Posts Tagged ‘From the field’

Pakistan NGO unveils new facility; First program to treat MDR-TB

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Posted 05 Apr 2010 — by Maria May
Category News

While visiting several organizations in Pakistan, I joined current and former patients and their families, local and international celebrities such as Miss Zeba Bakhtiar, and staff in a ‘Open House’ event at the new TB care facility of Indus Hospital on March 23, a national public holiday.

“We really held this event for the patients. Today’s about them,” commented Tariq Qaiser, the building’s chief architect. Patients took a tour of the facility, learning what to expect when they soon returned for appointments. Some shared their struggles with the illness, the difficulties in accessing effective treatment and their gratitude for the program, while others won prizes by answering trivia questions on TB. The hospital leadership provided words of encouragement to current patients and congratulated those who had successfully completed their treatment course. Hundreds traveled several hours to attend the event. Excitement was palpable, one patient rejoicing “This is just like a picnic!”

Dr. Abdul Bari Khan, CEO of Indus Hospital, speaking at the event.

Pakistan is ranked 8 out of 22 high burden TB countries, and accounts for an estimated 57% of MDR-TB in the WHO’s Eastern Mediterranean Region, with 250,000 TB cases reported in 2008 by the National Tuberculosis Program, or 181/100,000.

According to the most recent WHO report on MDR-TB, many countries including Pakistan do not have sufficient surveillance infrastructure to accurately assess their burden of MDR-TB; only 59% of all countries have been able to collect high quality, representative data on drug resistance. When not diagnosed properly – the WHO estimates that only 7% of patients with MDR-TB are diagnosed worldwide – patients end up taking the same regimen multiple times which leads to resistance.

Built primarily with local materials, the new TB facility combines a regal design with expert advice on infection control, and applies recent lessons learned on natural ventilation by providing a shady outdoor waiting area with stone benches and an open structure allowing for a constant natural breeze. Though still controversial and not always possible or reliable depending on climate and varying conditions (wind direction, seasons, etc.), “there has been an outpouring of enthusiasm for the natural ventilation approach,” notes TB Infection Control expert Dr. Ed Nardell. Dr. Aamir Khan, Executive Director of Interactive Research and Development, a partner of Indus Hospital in several of its service-research initiatives including MDR-TB, commented,

This building is a testament to Indus Hospital’s mission of providing quality care to all its patients with dignity, completely free of cost. My hope is that this building is known not just for its striking architecture, but for the integration of airborne infection control and the functionality of every day use. It inspires me to do more, faster and better for the control of drug resistance TB in Pakistan and the developing world.

Open structure allowing for a constant natural breeze

Indus’ TB treatment model includes lay-people in the community who provide treatment support, and the use of a sophisticated electronic medical record system developed using the open-source technology OpenMRS. In addition, Indus’ partners at Interactive Research & Development are currently working to integrate cell phones with the EMR system to allow community-based staff to access and enter patient information in their daily activities. As the program expands in Karachi and is potentially replicated elsewhere in Pakistan, having a robust delivery model that includes smart management of information will be critical to patient adherence necessary to effectively combat MDR TB.


Opened in 2007 with the aim of providing high quality care at no cost to patients, Indus Hospital also provides specialized services such as orthopedic surgery, dialysis treatment, and angioplasty – services whose prohibitive costs make them unaffordable to many poor patients, or come at the expense of selling all one’s property. Over the past two years, several new departments were added, and Indus’ leadership is now strategizing about how to increase the care it delivers at the community level.

From TB infection control issues to management of MDR-TB treatment, many of these topics are addressed by GHDonline members. We invite you to discover the following discussions and resources on GHDonline:

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Scaling up HIV testing and treatment in South Africa

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Posted 31 Mar 2010 — by Sarah Arnquist
Category News

Starting next month, South Africa plans to implement a massive expansion of HIV testing and treatment outlined by President Jacob Zuma last December on World AIDS Day.

Health Minister Dr. Aaron Motsoaledi insisted at a press conference Thursday that the nation’s health system is ready to tackle the challenge of testing 15 million people by 2011.

“The counseling and testing shall take place at all government hospitals and clinics, all universities and FET campuses and mobile units will be deployed to villages, rural areas and other remote areas of the country,” Motsoaledi said.

This aggressive approach to HIV marks a new era in South Africa’s response to the disease, but whether  actions and a health system can back up the words is yet to be determined. People here remain skeptical, particularly given the recent controversy over the president’s decision to take a third wife after fathering a child out of wedlock.

Government leaders will test in public on April 15 to launch the campaign to test all South Africans. To increase capacity for voluntary testing and counseling the government has asked retired health care workers to undergo a one-day training and help out, and fourth-year medical students to volunteer during the campaign’s first week.

I am in South Africa now learning about loveLife, a youth HIV prevention organization. LoveLife focuses on youth development and empowerment. It works with government clinics to help them be youth friendly and has some clinics at its youth facilities, but does not focus on offering medical services. I’m not spending most of my time here visiting medical facilities and learning about the health system, but I am  visiting some clinics and the largest government hospital in Soweto, Chris Hani Baragwanath Hospital.

At the first provincial clinic I went to last week in an informal community (SA’s euphamism for the ghettos blacks were contained to under Apartheid), hundreds of patients lined benches in the hallways, waiting up to four hours for care. That day, apparently, was worse than most because three of the six primary health nurses were away for training.

Chris Hani Baragwanath Hospital Soweto, the largest public hospital in South Africa

In the ARV ward of the clinic, no bench space was available. Under the HIV testing and treatment expansion plan President Zuma announced last December, patients are expected to increase because treatment will now start when patients have a CD4 count of 350 instead of 200.

“Young & full of like?” asks the sign at this health center for youth providing ARV treatment in an underserved community in South Africa

The World Health Organization released new guidelines in 2009, recommending that HIV treatment begin earlier to prevent more opportunistic infections and decrease mortality.

Other changes to HIV treatment include earlier treatment initiation  for all pregnant women at 14 weeks, treating all positive infants younger than age 1 regardless of CD4 counts, treating all patients with TB & HIV under one roof. About 1 percent of South Africa’s population has TB and the prevalence of co-infection between TB and HIV is 73 percent.

Yet, it is estimated that only 4 percent of South Africans with HIV receive preventative TB treatment and only 1 percent are screened for TB.

I’m not in a position to judge whether the system has the capacity to meet these new goals, but they are ambitious. To reach the goals, Zuma said HIV services must be available at all health institutions and not siloed in separate ARV centers. The president said, “Any citizen should be able to move into any health centre and ask for counseling, testing and even treatment if needed.”

That means ARV provision will be have to expand from the current 400 facilities to more than 4,000 health centers. Beyond critical workforce implications that come with expanding ARV, what implications these new guidelines will have on patient adherence and retention remains to be seen.

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