Médecins Sans Frontières
in collaboration with
Treatment Action Campaign
Provincial Government of the Western Cape
City of Cape Town
University of Cape Town, Infectious Disease Epidemiology Unit




Population = 500.000
Adult HIV prevalence: 32% in 2007
Highest TB case finding in the world:
1600/100.000 in 2006
Mostly informal housing; unemployment rate
± 60%; highly mobile population; pop.
density > 6000/km2; electricity 76% of
households; high rates of crime and sexual
violence.
40%
35%
30%
25%
20%
15%
10%
5%
0%
1999
2000
2001
2002
2003
2004
2005
Mean Prevalence (95 % CI)
2006
2007
1998: Creation of TAC
1999: start of PMTCT programme
2000: HIV care pilot project (3 clinics)
 2001: First patient started on ART
 2004: National HIV plan leads to increased
enrolment on ART
 2009: 12,000 people started on ART at 9
sites



ER1 :To develop a new model of care and to decentralise existing
HIV/AIDS dedicated services -including ART- to five peripheral clinics
Existing ARV clincis
Extension 2006/07
Existing public health facilities
• 3 community health centers (day hospitals)
• 2 maternities (MTCT ante and peri-natal)
• 8 local clinics (STI, FP, TB, <5 health, post-natal
MTCT)
• No hospital (under construction)
• 3 hospices – 1 only for DR TB
• “Home based care” NGOs
CHC based
ARV clincis
New HIV clinics


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2000: demonstrate feasibility of ART at
primary health care level in resource-limited,
peri-urban setting
2004: scaling up ART, TB/HIV integration, and
integration into Provincial ART programme
2008: feasibility of achieving NSP targets,
including “universal coverage” by 2011

80 % of needs ART coverage ->
800.000 to 1 million on Rx

80 % initiated and followed by nurses

50 % of children treated at PHC

Reduction of HIV transmission by 50%
1998: 450 people tested for HIV in Khayelitsha
Year
2003
2004
2005
2006
2007
Tested
16,024
20,576
26,681
32,383
32,069
Positive
4,928
6,474
8,804
9,691
8,749
%HIV
+ve
31%
31%
33%
29.9%
27.3%
Well functioning
PMTCT programme
since 1999
 Vertical transmission =
3.5% in 2007
 100% acceptance rate,
formula feeding,
AZT+NVP
 Integration of ART
provision within MOU
since 2004
Khayelitsha: IMR, 2001-2007

(Deaths of babies under 1 yr of age, out of 1,000 live births)
43
43
42
37
34
2001
2002
2003
2004
2005
31
30
2006
2007
450%
70000
400%
60000
350%
300%
50000
250%
40000
200%
30000
150%
20000
100%
10000
50%
0
0%
2001
2002 2003
Tot ART
2004 2005
Tot non ART
2006 2007
Ratio
Ratio ART/nonART
Total nmb of visits
80000
New patients
2006
2007
2008
2009
2010
2007
2008
2009
2010
2011
2,122
2,322
Target (new stage IV)*
3217
3485
3708
3847
3929
% needs covered
66%
67%
Enrolled
Remaining in care (%)
12 M
24 M
36 M
48 M
2001
2002
2003
83.4
84.9
86.4
81.2
79.5
81.7
78.0
78.3
77.3
73.8
75.4
73.5
2004
88.6
82.6
77.0
74.2
2005
87.8
82.6
77.6
2006
88.3
81.5
2007
86.6
Remaining in care (RIC) = (total initiated) – (deaths + loss to follow-up)
Children < 14 years
250
2000
200
Adults started on ART
Adults started on ART
Adults
2500
1500
1000
100
50
500
0
150
0
2001
2002
2003
2004
2005
2006
2002
2003
2004
2005
2006
2007
Treatment naïve
33
37
63
98
127
101
Prior treatment or transferred in
6
24
39
64
56
35
2007
Treatment naïve
82
206
389
1,063
1,647
2,122
2,322
Prior treatment or transferred in
9
7
18
66
229
304
168
Median baseline CD4 and IQR by year (Adults)
200
150
105
100
73
50
48
112
85
41.5
0
2001
2002
2003
2004
2005
2006
100
200
150
Median time
from
date
eligible
to
starting
treatment
50
0
Time eligible for ARV's to treatment start
Source:
2008, internal
report
2002
2001
2000Louise Knight
excludes outside values
2005
2004
2003
Year eligible for treatment
2006
2007

Expand providers:
 nurse based follow-up

Simplify follow-up routines:
 Fast track systems (clubs, “chronic
dispensing”)
 Limit number of follow-ups

Improve functioning of administrative
section
 Blood results, data entry
Khayelitsha
Monthly Total in Care
May
2009
Total Adults
Total Children
TOTAL
% of
total
Kuyasa
686
96
782
6,5
M. Goniwe
1000
45
1045
8,7
Michael M
3005
166
3171
26,5
Nolungile
2527
238
2765
23,1
Ubuntu
3702
278
3980
33,2
Site C Youth
87
87
0,7
Site B Youth
52
52
0,4
Town II
89
89
0,7
Khayelitsha
11148
823
11971
New
Adults
New
Children
TFI
Total
(New)
Target
% of total
Kuyasa
33
4
3
37
25
10,8
M.Goniwe
38
1
4
39
35
11,3
Michael M
85
1
1
86
75
25,0
Nolungile
74
6
3
80
75
23,3
Ubuntu
75
2
6
77
100
22,4
Site C Youth
2
222
2
2
10
Site B Youth
8
0
8
15
Town II
15
0
0
15
?
330
14
19
344
335
May
2009
Khayelitsha
total
0,6
2,3
4,4

Facility based “clubs”
▪ Green clinic: patient stable, > 12 months on ARV’s,
undetectable

Community based “clubs”
▪ Functions : monthly support group meeting, clinical screening,
drug distribution , data record.
▪ Management : community adherence counsellors
▪ Accountability : to the “mother clinic”
▪ Supply : drugs “patient’ labelled, nutritional support
Diagnosed DR-TB cases
All cases referred to Referral OPD
Severe clinical condition and
XDR-TB admitted for
intensive phase (or until
culture conversion) 4-6
months
Others referred for clinic
based treatment (intensive
and continuation phase)
Continuation phase
treatment, clinic based
Initiation of Treatment Quarter 1 2009
(prepared May 27th, 2009)
Patients Started Tx = 52
Patients started Tx in Hospital = 9
Patients started Tx in Clinic = 43
Patients not Started Tx = 8
43
9
3
4
Being recalled
Died before
Treatment
1
Never Found
Patients not started on treatment
Clinic treatment
In hospital
Patients started on treatment
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Increase in HIV has
been followed by
increase in TB
70% of TB patients are
HIV-infected in Khay.
Increase in smear-TB
and EPTB
Increase in M/XDR-TB
Need for TB/HIV
integration
1800
Incidence per 100 000

Khayelitsha TB incidence 2002-2006
1600
1400
1200
1000
800
600
400
200
0
2002
All TB
2003
New smear (+)TB
2004
2005
New smear (-)TB
2006
EPTB
Khayelitsha: VCT in TB services
Proportion TB patients
counselled
Proportion accepted
testing
Proportion testing HIV +
2002
49%
89%
26%
2003
62%
84%
45%
2004
62%
87%
73%
2005
72%
91%
76%
2006
99%
95 %
67%
2007
99%
95 %
67%

TB/HIV juxtaposition: 1 folder, different admin &
clinicians

Managerial integration: 1 folder & same admin,
different clinicians and clinical pathway (Ubuntu).

True TB/HIV integration: ARV delivery integrated
within TB programme: one-stop service with same
staff (admin & clinical) and patient flow (Town 2).
1.
2.
3.
4.
5.
6.
7.
ART in a poor public sector setting is feasible.
Increased enrolment on ART has resulted in decreased
mortality.
Saturation of large sites led to increased losses to follow-up.
There is a need for decentralisation of ART to the most
peripheral clinics.
Success of nurse-based, doctor-supported strategy.
Regulatory framework on the way.
TB/HIV integrated services led to quicker diagnosis and
treatment of both diseases in co-infected patients.
Decentralized management of DR TB has led to increased
diagnosis and number started on treatment.
Collaboration between MSF, CoCT, and PGWC was an
essential condition for success.
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Enrolment of children on ART
Adherence in youth and pregnant women
Enhanced adherence strategies
Further decentralization
Regulatory framework for decentralised
nurse-based care
DR- TB: new diagnostic and treatment
options