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World TB Day Memorandum - A Call to Action

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The following joint -statement was released today by the Treatment Action Campaign and the TB/HIV Care Association. A copy of the statement was handed over to Dr. Joey Cupido who received the memo on behalf of the National Department of Health following a march to Parliament.

World TB Day Memorandum - A Call to Action

24 March, 2009

Work in partnership to save lives: Increase access to TB prevention, diagnosis, treatment and adherence support

We, as nongovernmental organisations, health workers and community care givers working to prevent and treat TB in our communities, are here today to show our commitment to increase our efforts and build partnerhips to end the TB and HIV coepidemics. We realise that we cannot overcome this immense public health challenge alone and that commitment is needed from every individual, organisation and sector. As civil society, we will continue to mobilise communities and collaborate with government to increase access to TB/HIV services. In turn, we call on government to commit to invest more financial and human resources to address the dual TB and HIV epidemics in South Africa in partnership with civil society.

TB is the leading cause of natural death in South Africa. The number of new cases is extremely high. Co-infection with HIV is at more than 50 %, and as high as 75 % in some areas. South Africa has the 4th highest number of TB cases in the world according to the World Health Organisation (WHO). The annual number of cases notified has tripled between 1996 and 2006 from 109,346 (269 cases per 100,000 population) to 342,315 (722 cases per 100,000). WHO estimated that the true incidence of TB in South Africa was 940 cases per 100,000 in 2006. The successful treatment rate for patients registered in 2005 was 69.4%, well below the target of 85%. As a result of poor TB treatment outcomes, there is also a growing number of people with multi-drug resistant TB.

Despite increased focus on TB by government in recent years, drug stock outs still occur, policies are not finalised, TB contacts are not traced, community health care workers’ stipends are not standardised and measures to address TB in HIV positive people are neglected. Today we say enough. Through partnerships, these problems can be solved and TB can be cured.

As civil society, the organisations below commit to addressing TB through evidence-based actions along side government and call for the following :

1. Collaboration:

We must all prevent and treat TB every day. This means that all government departments must come together, with civil society, to address the coepidemics of TB and HIV. Civil society must be able to participate meaningfully in addressing TB, including assisting government in drafting plans and policies and in being part of the decision-making processes of government.

2. Community care givers:

Community care givers play a critical role and must be recognised and appreciated for the major contribution which they are making. They assist with education, screening, referral, contact tracing and provision of adherence support for TB. In most parts of South Africa, community care givers who provide directly observed TB treatment are either unpaid or receive a small stipend. There should be a standardised stipend for all community care givers and they should be trained to provide support for both TB treatment and antiretroviral treatment.

3. TB/HIV integration:

At all levels of the health system, the TB and HIV programmes need to become integrated in their approach. This must occur in the National Department of Health’s TB and HIV programmes, provincial programmes, district offices, health care facilities and communities. Policies and plans of the Department of Health should specify what will be done to integrate TB and HIV services. In facilities, patients should be able to be screened, tested and treated for TB and HIV in one facility. All health facilities that provide antiretroviral treatment should also provide TB treatment. Where this is not possible, measures should be put into place to ensure efficient referral systems between TB and HIV services.

The National Department of Health should design and implement a standardised HIV patient record and HIV care registers which include information on TB screening and treatment to ensure that health care workers have complete patient information to treat TB and HIV effectively. If there is a patient with TB who is also on antiretroviral treatment, the same community care giver should support the patient rather than 2 different community workers.

The National Department of Health must increase its efforts to decrease the burden of TB in people living with HIV through adoption and implementation of interventions promoted by WHO as the 3 I’s - intensified TB case finding, infection control and isoniazid preventive therapy.

4. Intensified TB case finding:

Intensified TB case finding refers to screening HIV-positive clients for TB at every clinical visit. In 2006, less than 25% of people who tested HIV-positive were screened for TB. In the same year, only 32% of TB patients in South Africa were tested for HIV. HIV testing should be provided to all TB patients and all HIV-positive clients should be screened for TB. The Department of Health should provide educational materials encouraging people to know their HIV status and be screened for TB.

We call for intensified TB case finding to be scaled up from less than 25% to at least 80% of people who test HIV-positive. Additionally, the Department of Health should ensure that known HIV-positive clients get screened for TB whenever they access HIV clinical care. Clear and simple screening protocols need to be developed to assist health care workers in diagnosing TB in HIV positive patients. Health care workers need training in screening for TB, particularly extrapulmonary and smear negative TB.

5. Prevention- Infection control in health care facilities and communities:

The spread of TB can be easily prevented. This will decrease the burden of disease in years to come, allowing for the health system to better treat current patients and improve the quality of life of patients. We are failing at preventing TB in our communities. The TB Infection Control policy has been in draft format since 2007. This needs to be finalised urgently and should include guidance on cough hygiene, patient separation and triage (administrative controls), ventilation measures and other environmental controls, and mask supply (personal protection). Infection control should be practiced universally in clinics and in community settings. In clinics, N95 respirators should be made available to all clinic staff and masks should be provided to all coughing patients. We call on the Department of Health to show commitment to reducing the spread of TB infection by implementing infection control plans and developing and distributing educational materials. These should include information about the importance of covering your mouth when you cough (with your hand, a tissue or, in a clinic, with a mask) and of keeping windows open in crowded places such as taxis and clinics.

6. Prevention: Provision of Isoniazid Preventative Therapy (IPT) to all HIV
positive patients and health care workers

The efficacy of IPT for preventing latent TB from developing into active TB among people living with HIV (PLHIV) is well established. IPT decreases the risk of TB by 64% and is one of the only effective interventions available for PLHIV before they are eligible for antiretroviral therapy. Despite the existence of a national policy for IPT since 2002, less than 1% of PLHIV receive IPT in South Africa. IPT must be scaled up immediately in all facilities in all provinces. A circular should be sent to all health workers reminding them of the national policy and encouraging them to implement it. Any revision of the national policy should not be used as an excuse for delaying implementation of the existing policy.

7. Diagnosis of drug resistant TB:

Drug-resistant (DR) TB needs to be diagnosed as soon as possible in a patient to ensure access to treatment. Our diagnosis of DR TB is alarmingly slow. The current protocol for sending in culture samples allow for patients with DR TB to go undiagnosed for many months. Drug susceptibility testing (DST) protocols and diagnostics should be made available to all facilities. We need more labs that can conduct culture and DST and provide results as rapidly as possible.

8. Treatment:

TB is curable whether or not a person is HIV-positive provided patients complete their treatment. Once people are diagnosed with TB, they need to be provided with patient-centred community-based adherence support to ensure that they complete their treatment. This will result in better treatment outcomes and will help to prevent multi-drug resistant TB.

TB can be prevented and is entirely curable. We demand vision, commitment,
partnerships, funding, action and activism on TB/HIV and the crisis in public
health now!


Today a memorandum of

Today a memorandum of understanding (MOU), was signed between the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Stop TB Partnership to increase cooperation, improve resource allocation, and bring support to TB-affected communities of great need. Marking a major step in the fight against TB, the MOU, an agreement for two years, will engage partners through the Stop TB Partnership to provide technical assistance from Stop TB Partners for proposal preparation, implementation, and monitoring at country level following international standards. These include DOTS expansion, TB/HIV co-infection, and multi-drug resistant tuberculosis.

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TB is a hell of a worst

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