A prime example of a leading research centre                    

The Africa Centre for Health and Population Studies is a prime example of a leading research institution that is able to combine cutting-edge science with delivery of healthcare for the local community.

The Centre was established in 1997 as a joint initiative of the University of KwaZulu-Natal (UKZN) and the South African Medical Research Council (SA-MRC), with funding from the Wellcome Trust.  It is based at the heart of the HIV and tuberculosis epidemics in uMkhanyakude district, northern KwaZulu-Natal, with a laboratory based at the medical school in Durban.  The main aim of the research at the Centre is to work toward elimination of HIV transmission and to minimize the negative effects of HIV on population health.

The Centre’s research portfolio is designed to inform policies directly around the key public health priorities in rural South Africa, with particular focus on HIV prevention.  The past few years have seen the escalation of the combined epidemics of HIV and TB in South Africa.  KwaZulu-Natal is at the epicenter of these intertwined epidemics, with the highest HIV prevalence and incidence rates as well as the highest TB rates in the country. 

Research at the Centre has shown that over 70% of deaths in young adults are attributable to HIV or TB.  It is clear that delivery of antiretroviral treatment (ART) is critical to tackling the high mortality and morbidity rates in the population.  In 2004 the Centre partnered with the Department of Health to develop the Hlabisa HIV Treatment and Care Programme.

The Africa Centre receives funding from Pepfar (United States President’s Emergency Plan for AIDS relief) to support extra human resources, infrastructure and training for the programme.  The aim of the programme is to provide accessible, equitable and comprehensive HIV prevention, treatment and care to all people.  What makes the Africa Centre research unique is its ability to link high-quality demographic research with programmatic data.  This allows the evaluation of the impact of interventions on population health – this already has allowed the centre to demonstrate a reduction in population-level mortality within the general adult population; and in children less than two years of age, with the rollout of ART.  This information is crucial, particularly in the current economic climate, to emphasize to policy-makers and funders the real impact of such interventions.

In addition, the demographic data can complement the clinical research to given more detailed understanding of factors associated with retention on ART or in pre-ART care.  This research then can inform the development of targeted interventions within the public health delivery of HIV prevention, treatment and care.

Since its inception in 2004, the HIV Treatment and Care programme has initiated more than 12 000 individuals (including over 1 000 children) on ART, with a current average of 280 new patients per month.  From the beginning, it has pioneered decentralized care through the primary healthcare clinics and is now one of the largest programmes of its kind.

The programme operates through Hlabisa Hospital and its 17 primary healthcare clinics that serve a population of approximately 228 000.  The realization of the huge additional burden of TB within the HIV-infected population, and the emergence of drug-resistant TB as a major threat to the success of ART rollout, has led to new focus on integration of HIV and TB prevention, care and treatment.   The synergy between the two diseases is illustrated by the fact that 76% of people diagnosed with TB in Hlabisa are HIV infected; and that 25% of people starting ART are on TB treatment.

The first step in integrated care is early diagnosis of both HIV and TB.  In each primary clinic, the HIV and TB teams work side by side in shared park homes to facilitate patient access and retention.  The HIV programme team is responsible for HIV testing, CD4 count measurement and initiating and monitoring of ART, in accordance with national guidelines.  The TB team is responsible for diagnosis of TB infection and disease, initiation and monitoring of TB treatment.

TB/HIV Integration Plan

To improve collaborative service delivery, a TB/HIV integration plan was initiated in March 2008, and now has five key components:

·         Decentralised and integrated TB/HIV programme at the clinic level.  Close physical proximity of both the TB and HIV teams in the hospital and peripheral clinics to facilitate patient flow and retention.

·         Introduction of a central TB clinic located at Hlabisa Hospital for referral or smear-negative and extra-pulmonary TB suspects.  All referrals are seen by a clinician and undergo further investigation including sputum culture, chest X-ray, ultrasound, and other investigations as appropriate.  Specific counselling around the interactions of HIV and TB and the importance of HIV testing id offered to all individuals who remain unaware of their HIV status.

·         Regular and updated programme of combined training for healthcare workers on HIV and TB.

·         Development of a monitoring tool (Access® database) to allow evaluation of performance. One example is continuous monitoring of HIV testing rates for TB patients at each clinic, information that is fed back to clinics on a monthly basis.  Through this intervention, more than 90% of TB patients are aware of their HIV status.

·         Merging of tracking teams to locate individuals who have defaulted from TB or HIV care.

The Africa Centre research is done with the local community for the local community and the partnership with the Department of Health in service delivery enhances the opportunity to give back to the community.  It is through these partnerships and shared ambitions that the tide may eb turned on the twin terrors of HIV and TB.