Results from a Columbia University Mailman School of Public Health ICAP study show success by supporting patients and health workers in Lesotho—the country with the world’s highest rate of TB. Dr. Andrea Howard, associate professor of epidemiology and ICAP’s director of the clinical and training unit, was recently in Lesotho, a country with the world’s highest rate of tuberculosis and the second highest rate of HIV, to present preliminary findings from an ICAP study aiming to improve treatment for patients infected with both.
[Photo: Dr. Andrea Howard]
According to the World Health Organization, people with immune systems compromised by HIV are 20 to 30 times more likely to develop active TB. For this reason, high rates of TB are often seen in countries with high rates of HIV, including most of Southern Africa. In Lesotho, a landlocked country within South Africa, nearly three-quarters of TB patients also have HIV. “They tend to travel together,” said Dr.Howard. “Until we have control of the HIV epidemic, we’re not going to have control of the TB epidemic.”
Health officials already know how to treat co-infection: a series of studies support the WHO recommendation for early initiation of anti-retroviral therapy. Yet implementation has lagged. “We know that TB patients that initiate ART early have better survival,” says Dr. Howard. “But programmatically we weren’t seeing high uptake of ART, particularly early during TB treatment.”
The goal of the ICAP study, known as Start TB Patients on ART and Retain on Treatment (START), is to bridge what is referred to as the “know do” gap—between knowing the appropriate treatment and making it happen on the ground. Since 2012, START investigators, with funding by the PEPFAR through USAID, have tested an intervention package consisting of mentorship and training for nurses and village health workers alongside education and psychosocial support for patients, including home visits, phone calls, and text messages, as well as reimbursement for treatment-related transportation.
During patient visits, village health workers use a flipchart with easy-to-understand mix of text and illustrations by a local artist to communicate information such as when patients should take their medications.
Coinciding with events around World TB Day, Dr. Howard presented early study findings to Lesotho health officials, health workers, and patients who participated in the study: In the six facilities where the intervention was tested, a greater portion of patients were put on HIV drugs—and more quickly—than in control facilities. START has also been more successful in treating TB. In response, the Ministry of Health committed to rolling out several aspects of the intervention, including the flipchart and text messages, as well as increased funding to strengthen the village health worker system.