Diagnosis, Treatment and Prevention of Paediatric TB/HIV at Primary Care Level

The diagnosis of paediatric TB is currently very difficult at primary care level. WHWC is investigating whether the use of alternative methods of specimen collection, use of a family-oriented approach to paediatric TB diagnosis, and evaluation  of novel diagnostics will increase the feasibility of diagnosis of paediatric TB/HIV at primary care level.

Paediatric TB/HIV co-treatment is complicated by drug-drug interactions and poor adherence to complex treatment regimens.  Accurate and rapid diagnosis is key to ensure optimal treatment outcomes, fast-track ART initiation, and start isoniazid preventive therapy (IPT) in children without active TB.  WHWC is exploring and assessing new approaches to paediatric TB/HIV management at an integrated primary care level.  In addition, because the complexity of current TB/HIV co-treatment for children results in uncertainty at primary care level and poor treatment outcomes, we are developing a NIMART (Nurse Initiated and Managed ART) approach for paediatric TB/HIV co-treatment.

Integrated primary care model for optimal antenatal and infant care including Prevention of Mother-to-Child Transmission of HIV (PMTCT)

Despite clear benefits of earlier PMTCT (Prevention of Mother-to-Child Transmission) regimen initiation, delayed initiation of antenatal care (ANC) contributes to late maternal HIV diagnosis and suboptimal PMTCT, resulting in preventable infant infections. Furthermore, lack of male involvement in ANC has been associated with lower maternal adherence to PMTCT interventions and increased in-utero transmission to infants born to women infected during pregnancy. Poor linkages between services result in late infant HIV diagnosis.

Witkoppen Health and Welfare Centre is optimizing existing services and bringing to scale a comprehensive integrated primary care PMTCT model, through research with the specific aims of:

  • Achieving earlier detection of HIV-infection in pregnant women and improving linkages in health care systems to decrease time-to-PMTCT regimen initiation
  • Evaluating the impact of maternal HAART for all HIV-infected pregnant women on infant outcomes and post-partum maternal retention in care
  • Improving adherence to PMTCT by involving male partners and providing support to women throughout the PMTCT process and
  • Improving early infant diagnosis (EID) and increasing testing at 6 weeks and 18 months and timely initiation of infant ART

Community-based Intensified Case Finding (ICF) for TB and HIV

It is believed that the burden of undetected active TB among household contacts of TB patients is high, especially of people living with HIV, and partner testing for HIV continues to have low coverage in South Africa. In March 2012, Witkoppen Health and Welfare Centre started a pilot study of community ICF for TB and HIV targeted at households of TB and HIV index cases and with funding from the National Institutes of Health. The strategy was scaled up the strategy based on results of the pilot project, and then re-engineered based on lessons learned to a new model launched in October 2014.

Adherence Clubs for Stable ART Patients

Primary care clinics have increasingly become congested as the number of patients stable on ART grows and Nurse Initiated and Managed ART (NIMART) is implemented. Crowded clinics result in lengthy patient visits and poor quality of care. Adherence to ART is a challenge in South Africa and innovative approaches to improve patient treatment experiences and reduce the burden on health care workers are necessary.

Witkoppen Health and Welfare Centre is addressing this by task-shifting chronic HIV care to the community-level using “adherence clubs”. The principle of adherence clubs is to offer adherence support to virologically suppressed stable patients by bringing ART refills and basic services to the community level. The adherence club innovation was piloted in the Western Cape by the Department of Health (DoH) and MSF in 2007. WHWC will replicate this successful innovation in an effort to further reduce care and treatment costs, increase adherence, and alleviate the HIV burden on Primary Healthcare Centres.

For a preliminary write-up, see http://www.aidsmap.com/page/2981382/?utm_source=NAM-Email-Promotion&utm_medium=aidsmap-news&utm_campaign=aidsmap-news

Adolescent Adherence to antiretroviral treatment (ART)

With increasing scale-up of ART, more HIV-infected children are started on ART and survive into adolescence.  Healthcare workers at primary care level will thus increasingly be confronted with the care for HIV-infected adolescents.  Adolescents are a difficult population to retain in care, and frequently demonstrate poor adherence to care for any chronic disease, including HIV.  As adolescents mature, gain independence and become responsible for their own care, high rates of adherence are difficult to achieve and there is little evidence of effective interventions to improve adolescent adherence.

One strategy to improve adherence and retain adolescent retention in care is to offer support groups and counselling to HIV-infected adolescents. Witkoppen Health and Welfare Centre has developed support groups for HIV infected adolescents, which are expected to help retain adolescents in care.

Assessing the Unmet Health Needs of Informal Settlements

Witkoppen Health and Welfare Centre will contribute towards understanding and spatially mapping the comprehensive health risk profile of a community to inform the South African Government on how to prioritize interventions and identify training needs for community health workers (CHWs), by identifying the top ten health priorities and unmet health and safety needs and creating spatial maps using GIS software to identify “hotspots” of unmet health needs in the Diepsloot community. This project was implemented together with Right to Care and Clinical HIV Research Unit, and the University of North Carolina in the United States, with funding from USAID.

2000 households were randomly selected and a team of a CHW and enrolled nurse conducted interviews and health assessments to assess physical and mental health, health of other members in the household and general health priorities perceived as most important.

The survey was completed at the end of March 2014 and the data is being analysed and manuscripts written.

Safer Pregnancy for HIV affected couples

In South Africa many couples are affected by HIV. They can expect virtually normal life expectancy if they get started on treatment early and take their ART regularly. The PMTCT (Prevention of Mother-to-Child Transmission) programme at Witkoppen Health and Welfare Centre is well known and we have very strong links to the community. Couples who attend our HIV clinic have started asking about having children, and our response is a Safer Conception Clinic called Sakh'umndeni: “building the family”, to inform HIV-affected couples that safer conception is possible, risks can be minimised and there are options which are affordable, to help couples achieve their reproductive desires while minimizing the risk of HIV transmission between partners and preventing HIV infection of the baby.

The goal of Sakh'umndeni: “building the family”, is to help couples achieve their reproductive desires, while minimizing the risk of HIV transmission between partners trying to get pregnant, and preventing HIV infection of the baby, should they conceive. Evidence-based, lower cost methods will be utilized and evaluated. These include risk reduction counselling, HIV treatment, fertility awareness training that focuses on ensuring good health and reduced HIV viral load of the infected partner/s prior to conception, and reduced frequency of unprotected sex while the couple is trying to get pregnant.