Recommendations for policy in the Western Cape Province regarding the prevention of Major Infectious Diseases including hiv/AI

A key determinant of success or failure is the social and cultural context of the schools. If the school is dysfunctional and the school climate (defined as the sum and quality of the relationships of all members of the school community) is negative, it is unlikely that that a peer intervention will be able to be effective. South Africa’s first major attempt to reduce HIV at a community level used participatory peer education approaches among school students, sex workers and miners. The evaluation performed by Catherine Campbell and colleagues found that the student peer education initiatives were undermined by a school climate characterized by an authoritarian approach to student-teacher relationships and gender inequalities. The process evaluation of the Western Cape school-based peer education programme, conducted by the Adolescent Health Research Institute in 2005 identified that the school environment of the peer education intervention was crucial in either facilitating or frustrating peer education. An important consideration for South Africa is the extent to which peer education programmes will be embedded in broader school development programmes to improve school functioning and school climate, as opposed to functioning as a discrete programme.

The Western Cape schools based PEP will run alongside related initiatives (curriculum based lifeskills, adolescent friendly clinic initiative and numerous local NGO youth projects). Co-ordination, however, appears to be lacking. The appearance of notions of building “social and human capital” in the provincial government lexicon pinpoints the important advance in the thinking within government when tackling complex social ills such as the spread of HIV infection. Simply put, strengthening the fabric of the school environment constitutes an essential prerequisite for reducing adolescent sexual risk taking in a context of multiple exposures feeding the spread of HIV, including substance and alcohol abuse, gender inequality, gansterism, teenage pregnancy and sexual abuse. It would be a considerable achievement for the Departments of Health and Education to contribute to the understanding and implementation of effective peer educational interventions in complex settings.

It is essential that the Western Cape peer education programme is subject to process and outcome evaluations. The evaluation should be comprehensive, and address at least the following three aspects: input (the total resources required for the intervention); process (the quality of the implementation of the intervention) and outcome (the effectiveness of the intervention). In assessing the outcome, it is important to answer the question of why the intervention was effective as this will inform the ongoing development and refinement of the proposed peer education intervention, and also of course inform new interventions. In answering this question, it is crucial to include the social and cultural context of the schools, for example school climate. The Departments of Health and Education have demonstrated their commitment to evaluation by commissioning the Adolescent Health Research Institute to conduct such evaluation.

Appendix 4: TB in a high burden urban area

Overview of services at the sub-district level

The TB service is generally constructed as a nurse-based curative service that receives the support of visiting doctors. Usually, the ‘TB clinic’ is a number of allocated rooms within a primary health facility that also offers other curative and preventative services. TB services are commonly offered every day of the week. Doctors are assigned to a number of clinics within the district, with each individual TB clinic receiving a doctor, on average, about 2-3 half-days per week. Each TB clinic team leader reports to an area TB/HIV coordinator, of which there are two in Khayelitsha. These area coordinators in turn report to the area manager of primary health programmes. Their responsibility is largely the maintenance of the TB register information systems
The nurse-based nature of the service is predicated on laboratory confirmation of the TB diagnosis. The diagnosis is usually made from a sputum specimen submitted to the clinic by a ‘TB suspect’.

Operational models

There are 8 TB clinics (excluding the MDR clinic) in the high burden area of Khayelitsha. These clinics broadly fall into two main operational models, depending on the size of the service burden. The smaller, more common model is that of the “clinic-based TB team closely allied with a community DOTS support network”. This is usually a 4-5 person clinic team, consisting of a professional nurse as a team leader, with a nursing assistant, a TB assistant and a TB clerk. In these clinics, the team of trained staff works with a team of between 4-10 lay DOTS supporters from the surrounding community. This process is usually managed through the DOTS team leader who spends more time at the clinic than the rest.

The larger clinics have more staff and the division between community DOTS management and clinic DOTS management is more defined, with two entirely separate teams running each.

As mentioned above, the TB team will be visited by a doctor 2 or 3 times in a week, usually to interpret x-rays, advise on diagnostic dilemmas or manage drug complications.

Individuals roles and task orientation

The system of TB management is based on individual task orientation, where every staff member performs a small part of the required process and the patient moves from one person to the next, either during the course of a single visit or during the course of their treatment. The kind of tasks that need to be done include

• 
  registering sputum suspects (usually done by staff nurses)
  
• 
  entering confirmed patients in the TB register (often a professional nurse)
  
• 
  maintaining the register with two month and five month sputa (seen to be source of uncertainty, with professional nurses keen to delegate the responsibility to data capturers or clerks)
  
• 
  filing laboratory results in folders (often junior nursing staff)
  
• 
  dispensing medication (professional nurses)
  
• 
  giving streptomycin injections (professional nurses)
  

In one typical TB clinic, patients went from one room for their sputum tests, to the next for entry into the register to a third for medication. During this process patients were moving in and out of a crowded corridor shared by the rest of the health facility.

The community DOTS system

Each DOTS team member is responsible for between 5-15 patients in the community and needs to ensure the drug supply and compliance of their individual patients. Because the DOTS team member collects drugs on behalf of the patient, the number of times such a patient is seen by clinic staff during the course of their treatment can be quite variable. Most of the patients who use this system tend to visit their DOTS supporter after hours (the reason why they are assigned to a DOTS supporter in the first place is often because they are full-time employed or are too ill to attend the clinic every day). It is the DOTS team member’s responsibility to tick off the medication in the patient’s individual ‘green card’ (TB record).

The clinic DOTS system

This is meant to be a system whereby those patients who are able to access the service daily (not employed, not too sick, in reasonable proximity to the clinic) do so for visual confirmation of them taking their pills. A clinic staff member is then responsible for maintaining and updating the patient’s ‘green card’. There are indications though that even people registered as clinic DOTS patients are being given a week’s supply of treatment to complete at home. This appears to be a response to the clinic’s burden and requests/pleading from patients.

Service burden

In general, the smaller clinics are responsible, at any one time, for the treatment and active management of between 150 and 250 people on TB therapy. Usually about half of these patients would need to report to the TB clinic daily for “clinic observed” DOTS (some visits are mandatory, like those receiving streptomycin injections) while the other half would be managed by the community DOTS network.
Some of the larger clinics, like Nolungile, are seeing well over 2000 patients a year. A tally of the September 2006 register for Nolungile revealed 150 newly registered cases for the month. Of these cases, 67% were recorded as HIV-positive in the register, 25% were known HIV-negative and just 7% had not tested. Worryingly, of all adult cases registered for the month, 55% were not bacteriologically confirmed.