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Cape Town, South Africa: integration of
TPT into ART clubs
Rheiner Mbaezue ; MBBS, MPH, PGD Fam Med
Clinical Medical Officer, City of Cape Town: City Health
28 March 2019
1
Cape Town
8 health sub-districts:
▪ Fixed PHC Facilities = 130
▪ District & Regional Hospitals
= 11
▪ Specialized TB Hospitals = 2
▪ Tertiary Hospitals = 3
▪ POPULATION : 3.8 million
Services rendered by City Health & MHS
City Health Metro Health Services
Child health 81 14
Reproductive health 86 44
STI 86 44
Adult curative 12 44
TB diagnostic 86 44
TB treatment 85 24
HIV testing 86 44
ART 59 33
TB Case Finding: Trends over Time by HIV status 2003- 2017
0
5000
10000
15000
20000
25000
30000
35000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
HIV Unknown HIV + TB HIV - TB
2010 - 2017HIV+ve:-22%HIV-ve: -16%
Source: ETR
29,726 patients877/100,000
23,326564/100,000
ART introduced; changing start criteria
78 7879
82 8283
84
8687
86 86 8685
8482
% treatment success: new smear positive
TPT ‘push’
5
Changing TPT policies in the
Western Cape
TST / MANTOUX TEST
neg pos unknown
pre-2012: ALL HIV+ nil 12/12 TPT x
2012: ALL HIV+ nil 36/12 TPT x
2014:HIV+ nil 36/12 TPT 6/12 TPT
ART 12/12 TPT 36/12 TPT 12/12 TPT
2016: ALL ART 12/12 TPT 36/12 TPT 12/12 TPT
Pre ART – TPT policies were well implemented by those who provided HIV care
ART introduction – those clinicians providing HIV care moved into ART care
where ART was prioritised and TPT not routinely done; pre-ART care left to
‘flounder’ (incl. TPT)
2014: directive from National for the Western Cape to boost TPT numbers:
new change to TPT protocol of 12/12 TPT for TST negative patients and
shortage of TST made targeting ART patients a sensible strategy; club patients
targeted as a population stable on ART with systems making mass TPT possible
policy to also screen all new ART start patients for TPT
2016: ALL HIV+ now eligible for ART; shortage of TST simplified eligibility criteria
6
ART clubs piloted by MSF in Khayelitsha,
Cape Town in 2008 as a potential solution to growing congestion
within the clinics
Two years of data showed good
remaining in care figures and good viral
load suppression rates; model spread throughout the Cape
Town Metro 2011-2013
Collaboration between:
WC ProvinceCity of Cape Town
**MSF (Club Model)*IHI (Spread Model)
Other NGOs
Currently the largest DMOC
scaled model in the world?
**MSF – Medecins Sans Frontiers (doctors without borders)*IHI – Institute of Healthcare Improvement
7
City Health provides care for just over a third of
primary care ART patients in Cape Town; over 67,500 patients on ART with over
36,500 (46%) in clubs
Patients in clinic care
Patients in club care
Introduction of TPT at scale into the club
model: < 10,000 patients in clubs
Rolled out over 3 years
% in club care: peak at 49%
Push for growthNew club model
CDU capping
8
Ikhwezi Clinic: largest ARV program at City Clinics:
• 5257 patients on ART
• 2557 (49%) patients in clubs
• 3 clubs run every day on an 8 week cycle (120)
• Once a year clubs have a blood visit
followed by a clinical visit
New ART site opened: May’16
9
Standard club visit (up to 30 patients per club)
Facilitator records weight of each patient
Facilitator screens patient for:- Symptoms of TB- Any other problems
Opportunity for group discussion
If all is well a 2/12 medication parcel is given
to the patient
Photo from the MSF facilitator training presentation
10
Standard club visit (up to 30 patients per club)
Facilitator records weight of each patient
Facilitator screens patient for:- Symptoms of TB- Any other problems
Opportunity for group discussion
If all is well a 2/12 medication parcel is given
to the patient
Doctor or nurse gives information about TPT
Doctor or nurse screens patient for
contraindications to TPT
INH and pyridoxine given to all patients qualifying for TPT along with ART;
un-used parcels returned to pharmacy and scripts
cancelled
NO
TE: TST Stock-o
ut in
20
14
; first club
imp
lem
en
tation
1
6 Ju
n to
8 A
ug 2
01
4 (to
miss fe
stive se
ason
jum
p)
Photo from the MSF facilitator training presentation
11
Standard club visit (up to 30 patients per club)
Facilitator records weight of each patient
Facilitator screens patient for:- Symptoms of TB- Any other problems
Opportunity for group discussion
If all is well a 2/12 medication parcel is given
to the patient
Standard information sheet put together for clinicians to
use
Clear policy for screening in place; club register
adjusted to include TPT
All patients pre-scripted for INH and pyridoxine and
2/12 supply dispensed by pharmacy
pre
paratio
n d
on
e prio
r to th
e clu
b m
ee
ting
Photo from the MSF facilitator training presentation
12
City Policy tool for TST screening 2014
13
Continue TPT
Completed TPT
TB treatment
started
Patient opted out
Register completion
In practice the TST has not been
available
IPT status column
added to register
TPT information captured electronically with club data at the end of the grace period; batch capture designed to assist
M38
14
0
1000
2000
3000
4000
5000
6000
Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4
2014 2015 2016 2017 2018
Wave 2: clubs
ART for all Sep 2016: increased new starts
Wave 1: clubs
ALL TPT new starts in HIV+ patients at City facilities: 2014 to 2018
Note seasonal dip each Dec/Jan period; mobile population
Note: <10,000 patients in clubs at this point
TPT in club care now:
• Mass TPT screening and provision of
IPT in clubs was done through
2014/2015; these patients have all
completed their TPT course
• The WC policy does not include
routine repetition of TPT, so currently
the TPT program focusses on
screening newly diagnosed HIV+
people for TPT as part of the ART
work-up
• Patients can be reviewed for club
care at 6/12 on ART: the systems put
into place for mass TPT provision
allow for patients on TPT to enter the
club and have their TPT appropriately
managed.
15
City Integrated Annual Audit - ART
Program: sampling - patients 4-6/12
on ART
Re
sults '1
4
Re
sults '1
5
Re
sults '1
6
Re
sults '1
7
Re
sults '1
8
IPT started 27% 41% 33% 49% 46%
Photo from the MSF ART adherence
club toolkit
