South African TB conference: an interview with conference co-chair Martie van der Walt

“This conference is on tuberculosis TB/HIV integration but when you can actually look at what is going on in the health services over all, there’s very little integration really,” said Professor Martie van der Walt, who currently heads the TB research unit of South Africa’s Medical Research Council.

She was also the chairperson of the 3rd South African TB Conference held in Durban in June, and was sharing with HATIP what she thought would be the important outcomes of the meeting — after she spotted me standing near the tanks of glow-in-the dark jellyfish at the conference’s welcoming function, hosted by eThekwini Municipality at uShaka Marine World.

We always attend these functions when a conference is held in Durban, because there is live music, and the people here really like to dance. Watching the peoples of South Africa dance together at the 2000 World AIDS Conference in Durban was half the reason I decided to stay in the country in the first place. Perhaps the fight against HIV brings that spirit out in people more, but the TB people in South Africa seem to be picking up the beat now. In fact, outside, at that very moment, about ten metres away from the shark tank, TB and HIV people were integrating just fine on the make shift dance floor.

But they will need to integrate in a much more important arena than that, according to the new National Strategic Plan on HIV, STIs and TB 2012-2016. The plan for the first time addresses TB and HIV services together, delivered in an integrated fashion. But there have been questions about whether TB wound up receiving less attention in the plan. There are concerns about whether enough thought has gone into how to operationalise integration of services system-wide — the specifics have largely been left to the provincial and local health departments to work out. And despite the roll-out of nurse-initiation and management of ART, (NiMART), there are still barriers preventing nurses from prescribing ART to coinfected people on TB treatment that must be addressed.

“Going forward, integration is going to be one of the challenges we need to be addressing: Integrated Service Delivery, what we call ‘the one-stop-shop’ for one patient with one coinfection. How are we going to integrate all of that?” Prof van der Walt said.

“The next issue is isoniazid preventive therapy (IPT) that we had the plenary on, or rather preventing TB infections,” she said.

Prof. Gavin Churchyard of Aurum Institute, had served as the primary investigator for the huge, and sadly disappointing Thibela TB study on the impact of community-wide IPT on the prevalence of TB in South Africa’s gold mines, spoke at the opening plenary. While treating entire communities with IPT was not beneficial, a post-hoc sub-analysis was able to demonstrate that targeted IPT was effective, while it was being taken, in people who would have qualified for it anyway on the basis of TB exposure and HIV status.

The next day at the conference, a session was devoted to presenting further analyses and modelling to explore why IPT fails and what it might take to more effectively prevent TB in at-risk populations. This will be discussed in a separate article. However, in light of data from the BOTUSA study of 6 months vs 36 months of IPT, which also showed a loss of benefit in tuberculin skin test (TST) positive not long after people ceased taking it, Prof Churchyard believes IPT should probably be taken continuously. This is in accordance with WHO policy at well, but not everyone — particularly the South African PLHIV community – is in complete agreement.

“IPT, is I think, at a crucial point - there are proponents for it, and then there are opponents,” said Prof van der Walt.  We mentioned one TB-HIV doctor who told us just before the conference that he felt the push to make IPT continuous for every PLHIV, regardless of their TST status, was wrong-headed and not patient-centred. Prof van der Walt agreed there needs to be an open discussion around this, in which

“I hope that the opponents to IPT will also step out,” she said.

“There are a lot of sessions on the Xpert MTB/Rif test. We’re also hoping that this conference could tell us where Xpert could go, or what remains to be done to deliver the promises we’ve had,” said Prof van der Walt, adding, “it may be well worthwhile at the GeneXpert presentations, to listen to the questions from the audience, to see exactly what are challenges in terms of GeneXpert.”

The other topic she felt was especially important was patient mobilization, advocacy, community engagement — about a third of the conference focused on that. “What do we need to generate more awareness amongst people or communities on TB, to create demand for intensified case finding?”

Other issues HATIP discussed with her, that we hope to cover soon, involved questions around re-engineering primary health care, and whether TB outreach teams for intensified case finding or decentralised MDR-TB care fits into that, or where those teams need to be situated within the health system. Finally, how, aside from finding and treating cases of TB earlier through intensified case finding, can the high rates of TB transmission in South Africa be better addressed in the community. How do we improve infection control in homes andcommunities to reduce transmission, and how do we reduce its transmission to healthcare workers?

“With community-based MDR-TB, how are we going to do infection control in the home?  So we know what you need to do:  You need to sleep in separate rooms, you need to have movement of air, but that’s not really sustainable. So how are we going to address infection control in the home?” she said. “Probably it’s mostly public awareness, if you can’t put in a window or two windows, or get in a mechanical ventilator —it’s actually more awareness of the issue — the awareness of the whole household in terms the risk of TB and the need to protect ourselves. Infection control needs to really get some of your attention. We’ve got some interesting work that has been done on it in TB in health care workers, which relates to it,” she said before saying goodbye.

We promised her at least one full HATIP covering the conference, and then wandered off to watch the dancing.

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