GF Jooste leads the way in TB care

He looks terrified and confused, the whites of his eyes showing as he pulls the bedding up to his chin. Next to his sister, Thandi Mngxuma, dressed in a t-shirt with red AIDS ribbons, holds up a chart which has various pills glued to a piece of cardboard.

Mngxuma patiently asks the 38-year-old several questions and when he fails to answer, looking in desperation at his young sister, she waits for the woman to again explain to him what they are trying to establish. At one point he holds three bony fingers in the air.

‘€œHe’€™s had TB three times, but the clinic never told him what TB was,’€ Mngxuma translates, making notes in a huge white file.

Mngxuma is a counsellor at a TB Unit which is revolutionising TB care at Cape Town’€™s busiest hospital, GF Jooste in A TB Unit at one of South Africa’€™s busiest hospitals is at the forefront of showing why this disease which is killing thousands of South Africans, is curable.

Manenberg. For many years, the secondary hospital has served 1,5-million people in the socio-economically dense districts of Mitchells Plain, Klipfontein and Khayelitsha.

In the hospital’€™s medical wards emaciated figures, some moaning, others simply staring into space serve as reminder of the very real and devastating impact the HIV epidemic is having on communities. However, a project started by Farzaneh Behroozi, a public health researcher, is showing promise as an intervention which could dramatically cut the deaths linked to TB.

Sixteen TB clinics and 10 antiretroviral clinics refer patients to GF Jooste. Khayelitsha is the largest of the referral areas with a TB incidence (new cases) of 1 612 per 100 000 people per year and an antenatal HIV sero-prevalence of 33% (number of pregnant women found to be HIV-positive at a number of antenatal clinics surveyed).

Research conducted in the hospital’€™s medical wards, which admit up to 35 patients daily, revealed that 83% of TB patients were co-infected with HIV. A mortality audit at the hospital showed that among HIV positive adults who died at the hospital, the leading cause of death was TB, which was responsible for 56% of deaths.   Although tuberculosis is a preventable and curable disease, it is the most common notified natural cause of death in South Africa.

 TB patients with HIV need to be urgently diagnosed and started on treatment, but they often are not. A study conducted by Dr. Graeme Meintjes and others at the hospital showed that patients co-infected with TB and HIV deteriorate rapidly.   The mortality rate was often high and the delay in getting them onto treatment was often found to be on the side of the healthcare provider.     With the assistance of three doctors, Behroozi did a retrospective review of patient folders, death certificates andthe morgue book. They found that many of the patients had been through the health system several times and that they were returning to the hospital to die.

‘€œIt is difficult to diagnose TB in HIV positive patients at the clinics, as many of them are sputum negative, and we also realised there was a problem once the patients left the hospital –   they often did not arrive for TB treatment at the clinics.’€ said Behroozi. Left untreated, each person with active smear-positive TB will infect on average between 10 and 15 people every year.

The research findings led to the establishment of the TB Unit in July 2008 and so far over 2 800 patients have been counselled,

Behroozi and the three counsellors, Mngxuma, Zuziwe Boyana and Pam Bisholo, identify an average of 178 TB patients per month and around 144 are counselled. This translates to 80% of patients identified with TB being counselled.   Behroozi explained that those patients who are not counselled are either confused or have been transferred to another facility too soon.

The fact that 82% of patients discharged from hospital arrive at their referral TB clinic is testament to the success of the TB Unit. This is a massive increase from previous figures, which reflected that only around 40% of patients were reporting for TB treatment after discharge.

‘€œWe found that many patients didn’€™t understand their condition, they didn’€™t understand the importance of finishing their TB treatment,’€ said Boyana.

‘€œSome patients don’€™t know they have TB and many stop their treatment when they feel better, thinking they are cured,’€ added Mngxuma.

Bisholo explained that they go from ward to ward every morning, check files and find new TB patients and check on those they have already counselled, and again speak to patients to reinforce the messages upon discharge. . The counsellors often educate visiting family members around treatment support and infection control.

The presence of counsellors who speak the same language as the patient is also essential, as there is often a language barrier between doctor and patient, but the counsellors are able to bridge this and ensure patients leave hospital with a good understanding of their disease.
Dr Rosie Burton oversees the TB Unit, as the head of Infectious Diseases Unit at GF Jooste. ‘€œThere is massive pressure on doctors to admit emergencies, discharge patients to alleviate the bed pressure ‘€“ there is no time to have extensive discussions with patients. Often the patients are also not comfortable to disclose everything to the doctor, they feel much more comfortable speaking to the counsellor. There is no doubt that the unit has made a huge difference to our patient care,’€ said Burton. A similar intervention was first created at Chris Hani Baragwanath Hospital.   Initially in a clinical service audit done at the hospital from 2000-2001, TB case notification was at 30%, and only 50% of referred patients arrived at TB clinics for care.   Diagnosis results were often delayed.  

The intervention aimed to educate and support patients to initiate TB treatment, advise clinicians, strengthen TB surveillance and streamline hospital discharges, and ensure that patients diagnosed in hospital were getting TB treatment after discharge. In the first year of the intervention, 93% of patients arrived for their TB clinic visit.

The GF Jooste TB Unit is funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) until 2011.

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