Data collected from the ground up is one of the pillars of Ritshidze’s work and impact. We rely on our vast network of community monitors to not just be the eyes and ears on the ground, but also to be a trained crew equipped with the skills to bring new information to the attention of decision-makers and hold them accountable for acting on it. Our toolkits and techniques guide our teams about what to typically look for in a clinic as minimum acceptable standards whilst talking to patients, clinical staff and management.
Data gathered through Ritshidze is at the centre of this year’s “People’s COP21” — an advocacy document aimed at influencing the United States President’s Emergency Plan for AIDS Relief (PEPFAR) as it determines how it will spend millions of dollars on HIV and TB programmes in South Africa through its Country Operational Plan (COP) for 2021. This year’s People’s COP clearly outlines a number of community recommended interventions that can better ensure that TB is diagnosed and treated early.
Early TB detection remains the key to successful treatment. It should be noted that a key driver of excess morbidity and mortality amongst people living with HIV is that symptoms of TB or other risk factors are often overlooked by clinics and healthcare workers. Most TB in people living with HIV is diagnosed very late or not at all. It means the window for early TB diagnosis and treatment is often missed.
TB LAM is a cheap, easy to use, and effective TB test that can be used in clinics on the frontline of the TB response. It is recommended for use in people living with HIV who have any TB symptoms or those with advanced HIV disease. The accessibility of this test is critical given it is estimated that 1 in 3 people living with HIV present to care with advanced HIV disease in South Africa and those people are at increased risk of getting and dying from TB. Yet Ritshidze’s findings showed that at least 75% of facilities reported having no TB LAM testing available in the reporting period*.
Another intervention needed to rapidly diagnose people with TB are rapid molecular tests. GeneXpert is one kind of rapid molecular test that analyses a sputum sample for TB. Ritshidze’s monitoring found that 53 of 374 facilities (around 14% of clinics surveyed) had no access to GeneXpert testing. For the majority of clinics though, GeneXpert testing was available — 32% onsite and 53% offsite.
In COP20, PEPFAR South Africa committed to including urine-LAM and GeneXpert testing for TB at primary facilities and outpatient settings — however Ritshidze monitoring has shown that many clinics have fallen short. To worsen matters, TB testing dramatically decreased during the COVID-19 pandemic according to the health department.
The People’s COP21 is a renewed call for South Africa to recommit to providing urine-LAM, not only in hospitals, but in clinics too, and for the availability of rapid molecular testing for TB as part of the package for advanced clinical care. There also has to be expanded efforts to reduce preventable morbidity and mortality amongst people living with HIV and their close contacts by implementing TB screening at every clinical encounter followed by urine-LAM and rapid molecular testing as per World Health Organization (WHO) guidelines.
In total there are seven key recommendations relating to TB screening and testing for COP21. They are:
- 100% of PLHIV, including children living with HIV, are screened for TB upon presentation to care at every clinical encounter.
- 100% of PLHIV, including children living with HIV, who present to care with signs and symptoms of TB or advanced HIV disease in inpatient and outpatient settings receive both urine-LAM and rapid molecular testing upon their first presentation to care.
- 100% of PLHIV, including children living with HIV, with positive urine-LAM results immediately initiate TB treatment, while awaiting confirmatory rapid molecular test results.
- 100% of PLHIV, including children living with HIV, who are co-infected with TB receive confirmatory diagnostic test results and are linked to TB treatment in less than five days after their first presentation to care.
- Procurement quantities of commodities required for urine-LAM and rapid molecular testing should each exceed 200,000, the estimated number of PLHIV, including children living with HIV, expected to present to care at PEPFAR-supported sites with advanced HIV disease in COP21 (according to estimates that 1 in 3 PLHIV present to care with advanced HIV disease in South Africa).
- All patients are screened for TB symptoms upon arrival at the facility (this can be integrated with COVID-19 screening).
- Any person with a cough of any duration should be tested for both TB and COVID-19.
Ritshidze’s presence is helping to build solidarity and trust amongst patients. As an added avenue of engagement and communication between clinic staff and patients, it also means they have a platform for complaints, to raise concerns, and also to help come up with solutions that are locally appropriate. The recommendations in the People’s COP21 are based on the realities of what’s needed on the ground as community monitors experience or witness at the 400 clinics that are part of Ritshidze’s monitoring project.
* Data was gathered between October to December 2020.
This data set was presented to the Operation Phuthuma meeting on 25th March 2021. You can view the full presentation here.