The woman pulls a face as she peers at the five huge, round tablets in the palm of her hand. In one swift movement, she flicks them into the back of her mouth, throws her head back and takes a big gulp of water from the white paper cup. She gathers her umbrella and handbag and saunters out of the small room and the down the noisy clinic passage.
In that small room, TB assistant Vuyelwa Nkohla doesn’t do anything slowly. She works in the tuberculosis clinic at Nyanga Clinic and is part of a team ensuring that more than 300 TB patients take their handful of pills every day.
‘Most of the patients come back every day and if they don’t, we go and find them,’ explains Nkohla, a slightly built woman with an easy smile.
She works under the supervision of the clinic’s nursing staff and is part of Zamstar – the Zambia South Africa Tuberculosis and Aids Reduction Study – group.
Run in eight communities in the Western Cape and 16 in Zambia, Zamstar is trying to improve TB treatment in the absence of any new TB drugs or a new TB vaccine.
‘We are seeing whether public health interventions can be used to stem the TB epidemic,’ explains Professor Nulda Beyers, director of the Desmond Tutu TB Centre at Stellenbosch University, one of the main collaborators in the long-term study.
Clinic-based HIV and TB interventions are a critical part of the study, with both TB and HIV services working closely together.
In practice, this means that all TB patients will be tested for HIV and all patients going for Voluntary Counseling and Testing at the HIV Clinic will be referred for TB testing.
At community level, awareness will also be raised using simple messages.
‘There are too many people with undiagnosed TB. The message must be clear. If you have been coughing for two to three weeks you must go for a TB test, not wait 18 months and infect another 15 people in the process,’ says Beyers.
At school level, Zamstar workers will be raising TB awareness from grade one to 12, moving from school to school and setting up sputum (mucus) collection points.
‘Hopefully, as was the case with messages in the early days that we have to brush our teeth, children will take home the three basic TB messages we will be communicating,’ says Beyers.
Youth and drama groups will also be going to places ‘wherever there are lots of people’ such as markets and churches.
‘Social scientists have mapped out the communities in terms of what happens where and who congregates where. These are the area the groups will be going to with the aim of ensuring that every person in the target communities will be able to give a sputum sample at least three times a year at a place which is within a 30 minute walk,’ says Beyers.
Taking it to the next level, community health workers will also be doing household interventions where TB has been diagnosed. These homes will be viewed as being at risk of HIV and TB.
Repeat visits will be carried out and household members motivated to take HIV and TB tests.
‘We need to make it easy for them to be tested, accompany them to the testing points and of course also make sure that those people who are put on treatment complete their treatment,’ says Beyers.
In 2009, prevalence studies will be done where 5 000 adults will be tested for TB. It will be key to establish how many people remained undiagnosed despite the interventions.
Nyanga, Phillipi, Khayelitsha Site C, Harare, Wallacedene, Delft-South, Kayamandi and Mbekweni/Phola Park will all be participating in the study.
Exactly the same interventions will be done at the 16 sites in Zambia.
A quality assurance team will travel between the two countries to monitor among others the quality of the interventions as well as the laboratory services, a key cog in the TB programme.
‘We will definitely not see a new TB drug before 2015 which makes it critical that these interventions show good results,’ said Beyers.
The South African leg of the study is run in close collaboration with the Provincial TB Programme and TB services in the Cape Town metro.
The intervention, which will last three years, starts in April. It has already taken 18 months to get support from the community and establish a community advisory board.
‘Together we have a wonderful opportunity to ensure that the incidence of TB decreases, but we have to ensure that this opportunity is handled in a responsible way, leading to empowerment of people and services in high-burden countries,’ says Beyers.
