What should an integrated TB-HIV clinic look like?
I got the answer when I recently visited the Ubuntu Clinic near Cape Town, South Africa, in a township called Khayelitsha. Thanks to the IAS 2009 conference I had a chance to take some photos and meet the dedicated personnel.
The Ubuntu Clinic, a collaboration effort begun in 2001 by the local municipal and provincial governments as well as Medecins Sans Frontieres, is so highly regarded that the South African government wants to use it as a model for all clinics nationwide. In 2008, the Ubuntu Clinic along with the rest of the Khayelitsha community celebrated 7 years of successful ARV programming and more than 10,000 patient visits.
One reason the clinic stands out is its determined effort to treat and contain the spread of tuberculosis, the most common opportunistic infection affecting people living with HIV. TB requires good infection control, including ample air-flow, which this clinic has done a lot to ensure through ventilation (see photos). This is a crucial innovation that should be the standard, since right now we have good reason to suspect that many people living with HIV are getting infected with TB when they visit a clinic! TB-HIV coinfection also requires integrated care — an area where the clinic is also doing a stellar job.
Our guide on the tour was the clinic’s operational manager, a professional nurse named Mpumi Matangana. Her obvious dedication to the clinic and serving the community really impressed me and the other tour participants. She started working as a nurse at the clinic in 2003, but now has added managerial responsibilities. We learned about the achievements of the clinic as well as the serious challenges it is now facing, especially in the area of human resources.
First some background. Khayelitsha is a low-income community of about 500,000 people which lies to the east of Cape Town. The population is highly mobile, as the town is a common stopping point for people from the Eastern Cape and other regions who are making their way to the Cape Town area in hopes of finding work.
The population density is very high; the crowding and poor housing conditions are one of the reasons the area has one of the highest levels of TB, including drug-resistant TB, in the world. MSF recently reported that 196 of the 6,000 people diagnosed with tuberculosis in Khayelitsha last year had the drug-resistant strain of the disease and of those, three-quarters were also HIV-positive.
For many years, HIV and TB care were separate, but since 2003 the Ubuntu Clinic has effectively brought TB and HIV care under one roof. It is also using a community-based care model that aims to show TB can be treated without long-term hospitalization. 70% of the patients are co-infected with HIV and TB, and the clinic has 51 patients with MDR-TB.
I was not used to entering an HIV clinic wearing a surgical mask. But, the managers of the clinics advised me and the other participants on the tour to wear masks, because of the risk of tuberculosis in the clinic and to support their effort to destigmatize the use of masks.
The design of the clinic allows for significant air ventilation, including through the use of a ceiling exhaust fan and windows. There are also permanent openings built into the ceiling and roof design, and, since it can get cold in the South African winter, there are also gas heaters placed in the waiting room (see photos). In addition, the Khayelitsha programs are urging taxi owners to keep windows open and seats clean, and they are spreading the word in the community about how to reduce the risk of TB infection by keeping windows open if possible and practicing cough etiquette.
The Ubuntu Clinic is part of a large network, now comprising nine clinics in the entire community. 4,000 patients are receiving their HIV/AIDS medications through the Ubuntu Clinic alone, including 350 children, and each month the clinic adds another 120 new patients to its rolls.
The network of clinics is supporting “adherence clubs,” which are open to patients whose health status has been stable for at 13 months. These clubs provide an opportunity for information sharing and discussion, checking patients’ weight, and distribution of medication.
Matangana told us that the biggest challenge the clinic is facing is the lack of human resources. The number of health workers on staff has not kept pace with the expansion of services, including the adherence clubs, and salaries are inadequate.
“Salaries are a serious problem and the situation forces you to do some introspection,” Matangana said. “What are you going to offer your kids when you stop working? We are getting old and we have to think about this, and this is why retention is a major problem.”
Another major challenge is ensuring children get their anti-retroviral medication. Most of the children are in the care of their grandmothers, since the parents have died. “The grannies have to be taught the use of the anti-retroviral syrup for the children, it is hard for them to come to the clinic to get the multiple boxes of syrup, and it’s often impossible to be precise in the dosage. It’s a nightmare,” she said.
She also cited the lack of medications to meet the needs of patients with difficult HIV/AIDS cases. In this area, 16 percent of patients are experiencing treatment failure on their first-line regimen within five years and a significant number these patients then fail on this alternative treatment line within two years.
MSF states that, as no third-line regimen is available in South Africa, like in many other developing countries, these patients are now at risk of dying. Most second- and third-line drugs are patented and priced out of reach for patients in developing countries, says MSF.
For more information on these issues and the Ubuntu Clinic go here: