The Zambian ProTEST Experience Lessons learnt workshop Durban 3 – 6 Feb 2003

1. The Zambian ProTEST ExperienceLessons learnt workshop Durban 3 – 6 Feb 2003 Dr H Ayles, Dr R Ginwalla

2. Overview of the Zambian Situation • Population: over 10,000,000 • National HIV prevalence: 15.6% (22 % in the capital, Lusaka) • MTCT rates: 30 - 40% • TB notification rates: 510/100,000 population (>800/100,000 in Lusaka) • 70 - 80% of TB cases HIV positive (Elliot et al, Lusaka 1990)

3. 800/100,000 HIV Rates: 22% Both clinic based ProTEST sites Lusaka Chawama 1999 Pop.: 68,515 Matero 2001 Pop: 61,076

4. Aims ofProTEST • To encourage VCT as an entry point to integrated management and prevention of HIV-related TB • To enhance collaboration between government health services and community organisations • To introduce TB-related issues into HIV-related social mobilisation and activism • To act as a model that can be integrated into the essential health package

5. Interfaith HBC Jon Hospice Catholic HBC Chawama Health Centre TB corner OPD Youth Friendly MCH Outreach Lab Kara Counselling centre NZP+ Mobilisers HIV clinic Post test club Outreach Outreach Outreach

6. Chawama VCT

7. Sex Distribution

8. Age Distribution

9. Equity and Penetration Overall assessment: • VCT service widely valued • Equity - majority clients were young men (15-24 age group) • Penetration - services better known by people living nearer the clinic • Access - young women had limited access • Quality of counselling service • IPT - both client and patients positive about IPT • STI services - inadequate

10. Responses • Increased counselling capacity: More space, increased counsellors • Mobiliser training • Sex-worker initiative • STI studies and intervention: Training, syndromic guidelines pocket and desk guides, monitoring and evaluation

11. Situation analysis Matero • Baseline Situation analysis outlining: NGO’s in the area (HBC’s, HIV/AIDS prevention programmes) Staffing at the clinic Services (TB,VCT,STI,MCH) Facilities (Lab, X-ray,drugs) Outreach activities/groups Support services

12. 2 HBC Matero Ref Health Centre TB corner OPD Youth Friendly MCH Outreach Lab VCT centre X-ray HIV clinic Mobilizers Post test club NZP+ Outreach

13. KCTT - NGO Training Supervision Supplies Outreach LDHMT Counsellor Space Laboratory X-ray service Matero VCT: NGO/Government Partnership

14. VCT Matero

15. Sex Differences in Matero

16. TB Case detection Jan 99-May 02Chawama and Matero • All HIV +ve clients screened for TB • Symptom screen in VCT centre • Symptomatics referred to protest clinic (weekly) • Diagnosis made according to algorithm • Transferred to usual district TB services 2531 HIV+ 1453 screened 141 TB 55 sm+ 86 sm-

17. TB Diagnostic algorithm

18. VCT centre Clients asked about symptoms of STI Referred to ProTEST clinic Syndromic management of STIs Clinic All STI patients treated syndromically All patients referred to VCT centre Drugs made available at clinics STI Diagnosis and management: A two pronged attack

19. STI’s Clinic STI service: Chawama and Matero (3 month period) – Total of 445 clients seen – Syndromic guidelines followed in 86% – 88% given information on VCT service STI's - VCT service 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Chawama Matero

20. IPT: Chawama and Matero • Screening as per TB detection • Asymptomatics given IPT • Received drugs monthly via VCT centre • Adherence poor but recording inaccurate

21. IPT cohort analysis

22. Why is adherence so poor? • Focus group discussions • In-depth interviews with clients and counsellors • Case control study • Prospective cohort testing a theoretical model of adherence (221 individuals)

23. Outcome after 6/12 IPT

24. Reasons for poor adherence • Hunger “I was too hungry. I had no food and no support from friends and relatives so I stopped taking PT” (HIV+woman) • Lack of disclosure • Beliefs about IPT • Valued by counsellors and clients • Lack of belief in efficacy • Concerns about side effects (more than reality)

25. CPT • CPT study in Lusaka ongoing • Results of study expected by the end of year and will guide Zambian position on CPT

26. MTCT • Currently 3 districts in Zambia, offering MTCT as part of the National programme • MTCT offers a minimum package of care to mothers during pregnancy, labour and delivery to reduce the risk of transmission to baby • Criticism of MTCT: Poor partner participation (<1%) and lack of interventions for the mother • With the combined intervention these problems are being addressed, with already better partner involvement

27. MTCT/ ProTEST General Objective • To reduce the combined burden of HIV/TB using the MTCT and VCT programmes as entry points to the community Specific Aims • Increased access to VCT service by women and their spouses • Active TB and STI case finding and treatment • Set up a framework for TB preventive therapy • Two-way referral system between all services • Integration of MTCT / VCT / TB services / IPT • Advocacy to reduce stigma

28. OUTPUT Increased collaboration between partners VCT service TB and STI case finding IPT Referral network INDICATORS Set up of ProTEST PMG Reviewed manual, refresher training of counsellors,# of people counselled,origin of referred clients,Proportion post-test counselled # of TB suspects, # TB notified, TB cure rate, # STI’s detected, # STI’s treated Proportion eligible for IPT, IPT Acceptance rate, IPT completion rate, IPT Toxitiy Design and produce referral cards, # referred who reach referral centre MTCT ProTEST

29. Chipata clinic Situationanalysis LAB 3 HBC NewHBC ProTEST TB Corner VCT Peers VCT C H W’s Y F S MTCT N H C MCH OPD VCT/ProTEST clinic Set up PTC

30. Chipata VCT Outputs

31. Age Distribution

32. Sex Distribution

33. PMTCT 10,459 New ANC - Group counselled 3,490 Individual counselled 1,783 Women tested (17%) 1,001 Post-test counselled 467 positive women (26.2%) 346 women on PMTCT intervention

34. Couple counselling • VCTCouples • 94 couples counselled • 15 single mothers referred to MTCT • 5 Expectant couples referred to MTCT • MTCT Couples • 4 at start of ProTEST (~2 years in operation) • 22 at end of Year 1 Two way referral exists to facilitate couple counselling

35. TB Screening and IPT

36. MTCT TB/IPT • Numbers of pregnant women referred for TB screening – 18 • Number of pregnant women diagnosed TB – 4 (already on TB from clinic) • Post-Natal women with TB – 3 • Mothers referred for IPT – 10 • (of total clients on IPT not clear how many are post-natal mothers)

37. VCT- 170 cases of STI MTCT all screened for STI Condom Distribution on average 30,000 condoms distributed monthly STI/CONDOMS

38. MTCT/ProTEST referrals - 2002

39. Other Indicators • TB/HIV collaboration • Govt/NGO collaboration • Social Mobilisation • Knowledge/attitudes/behaviour • Equity and Access • Capacity building • Outreach

40. Lessons Learnt-1 • ProTEST is difficult and time consuming • Situation analysis vital in planning and implementing ProTEST • Importance of partnership, both at national, district and community levels • Single counsellor centres fail to meet demand for VCT • Outreach work key in raising community awareness and increasing VCT • Monitoring and evaluation helped identify problems, impact on community, benefit, costs and long term sustainability

41. Lessons Learnt -2 • Role of existing health staff in counselling • ProTEST clinics for HIV patients are highly in demand- overcoming stigma • IPT adherence a challenge • DOTS possible with community involvement (more practical than clinic based DOTS) • Benefits of continued training resource persons • Integrated HIV/TB/STI activities through ProTEST are acceptable feasible and cost-effective - “providing the bridge” • Integration with the MTCT programme promises a wider application with the scaling up

42. Successes • Integration of services within AND outside the clinic • Integration of government and NGO services • Improved referral mechanism • Male involvement improved with MTCT/VCT integration and promises better IPT adherence • Improved TB case finding • Reduction in Stigma associated to HIV with improved access to services • Greater government commitment

43. Failures • Adherence to IPT • Severe lack of resources in the government clinics • Matero - Why did it not work despite government involvment? • 1 counsellor only-lack of involvement of other staff • Jealousy within clinic • Lack of collaboration between clinic staff and NGOs • Other constraints on clinic - big research programmes • Location of counselling room

44. The Future for Zambia • District sites - LUDHMT - Scaling out with MTCT • GFATM component on expansion of ProTEST country wide • ? ARV programme in Zambia through ProTEST clinics?

45. Acknowledgements • London School of Hygiene and Tropical Med • Zambia Aids related TB project • Kara Counselling and Training Trust • Lusaka District Health Management Team • Network of Zambian People living with HIV • Home based care groups • Central Board of Health • National HIV/AIDS Council