Zimbabwe’s TB burden
The TB epidemic in Zimbabwe, like in many countries in sub-Saharan African, is largely HIV driven. Reflecting the maturation of the HIV epidemic, Zimbabwe is ranked 17th among the 22 high TB burden countries in the world. The proportion of all TB patients tested for HIV was 61%, of whom 78% were HIV-infected.
Challenges to TB Control Efforts
The challenges to TB control are multifaceted: socio-economic factors, limited access to convenient TB diagnostic centers and lack of sensitive and rapid TB tests.
The TB case detection rate for Zimbabwe is reported at 46%, of which 29% are smear positive. Smear microscopy is the routinely available test for TB with a sensitivity of less than 50%. TB patients who are smear negative have to make numerous return visits to a health facility with referrals for chest radiography before they can be started on TB treatment based on clinical grounds.
Because HIV complicates the symptoms of TB, HIV co-infected TB patients lack the classic symptoms for TB, making clinical diagnosis difficult and protracted. This process is characterized by low follow-up rates and high morbidity and mortality. In Harare, a study showed that 35% of still symptomatic TB suspects had culture proven TB and of these 13% died within 2 months of their first clinic visit.
A significant number of undiagnosed TB cases exist in the community as TB suspects fail to report for TB investigations at health facilities due to lack of knowledge of TB symptoms and opportunity costs. Studies in Malawi have shown that the cost of seeking a TB diagnosis in so called “free government facilities” can be up to of 240% of a family’s monthly income.
PSI/Zimbabwe’s HIV/TB Collaborative Activities and Outcomes
The National TB Program (NTP) in Zimbawe, with the help of partners, is implementing several strategies of identifying and treating TB cases. In collaboration with NTP’s efforts on active TB cases finding, since 2005, PSI/Zimbabwe has been offering TB screening and referrals, using a standard questionnaire administered to clients seeking HIV testing and counselling in its network of 18 centres branded New Start. All councelors at New Start centers are equipped with counseling skills necessary to administer the screening tool and identify TB suspects. Since the introduction of the TB screening questionnaire, a total of 24,000 TB suspects have been identified and referred to TB diagnostic centers for investigation and possible treatment. Of the referred TB suspects, 10,000 received TB diagnostic services and 3,000 started TB treatment.
PSI/Zimbabwe also implements an advocacy, communication and social mobilization (ACSM) intervention aimed at addressing the TB information gap in the community. The intervention has reached 2.4 million individuals with interpersonal communications and a further 3.8 million individuals each month via mass media
The program has also resulted in good collaboration between New Start and TB care service providers in Zimbabwe, improved capacity of New Start testing and counseling counselors to handle TB suspects, and benefitted non-symptomatic HIV positive clients with preventive TB counseling.
Lessons Learned and Next Steps
In spite of the many successes recorded, several inadequacies with the program were noted. Chief among these was the relatively low rate of successful referrals; tracked referrals ranged from 45% to 55%. Staff and reagent shortages further reduced the number of TB patients who were identified.
In order to address some of these challenges, PSI/Zimbabwe plans to do the following:
- Integrate LED fluorescence microscopy at 2 of the busiest HTC centers. Fluorescence microscopy is more sensitive than ordinary light microscopy. Service integration will allow for same-day TB investigation and the client will not need to travel to another service provider. With this, it is expected that almost all TB suspects at these centers can access TB sputum microscopy. Services will be available in April this year.
- Introduce innovative TB diagnostic techniques. In order to better diagnose smear-negative TB, operational research into the possibility of using GeneXpert molecular techniques will be instituted. This is still pending funding through TB Reach.
- Improve referral tracking using SMS technology. Smear-positive clients and other smear-negative TB suspects will be asked to supply a contact number for easier follow-up. This is planned to be in place by mid-year.
- Intensify TB case finding through community mobile outreach. This intervention is meant to identify undiagnosed TB in the community using mobile vans to collect sputum samples from TB suspects in the community after community mobilization. Sputum will be analyzed for presence of TB bacilli at New Start HTC centers and results will be transmitted to community members. All identified TB cases will be referred into care at public sector hospitals. This is still pending funding through TB Reach.
