for adherence definitions for isoniazid and cotrimoxazole preventive therapies) between projects. The ProTEST projects have demonstrated that HIV/AIDS and TB control programs can work together effectively, at all levels, towards the same goal, i.e. providing comprehensive prevention, care and support services for the benefit of people living with HIV/AIDS and/or TB. Project results have convinced policy-makers, planners and program managers in HIV/AIDS and TB that these collaborative activities are necessary and feasible, and that they contribute to improving health services for people living with HIV/AIDS and/or TB. The involvement of all stakeholders, including the district health management team, community-based organizations, nongovernmental organizations (NGOs), from the early stages of situational analysis and project development is critical to project success. TB and HIV program collaboration is important for
In addition, collaboration between TB and HIV programs may be important for increasing access to antiretroviral therapy (ART) for HIV-positive clients with TB. (ART was not included in the pilot projects as the drugs were not affordable at the time of project development. However, participants viewed the ProTEST model as a useful foundation for provision of antiretrovirals in the future.) The provision of high-quality, accessible VCT, using rapid HIV tests and linked to a comprehensive package of prevention, care and support, greatly increases the number of people who know their HIV status, are counseled about HIV prevention and have access to the most appropriate prevention and care services based on their needs. The provision of isoniazid and co-trimoxazole preventive therapies is feasible in the context of collaborative TB/HIV activities. The inclusion criteria for these therapies need to be reassessed in the light of the low uptake. Culturally specific information is needed on how to promote the uptake of and adherence to IPT and CPT, which will be important in their own right and when ART is introduced. The efficacy and effectiveness of CPT in reducing TB mortality in different country settings has been questioned and these studies have not clarified the picture. The impact of IPT on TB control has so far been small. However, as part of a total package of care for people with HIV and TB, health care workers (HCWs) had confidence in the use of IPT and CPT for the management of individual clients, as provision of these therapies had clearly improved morale and reduced stigma. Standard tools are needed for monitoring and evaluating collaborative TB and HIV activities. Additional resources and technical support may be needed to improve data collection, analysis and dissemination. Linked, multicenter, operational research studies can produce a wealth of information to assist policy-makers and implementing agencies in deciding on the most efficient manner of delivering the interventions that have already shown their effectiveness. Joint TB/HIV planning is essential in all countries with a significant epidemic of HIV-related TB. This planning must include a specific description of the roles and responsibilities of TB and HIV/AIDS programs, a formal mechanism for cooperation and collaboration, and mainstreaming of TB/HIV activities into national TB/DOTS expansion plans and HIV/AIDS strategic development plans. The challenge now is to ensure that TB prevention, care and control are regarded as elementary interventions for PLWHA, with or without ART. Similarly, TB programs should regard HIV prevention, care and support as key components of TB control. Efforts to prevent new HIV infections will ultimately contribute to a reduction in HIV-related TB—and reduced HIV mortality among TB patients will improve both TB and HIV treatment outcomes. To supplement this brief summary, the reader whose time is limited is strongly encouraged to read the detailed recommendations given at the end of each section in Chapter 3.
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