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

Thank You

Rheiner.Mbaezue@capetown.gov.za