On World AIDS day of last year Zuma stated, ‘We have no choice but to deploy every effort, mobilise every resource, and utilise every skill that our nation possesses, to ensure that we prevail in this struggle for the health and prosperity of our nation’¦ The amount of resources dedicated to prevention, treatment and care [for HIV and TB] has increased…but it is not enough. Much more needs to be done. We need extraordinary measures to reverse the trends we are seeing in the health profile of our people.’
Despite the poverty of the area, the Khayelitsha programme is a place where extraordinary measures have been implemented for more than a decade. It is an important model for demonstrating the feasibility of different strategies to achieve the targets set forth in the National Strategic Plan (NSP) for HIV/AIDS and Sexually Transmitted Infections (STIs), including achieving “universal coverage” of antiretrovirals, by 2011’ all of which would have been impossible without the relentless combined efforts of Khayelitsha residents, the Treatment Action Campaign, MÃ©decins Sans FrontiÃ¨res, the Provincial Government of the Western Cape, the City of Cape Town, the Universities of Cape Town and Stellenbosch, and many others.
Khayelitsha was the first in South Africa to provide ARVs in public sector clinics and its initial success contributed to the paradigm shift from the consensus that providing ARVs was not feasible in poor settings, to making it a priority. It is also one of two pilot projects in the country to provide treatment for drug-resistant tuberculosis (DR-TB) in clinics while patients live at home, rather than requiring hospitalisation away from family and friends for at least six months.
Doctors working in Khayelitsha hailed the first of December 2009 as the first ‘happy’ World AIDS Day this country had ever seen. Indeed President Zuma’s speech and the newly approved HIV treatment guidelines include evidence-based HIV and TB policy shifts that many had been fighting for for years, such as providing ARVs to all HIV-infected infants and to pregnant women and people with TB with a CD4 count of less than 350. The President also committed to treating TB and HIV ‘under one roof’ and ensuring that all the health institutions in the country are ready to assist patients and not just a few accredited ARV centres.
For these objectives to become a national reality, ARVs will need to be provided in close to 4000 health centres, while currently it is only being provided in 400. A scale-up of this immensity will require the implementation of many of the lessons learnt in Khayelitsha, including task-shifting to nurse-led initiation of ARVs, TB/HIV integration, and adherence clubs for patients on long-term ARV treatment.
By the end of last year, more than 13 000 patients had been started on ARVs in Khayelitsha and new enrollments are increasing despite the scarcity of staff. This was only possible because nurses provide ARVs and ARV services were decentralised to all clinics.
This nurse-based scale up of ARV treatment has not jeopardised standard of care or patient outcomes. At 5 years on ARVs, 70 % of people started on treatment remain in care with copies of the virus in their blood increasing in less than 15 % of patients. There has also been a decrease in patients presenting with low CD4 counts, and mortality has decreased significantly.
The greatest challenge for the scale-up now is how to retain patients in care over the long-term, while at the same time increasing enrolment on ARVs. Adherence clubs were started in Khayelitsha to maximize clinic efficiency and improve support for stable patients on chronic ARVs. Early results of this pilot project are promising and it is expected that adherence clubs will play a major role in achieving the NSP targets of coverage. Youth proved to be at especially high risk of defaulting ARVs. Treatment literacy provided by the TAC in facilities and the community is an essential part of the programme.
The Integration of ARVs within TB services in Khayelitsha (where approximately 70% of all TB patients are HIV positive) has improved efficiency and clinical care. Previously, patients were referred from TB clinics to distant ARV service points (and vice-versa), resulting in long waiting times and duplication of both clinical and laboratory investigations and medical records. Patients were also seen by different health care staff, which was a waste of resources and a confusion for patients, as is the case for most patients in other parts of the country.
Integration of ARVs in TB clinics is also an incentive for TB patients to take an HIV test: in 2008, 99% of TB patients received counselling and 95% accepted to be tested due to the opting ‘ out strategy. Increased detection of TB in co-infected patients improves the detection of smear negative TB more common in HIV-positive patients, which traditional TB services are less equipped to do.
Enrolment on ARVs for TB patients was low prior to integration. In 2007, only 19 % of patient enrolled on ARVs were referred from TB services. The newly integrated Khayelitsha clinics show a radically different picture: a folder review in one clinic reveals that up to 68 % of patients enrolled on ARVs are on TB treatment. TB/HIV integration has also shortened the time to initiation of TB treatment as well as of ARV treatment in co-infected patients.
While treatment outcomes for drug-sensitive tuberculosis are satisfactory in Khayelitsha, with 82 % success rate and 74 % cure rate (2007), an increasing number of patients have been diagnosed with drug-resistant TB.
The decentralisation of care for DR TB patients has resulted in greatly increased detection, a 50% reduction in time to initiation of treatment and improved early treatment outcomes. Increased focus on infection control in health facilities as well as patients’ homes is being implemented to curb transmission. In total, 582 patients from Khayelitsha have been initiated on DR-TB treatment during the first 3 years of the programme. While it is too early to assess long-term outcomes, it is clear that this programme places the needs of patients first, resulting in better adherence to treatment and increased community support.
In terms of prevention of HIV transmission, the Khayelitsha project has implemented some very successful interventions. The number of HIV-infected pregnant women (prevalence) reporting to antenatal clinics has stabilised since 2006, despite the initial rise from 15% in 1999 to 32% in 2006. Khayelitsha has also massively scaled up the distribution of condoms which has resulted in a 50% decrease in the number of new sexually transmitted infections (STIs). The introduction of large scale voluntary counselling and testing by lay counsellors, the availability of prevention of mother to child transmission, and later the shift to ‘opt-out’ HIV testing and counselling for TB suspects, STI clients, family planning services and youth where people are routinely offered HIV-testing, resulted in the increase of people tested in Khayelitsha from less than 500 in 1998 to 40,000 in 2008. The opening of a male only walk-in clinic also led to a sharp increase in the proportion of men testing for HIV and attending STI consultations within the first year of implementation.
The mother-to-child transmission of HIV rate in Khayelitsha is one of the lowest in the world at 3.3%. This success is due to the fact that almost 100% of pregnant women are tested for HIV in Khayelitsha and ARV provision has been integrated into the midwife obstetric units (MOU). HIV-positive women with a CD4 count below 200 receive ARVs while women not eligible for ARVs receive AZT from 28 weeks of pregnancy and single dose of nevirapine during labour. To achieve universal coverage, it will be necessary to integrate midwife-led ARVs within antenatal consultations everywhere in South Africa.
All of the achievements have been made without a proportional increase in staffing. Non-financial incentives such as ongoing training, clinical on-site coaching and ongoing supervision are essential. What might not transpire from the NSP is what it requires in terms of management: a dedicated district management team open to regular meetings with community organizations; constant program adjustments informed by a rigorous monitoring and evaluation system and streamlined decision-lines to allow for quick decisions and additional resource-allocation where justified.
We now have the political will, we may have the resources with the additional R8,4 billion announced in the Budget for ARVs, but if we want to meet the NSP targets we’ll need a new paradigm shift towards nurse-initiated, decentralised ARV provision, integrated within TB services and antenatal consultations. In this new era of HIV care, resistance to change must make place for openness to innovative ways to respond to the epidemic.
For more information, see the Khayelitsha Annual Activity Report 2008-09 at www.msf.org.za. Lesley Odendal works for the MSF Khayelitsha Project