In-depth: Getting Gauteng’s HIV and TB response back on track
When Gauteng Premier David Makhura took to the podium during a World AIDS Day event in Soweto last week, he painted a sobering picture of the province’s progress in the fight against HIV and the impact of COVID-19 on these efforts.
Referring to the recent Thembisa model national and provincial estimates on HIV, Makhura said, “we (Gauteng) will have to work a little harder”.
“We have also noted that HIV infections are increasing in our metros, especially in Johannesburg and Ekurhuleni. This is a matter of great concern to us.”
The numbers: HIV
A Second Quarter Performance Monitoring report tabled in the Gauteng Legislature last month confirmed the impact COVID-19 and the associated lockdown had on HIV and TB services in the province.
Although the province met its HIV testing target, its performance on the other 90-90-90 targets, including getting 90% of people diagnosed with HIV on ARVs and 90% of those on ARVs virally suppressed, were below par. (See how provinces compare on the 90-90-90 targets on this interactive table.)
The report shows that the number of people tested for HIV in Gauteng increased from 728 532 tests done in the first quarter (April to June) to 1.78m by the end of the second quarter (July until September) which means the province exceeded its target of 1.75m tests for the two quarters.
The provincial health department in the report says the “good performance was due to the catch-up plans it developed and implemented along with integrating the COVID-19 response to routine health services”.
But when it comes to helping people who are living with HIV to start and stay on treatment, the picture is less rosy.
About 225 000 people living with HIV in Gauteng stopped accessing HIV treatment through the public healthcare sector from July to September.
The department set itself a target of having 1.3m adults and 32 500 children living with HIV on treatment, but only reached 1.076m. This means although it recorded a 2% increase since the first quarter (April to June) in adults starting treatment, the province still fell short of its target. Similarly, it also only started 21 503 children younger than 15 on treatment, which is a 1.6% decline compared to the first quarter and over 10 000 short of the target.
In the report, the department attribute this to “high number of loss to follow-up” and undertook to “trace all the loss to follow-up clients and decanting stable clients to external pick-up points”.
The Department says it will, among others, strengthen its efforts on same-day-initiation, intensify its case finding efforts and implement index testing (whereby people living with HIV ask their contacts to test), and HIV self-testing. It also committed to develop catch-up plans which focus on children living with HIV.
Keeping those on treatment virally suppressed was another challenge where the provincial health department did not meet its target of 95% (the UNAIDS target is 90%).
The adult viral load suppressed rate in the first quarter was at 87,6 percent and for children younger than 15 years, it was 67%. This, the department attributed to poor record keeping and data management in facilities. In an effort to address this, the department undertook to “conduct data verification of viral load suppression and extract the line list of unsuppressed clients for follow-up purposes”. They said Ward-Based Outreach Teams will help with the trace and delivering of treatment efforts.
The Numbers: TB
From March to July this year, the Gauteng Department of Health recorded 57 848 TB tests which means a decrease of about 30 000 tests compared to the same period last year. Last year the number of tests for TB recorded between March and July stood at 88 044.
Between July and September, the drug-sensitive TB (DS-TB) client treatment success rate in the province was at 80,5%, far short of the 90% target the province set for itself. The rate of DS-TB client lost to follow-up for this period was at 12,2%.
In a briefing to the Health Committee in the Gauteng Legislature last month, the department attributed this to patients who often provide incorrect addresses and those who “leave the province without formal transfer processes which increase TB lost to follow-up”. The department now plans to strengthen its tracing efforts of those who were lost to treatment through its WBOT teams and Professional Nurses. It said in a presentation that 34 Professional Nurses have been contracted to trace people who have stopped treatment.
Gauteng Health spokesperson, Kwara Kekana says lockdown regulations, as is the case in most provinces, have contributed to the decline in testing.
“Health care services have been strained and severely tested by the COVID-19 pandemic,” she says. “Most patients were not able to access services during levels 4 and 5 of the lockdown. Some did not come to facilities for fear of contracting the infection; others were discouraged by the perceived long queues brought about by physical distancing.”
Concerns over TB prevention and treatment efforts
Wieda Human, communications officer at the advocacy organisation TB Proof, says they are concerned about the decrease in the number of diagnostic tests done for TB during the COVID-19 pandemic.
“The 2020 WHO Global TB Report indicated that there was a 20% increase in the number of South Africans who became ill with TB in 2019, and that 150 455 (or 42%) were missed by TB services. With this said, one could expect that TB will again be our country’s leading cause of death,” says Human.
She calls on the South African government to release the National TB Prevalence Survey and the much anticipated TB recovery plan. The National TB Prevalence Survey would have been released earlier in October but its release was postponed indefinitely.
“Furthermore, there is a pressing need for the release of the Occupational Health policy dealing with TB and HIV in health workers and the updated TB preventive therapy and Urine LAM guidelines (relating to a TB test using urine). Our people deserve the highest quality TB prevention and care, and guidelines that languish in draft format for years do not reflect the urgency with which we need to tackle this pandemic.”
Human says TB-affected communities have reported that stigma, fear of contracting COVID-19 at health facilities coupled with strict lockdown regulations, made it difficult for many TB patients to receive quality care.
“Financial, human- and other resources have been primarily reallocated from TB to COVID-19. Many of our frontline health workers have become sick with COVID-19, leaving an even larger gap in human resources, with many others fearing infection at health facilities,” says Human.
ARV shortages and other challenges
Makhosazana Mkhatshwa, Research Officer at the Treatment Action Campaign, tells Spotlight they received several complaints from patients who visited clinics during the lockdown. “Out of ten clinics we monitored in Gauteng in October, only two were found to be giving three months’ supply of ARVs,” Mkhatshwa says.
According to her, they also received complaints about ARV shortages. “This means that patients got very little (ARVs), instead of getting 28 day packs. Some were given as little as seven pills, which is absurd considering that we’re supposed to take ARVs every day,” she says.
“So, seven pills mean I need to go back for more soon and most people are poor in the communities. They don’t have transport money to go up and down. Some of us are working so it means we have to miss work again and again to go to the clinic because there are long queues and things move slowly,” she explains.
“Some employers don’t have that spirit of understanding for [when you have to] fetch your medication, so people find themselves having to choose between having a job and adhering to treatment. These are the problems that force people to default [on] treatment and one of the biggest problems we have in the fight against HIV, is adherence. People stop taking their treatment and that’s one of the worst things because it takes us back, you know.”
Organisations feeling the impact
Peter Mabulana, CEO of South African National Tuberculosis Association (SANTA), says they had to stop all their programs due to lockdown. This meant that their TB and HIV patients were neglected and TB treatments were disrupted.
The organisation, through its 4 300 community health workers, test and treat people for TB throughout the country. This service includes administering DOT (directly observed treatment).
Mabulana says that “interaction has been minimised due to COVID-19 restrictions” and that this has impacted the physical aspect of their work and resulted in them losing many of their TB patients.
He says it is challenging for their community workers to get the right treatment to the right individuals. But he remains optimistic. “Every challenge can be overcome.”
From the frontlines: CHWs’ experiences
Meanwhile, community health care workers who are at the forefront of tracing and testing efforts, say they have many challenges in keeping and getting things on track-of which the biggest is stigma.
One community healthcare worker from Soweto in Johannesburg who wants to stay anonymous, says the number of new cases of people showing signs of positive TB symptoms were high during lockdown level 5. She describes some situations in the community as dreadful because of stigma. “Some people wouldn’t want help from us, others would call us from the street and say something like ‘there’s a granny struggling to breathe, come help’.”
Many community members also thought of the health workers as the ones “bringing COVID-19 into people’s homes”. “We would get rejection from some (patients). They didn’t want us in their houses. They would say we bring COVID-19 to their houses. It was a major challenge.”
She says sometimes patients would ask them not to come dressed in their navy shirt, which shows they are from the Gauteng department of health.
Another community health worker who works in Soweto and also wants to remain anonymous, says he also had several patients not trusting him at the beginning of the pandemic. “We had to overcome this challenge by giving education about what it is we do.”
He says because the lockdown no longer has strict regulations, things went back to normal. One concern he has, is that TB symptoms are similar to COVID-19 symptoms, so there are fewer TB cases recorded because many people are scared to get tested. “They think if they cough that it might be COVID-19 and not TB. We have now set up a workstation where we can test people for TB and COVID-19.”
Windy Mogosi, a CHW from Hammanskraal in the Tshwane sub-district, also cites stigma as a challenge. “Another element of stigma is showing its head, he says. It’s self-stigmatisation. Some patients would automatically assume that they are being stigmatised even though it is not the case.”
He says during this pandemic stigma appeared to have been slightly higher. “Some patients diagnosed with TB would mention that when they coughed, their family member would associate their coughing with COVID-19, even when they are well aware that they have been diagnosed with TB. As a result, they would be told they should isolate themselves.”
He admitted that the similar symptoms of COVID-19 and TB is a challenge. “When screening in households at times I wouldn’t be sure for which condition to refer patients.”
Training: COVID, TB, HIV
Dr Tom Boyles, an infectious diseases specialist at Helen Joseph Hospital, says in response to the COVID-19 pandemic from March to May this year, they had assisted with training of staff and community health workers at 129 clinics in the City of Joburg. Boyles says this training included among others, managing social distancing inside and outside the clinics, as well as how to investigate people for a cough.
According to Mkhatshwa, the TAC offers treatment literacy training which entails that they teach communities about the science of HIV and TB.
“We teach about the different tests one has to take like the viral load, CD4 counts, importance of adhering to treatment, drug resistance. We also teach about TB infection, the different TB drugs, prevention therapy and treatment, management of TB for different kinds of people, for example HIV-positive or pregnant women and so on.”
A way forward
Kekana says in a bid to ensure continuity of TB testing and treatment at the required levels, the Gauteng Department of Health integrated TB services with COVID-19 services at community level through Ward Based Outreach services (CHWs) as well as in health-facilities. Screening for TB symptoms are now supposed to be conducted in all areas where COVID-19 screening and testing are conducted.
Kekana says all pregnant women living with HIV are also screened and tested for TB at their first visit. Other people living with HIV are screened during all their facility visits.
NOTE: The TAC is mentioned in this article. Spotlight is published by SECTION27 and the TAC, but is editorially independent, an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.