In the year October 2008 to September 2009, the TB programme more than doubled the number of sites providing integrated TB-HIV care. These sites now number 46, of which 36 are hospitals, four local clinics, and six NGOs, across the five provinces in which Right to Care operates.
Right to Care is rigorously pursuing a policy of TB-HIV integration, as endorsed by the World Health Organisation and South African Department of Health. A key element of this policy is the provision of TB symptom screening, using a standardised tool, for every HIV-positive patient at every visit. In the year under review, TB screening was done on 50　469 patients after VCT and 6423 patients at a PMTCT visit. Of patients in HIV care, TB screening was done at 95% of visits. Nearly 10　000 HIV-positive patients were started on TB treatment.
Infection control is key to preventing TB transmission to HIV-positive and HIV-negative patients and staff. Although comprehensive guidelines are available, few staff members feel competent in implementing infection control at their sites. Infection control training was provided to 50 staff members, representing the majority of Right to Care supported sites. Of supported sites, 92% submitted a standardised infection control assessment by the end of the year under review. In collaboration with Department of Health staff, 85% of these sites also submitted infection-control plans. In consultation with an environmental engineer, infrastructure alterations to improve ventilation and correct airflow direction have been done at a number of sites. Examples include modification of waiting rooms and consulting rooms and the installation of paddle fans and extraction systems.
In collaboration with City of Johannesburg, we are assessing mechanisms of TB-HIV integration at primary healthcare clinics. Recognising the challenges faced by our patients when they are referred from hospitals to peripheral TB and ART clinics, we will be investigating reasons for initial default from the Helen Joseph Hospital TB Focal Point. Data management systems; TherapyEdge and E-Mums, receive ongoing attention and regular updating to improve patient management and facilitate TB-HIV integration.
All staff members must provide both HIV and TB services. To this end, in the year under review 911 people were trained in HIV-TB.
Multidrug- and extensively drug- resistant tuberculosis (M/XDR-TB) continue to be a challenge at a public-health level and for individual patients. A key intervention is provision of ART to all HIV-positive patients with M/XDR-TB. This goes hand-in-hand with improving our understanding of drug interactions and side effects of dual therapy and the need for new drugs to treat M/XDR-TB. We support M/XDR-TB services in Gauteng, Northern Cape, and Free State.
We are honoured to be spearheading collaboration among USAID-funded partners regarding our TB-HIV integration programmes, with a view to sharing expertise and developing standardised site-level procedures and assessment tools. To this end, a working group with representatives from all partners has been established and workshops have been held to facilitate improved TB-HIV integration.
In the year ahead, we will provide a TB-HIV training course for doctors in the five provinces. The challenge of early diagnosis of TB, especially in HIV-positive patients, is ongoing and we will be assessing second-generation PCR technology at point of care, to diagnose TB and drug-resistant TB within two hours. This will reduce loss to follow-up and illness caused by delayed TB diagnosis.
In line with South African Department of Health policy, we will be assisting sites to roll-out Isoniazid preventive therapy (IPT), focusing on patients in the wellness programme. We will continue to work with staff at sites to raise awareness regarding TB infection control and the need for formalised assessments, plans, and practical measures to reduce TB transmission risk.
We welcome the new South African Department of Health treatment guidelines which allow for provision of ART to TB patients earlier in their HIV disease process. We look forward to the consequent improved health of our HIV-positive TB patients.

National SA TB guidelines 2008

TB SA MDR-TB guidelines 2007

National TB Infection Control guidelines 2004