Team South Africa, Kwazulu-Natal

Photo by Lorien Abrams
The resource-constrained district of KwaZulu-Natal (KZN) is home to the South African AIDS Care Team. Six sites were selected through the KZN district health system, including tertiary, regional, district, and primary health care facilities. Since the site selection and group formation, the national HIV/AIDS policy has played a major role in shaping Team priorities in the region. The existence of an ECI Team was seen as a potentially important first step in improving specialized HIV/AIDS training for health care workers. Many health care providers also saw an ECI Team as a vehicle to unite stakeholders to speak with "a voice of power" to national government health officials on the subject of making ARV therapy universally available, especially to pregnant women.

In seeking to create a group that is both multidisciplinary and multisectoral, the South African ECI Team includes academic experts from the fields of epidemiology, health policy and planning, social and behavioral sciences, and health economics. Professors from the University of KwaZulu-Natal’s Department of Medicine provide clinical skills for treatment protocols, medical care, and clinic- and hospital-based care, and specialists in the departments of pediatrics, obstetrics, and gynecology focus on the clinical aspects of maternal and child health care. Team members from the KZN Department of Health provide experience in policy formulation and supply contacts that facilitate program development among the district’s 70 hospitals and 240 clinics, which serve 8.4 million people. NGOs such as the National Association of People Living with AIDS (NAPWA) and faith-based organizations facilitate the full involvement and participation of PLWHAs. The Team also includes representatives from the Durban Chamber of Commerce, and the Pietermaritzburg Chamber of Industries and Commerce. Collaborations with local and national government officials have been critical to the Team’s success.

Phase I - Situation Analysis
Care in a changing AIDS-policy context
In KwaZulu-Natal South Africa, AIDS Care Team members used multisectoral collaboration to develop and implement creative solutions to the challenges raised by inadequate medical infrastructure and severe poverty among the majority of HIV-infected people. The South African Cabinet’s recent announcement of a roll-out of HAART in the public sector of the health system has led to a shift in the Team’s work towards assisting the Department of Health with the HAART roll-out and in this changing context providing a continuum of quality AIDS care.

The Team’s training program provides training on low-cost palliative HIV/AIDS care for health care facilities with limited access to financial and medical resources, as well as focusing on prescription and monitoring of antiretroviral therapies to prepare for administration of these drugs as they become more widely available. Team members have forged a unique partnership between regional government, the academic sector, and NGOs to prepare KwaZulu-Natal’s health care workers to distribute HAART effectively. In this way, the Team has learned and taught others in the region how to shore up limited medical infrastructure and to share experience and knowledge to strengthen all areas of HIV/AIDS care.

To address issues ranging from shrinking human resources at health care centers to poverty, the South African Team has partnered with local hospices and clinic counselors to consider better ways to care for PLWHA. The formation of support groups for PLWHA has helped to create a network of community support, and to reduce the pressure of stigma surrounding HIV infection. The Team’s partnership between the University of KwaZulu-Natal and the South Coast Hospice has also given the hospice’s palliative care and home-based care training programs an added level of academic and medical credibility.
758 patients, 188 government health care providers, and 220 health care providers in the private sector from the six ECI Team sites (representing 6 of the 9 health districts in the province) were interviewed for the situation analysis. The survey used qualitative and quantitative methods, and was conducted by trained field workers. Based on the results of the analysis, Team members chose to focus on the key issues for health care providers and HIV/AIDS patients. Challenges for health care providers were identified as a lack of funding to ensure access to care, lack of staff training, low morale, and a general lack of resources and capacity at all health institutions. Challenges for HIV-infected patients included stigma and the perceived threat of violence were major barriers to acceptable quality of life and to obtaining appropriate care and support. For many, learning their HIV-positive status resulted in societal or familial rejection, poverty, and in some cases severe illness, rather than facilitating opportunities to access care, counseling, and support services.

Given this information, the Team identified four priority areas for future projects: research and development, training and education, policy and planning, and community action. Initial projects focused on training and education, responding to the 96.3% of 220 health workers surveyed who indicated a need for specialized HIV/AIDS care training. The Team established the KwaZulu-Natal HIV/AIDS Training Program to provide health care workers with accessible and immediately relevant training related to the unique issues faced by HIV/AIDS patients and their families. The Team has also worked in collaboration with the University of KwaZulu-Natal to establish the new HIV/AIDS Public Health Programme, piloted a VCT project using trained lay counselors, and conducted preliminary analyses of home-based care.

Phase II & III – Research and Implementation

Building a Training Program
In collaboration with the University of KwaZulu-Natal, the Team originally planned to develop a training course in issues specific to HIV/AIDS management for key personnel at the six South African ECI sites. As the program was developed, the collaboration grew and now includes the Nelson R. Mandela School of Medicine and the University’s HIV/AIDS Public Health Programme, the Provincial AIDS Action Unit, the Provincial Department of Health, the National Department of Health, and the International Association of Physicians in AIDS Care. When completed, the training program’s scope had expanded to a regional effort to train 30% of all KZN health workers in specialized HIV/AIDS care. The South African Team’s multisectoral approach encouraged participants from a wide variety of organizations and specialties to collaborate in producing a continuum of care well beyond the scale of what any one group could have supported on its own. The ECI Framework was used as a basis for the Training Program.

A series of Best Practice Seminars was developed as part of the Training Program to provide institutional management teams with an ongoing system for knowledge dissemination, and to introduce training on specific skills relevant to care and support of HIV/AIDS patients. The seminars also focused on informing healthcare managers and administrators of the specifics of the existing national HIV/ AIDS policy guidelines. The Training Program also includes a course for doctors and nurses to provide expert knowledge on the comprehensive clinical management of HIV/AIDS, and to prepare doctors for a new Post-graduate Diploma in Clinical HIV/AIDS Management program at the University of KwaZulu-Natal. The course focuses on ways to improve the quality of care and promotes an environment for ongoing knowledge dissemination. Through the mechanism of the Training Program, the Team plans to complete "gap analyses" of all health institutions in KwaZulu Natal.

Public Health and VCT
A second key project was the development of a program in the Department of Community Health at the Nelson R. Mandela School of Medicine to address HIV/AIDS issues. Using the unique approach mandated by ECI, the Team has thus created an interdisciplinary academic program which provides students with knowledge and expertise in a wide variety of sectors to promote HIV/AIDS care.

One of the areas of focus is voluntary HIV counseling and testing, a key entry point to care and support for both HIV-negative and -positive patients. In KwaZulu-Natal, the average time given to VCT per client was found to be 8 minutes, while the recommended time for pre-test counseling alone is at least 25 minutes. In addition, the ELISA test used for HIV testing had an average turn-around time of ten days- a long period that resulted in poor return rates for follow up . There simply were not enough VCT health workers to properly meet the demand for their services. In a effort improve this situation, a pilot group of ten Zulu women lay counselors were employed from 1999 to 200117. They had basic education, could speak both English and Zulu, and received intensive training on counseling, HIV/AIDS, sexually transmitted diseases, and tuberculosis. In this period, 8700 people were counseled, of which 50% were HIV positive, 68% of whom were women, with an average age of 28 years.

This study found that lay counselors are acceptable to, and considered essential by, health staff, and are perceived positively by clients. Rapid HIV tests are acceptable and preferable to the ELISA test. These results suggest that lay counselors and rapid HIV tests may be appropriate to other settings where prevalence is high, health services are lacking, and health personnel are overburdened from the impact of the HIV epidemic.

A Model for Home-Based Care
Through an assessment of the quality of care in home-, community-, and hospital-based settings in KZN, the Team created a model of home-based care from the perspective of caregivers and their clients. Quantitative and qualitative methods were employed to explore all various stakeholders’ ideas for feasible improvements to health care in resource-scare settings. Policy makers’ viewpoints were obtained through interviews of key informants and complemented by analysis of official government documents.

Based on the study, the majority of patients support the need for a continuum of care, with a strong emphasis on home-based care, and recognized that the policy framework is ambivalent, especially regarding treatment options. Programs at the community and health services level were found to be fragmented, unstructured, and highly dependent on the initiative of individual site coordinators. Service integration appeared limited, both within the health sector and among health, social, and education sectors. As such, the Team uncovered an urgent need for coherent, structured policy and programs for scaling up VCT, establishing HIV/AIDS care teams at health care institutions, and integrating home-based care into recognized health care frameworks.

Global Fund to Fight AIDS TB and Malaria Proposal

On 7 August 2003, the South African Government approved the receipt of funds allocated to the Enhancing Care Initiative, Kwa-Zulu Natal from the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). The Nelson R Mandela School of Medicine together with the Department of Health is a key stakeholder in the implementation of GFTAM funded programs in KZN. These programs were approved by the GFATM in April 2002.

This program was initially driven by the Nelson R Mandela School of Medicine’s commitments to express its social responsibility to the wider community, at a time when AIDS constitutes a major health crisis for KZN. The GFATM funding represents the largest HIV/AIDS implementation grant to South Africa to date, and is the Nelson R Mandela School of Medicine’s first community-focused program of such a great magnitude. This unique horizontal program is intended to bring experts and stakeholders at the University, the Departments of Health, NGO/CBOs and the private sector together to assist the Department of Health with a comprehensive HIV/AIDS implementation strategy, including provision of antiretrovirals, which were not available when the GFATM grant was first submitted.

In line with Government’s ARV roll-out policy, and led by Department of Health, the ECI Team recently took part in collaboratively re-developing the proposal to complement the potential roll-out of ARV in KZN. Overall, The ECI Team aims to bring together key stakeholders in HIV/AIDS programs in KZN with a vision to encourage best practices in response to local research, identified needs and international standards of care.

Impact of ECI in KwaZulu-Natal

ECI Impact in KZN

•AIDS Care Training Courses
•Collaboration between South Coast Hospice and Government
•PLWHA-sensitive Policy
•Certificate and Diploma Courses for Heath Professionals

By implementing the ECI Framework, the team connected patients and caregivers to a new potential for quality care and collaboration. The Team’s AIDS care training courses continue to provide important educational opportunities for health care workers, with the potential to dramatically increase the number of trained specialists in the area of HIV/AIDS medicine in the under served KZN province. These expert services are vital to the medical and mental health of patients, and allow both patients and caregivers to become part of a supportive and sensitive community. In the same way, collaboration fostered by the ECI Team between the South Coast Hospice and the South African Government has enabled clinics to form new hospice programs to provide PLWHA and their families with the option of care outside of a hospital setting.

At the strategic level, the Team has worked to integrate ECI’s 10 areas of care into the Government’s district, provincial, and national AIDS Action Plans. Provincial-level goals included working with Government officials to make health policy sensitive to and supportive of PLWHA, providing adequate and cost-effective care. This initiative specifically includes the region’s 45,000 health professionals, with the goal of ensuring the availability of the resources and drugs necessary to implement Government health policy in the public health sector’s 70 hospitals and 200 clinics. In addition, the South African Team used media coverage to highlight and combat the stigma that HIV/AIDS patients cited as a barrier to appropriate care and support.

Education and training have been a priority for this Team from its formation, leading to the development and present implementation of the short certificate course and the diploma-level interactive course for health professionals and NGOs throughout the province. A partnership with local government offices has sustained these programs, and has encouraged their utilization by medical workers and policy makers in KwaZulu-Natal. In the future, this multifaceted approach will translate into a model of care that ideally will be relevant to other provinces within South Africa, as well as other resource-scarce countries in sub-Saharan Africa.

The Future of ECI in KZN

Future models of care based on the work of ECI will focus on several areas. The Team’s vision of rapidly translating research into policy and practice has been extended by further funding in collaboration with Harvard University to form the ECI KZN Plus, which will be the research and implementation arm for the GFATM projects at the Doris Duke Medical Research Institute. The ECI KZN PLUS team will be involved in operational research issues surrounding implementation of a province-wide HIV/AIDS training program. In addition, the Team will be a sentinel partner working with the GFATM proposal consortium and supporting the provincial Department of Health with the roll-out of HAART in the province. Funded by the GFATM, ECI KZN Plus is based at the University of KwaZulu-Natal.

ECI KZN Plus currently has five main research tracks linked to the roll-out of HAART around which it will develop more projects in future: health economics; ethics and human rights; prevention of mother-to child transmission; adherence and health systems and operational research. This research will aim to inform the future of the HAART roll-out programs on an ongoing basis. The Team is also leading several training programs currently under development at the University of KwaZulu-Natal such as a Graduate Clinical HIV/AIDS Management Program, HAART training for nurses and clinicians and the Prevention of Mother to Child Transmission training being run for the Department of Health in the province. For example, the ECI costing model led to a further grant from the Centers for Disease Control to assist KZN policy-makers by conducting research into the costs of improving Prevention of Mother to Child Transmission (PMTCT) follow-up.

The South Africa AIDS Care Team specifically plans to focus on implementing a standardized program for the management of opportunistic infections, as well as a training program to prepare health care workers to prescribe and monitor antiretroviral therapy. The Team will maintain a strong role as a mentor and advocate for new HIV/AIDS programs, specifically by creating and maintaining a "center of excellence" for training medical staff in the management of HIV/AIDS at the King Edward Hospital site. As a parallel effort, the Team plans to work with the South African Government to develop infrastructure to deliver ARV, offering assistance in creating a new program.

In fulfilling its aims to develop research and training relevant to the HAART roll-out, ECI KZN Plus hopes to fulfill its commitment to working with partners in the province to provide optimal care to patients on HAART as well as those who, for a variety of reasons, remain unable to access ARV therapy.