HIV CARE AT MCCORD HOSPITAL, DURBAN, SOUTH AFRICA

Scope of the Problem

The HIV pandemic raging across Africa is a tragedy of epic proportions. It has been described as the worst epidemic and the deadliest disease in medical history, far surpassing the bubonic plague of the 14th Century. Sub Saharan Africa is the worst affected region in the world. Of the 42 million people estimated to have HIV globally,

70 % (29 400 000) live in this region. [1] It is altering the region's demographic future, reducing life expectancy, increasing mortality, lowering fertility and leaving millions of orphans in its wake. It is estimated that each day 6000 Africans die of AIDS [2].

South Africa is estimated to have between 5.1 million [3] and 6.5 million [4] infected people, and with more than 10% of the global burden of disease, is the most severely affected country in the world. The annual antenatal clinic sentinel surveys have tracked the exploding epidemic and shown the prevalence in pregnant women increasing from 0.7% in 1990 to 26.5% in 2002 [5]. The estimated accumulated deaths due to AIDS mid year in South Africa are estimated to be 688 488 (ASSA) [6]. AIDS mortality is rising rapidly; the mortality amongst 20-30 year old women has increased more than four-fold in the last 5 years.

According to the annual ANC sentinel surveys and the ASSA model, the province of KwaZulu-Natal is at the epicenter of the South African epidemic, with approximately 31% of the adult population and 36.5% of pregnant women attending public health facilities in 2002 estimated to be infected. AIDS-related diseases now account for large proportions of hospitalized patients: 50-80% of all patients at King Edward hospital (the biggest provincial referral hospital, located in Durban) [7].

Only 1% of South Africans who need antiretrovirals are presently able to access them..

McCord Hospital

The aim of McCord Hospital is to provide comprehensive and affordable quality health care to patients who do not have health insurance. Although some patients are employed, many are not the less privileged people of Durban. It is also a training centre for health care workers, including doctors, nurses and medical students. The greatest single medical need in the South African context for the foreseeable future is prevention of HIV infection and the care of affected people. In line with its history of seeking to serve those with the greatest needs, McCord Hospital has chosen to develop comprehensive programmes and services to meet the complex needs of individuals affected by this pandemic. Training in VCT [8], counselling and support is being extended to all staff at McCord Hospital. This will form a strong base for training of staff from other facilities in the province.

History of the Hospital

McCord Hospital attracts visionaries and nurtures future leaders. Dr James McCord, an American missionary doctor, had a vision to provide a good health care service to the Zulu people who had, at best, rudimentary care available to them. Against great opposition, he established McCord Hospital on the outskirts of the boundaries of the City of Durban in 1909. He also established the well recognized McCord Nursing School in the early 1920s. He was joined by Dr Alan Taylor who had a vision to train black doctors, which was in direct opposition to the principles of the racially discriminatory government of the day. The first black "Medical School" started by Dr Taylor in the current McCord Nurses Home was closed down. However, his vision persisted. The foundations had been laid, and the Natal Medical School opened its doors to black medical students in 1951, with Dr Taylor as the first Dean.

Many of today's leaders in the health care field have had their initial experience and training at McCord Hospital. Not the least amongst them are such people as Dr Zweli Mkhize, the previous Minister of Health in KwaZulu-Natal; Professor M.W. Makgoba, the Vice Chancellor of the University of Natal, Professor D.J. Ncayiyana, the Chancellor of the Durban Institute of Technology and Editor of the South African Medical Journal; and Dr J. Ndlovu, the first African psychiatrist in KwaZulu-Natal.

McCord Hospital has produced renowned nurse leaders nationally and internationally in the fields of nursing practice, education, management, research and professional organizations.

Since its humble beginnings, McCord Hospital has grown to become a well recognized 220 bed general hospital which provides quality medical care to the less privileged people of Durban. The culture of co-payment has been accepted by its patients from its inception, and it was both with dignity and gratitude that patients gave what they could in turn for care that they valued.

HIV/AIDS Care

In line with its history of seeking to meet the current and anticipated health care and training needs of the society it serves, McCord Hospital recognized the impending crisis which AIDS was to bring. In response to the growing and multi-faceted needs of people living with HIV/AIDS, the hospital set up a dedicated HIV clinic in 1996, which was named Sinikithemba, which is Zulu for "We give Hope". The Sinikithemba HIV/AIDS Care Centre developed a number of programmes which are wellestablished and independent and outgrew its original premises. Generous donations from a number of funders enabled the hospital to purchase and renovate a larger property in the same road which is the new Sinikithemba Centre. Comprehensive care is offered to patients at this centre, and includes out-patient medical care, social work, psychological services, pastoral care, training and income generation projects for support group members.

The vision is for the care network to extend beyond Sinikithemba to include Prevention of Mother to Child Transmission (pMTCT) at the hospital, in-patient care in the medical and paediatric wards, home based care, and terminal and/or longer term non-hospital based care at the Dream Centre in Pinetown. This model of comprehensive circles of care for both the infected and the affected is viewed as a strong model for replication in other sites.

Sinikithemba had been providing ART [9] to patients since the late 1990's and the numbers of patients accessing this life saving treatment had been slowly increasing. However, because patients had to self fund and ART was very expensive, the numbers were low. A successful PEPFAR [10] funding proposal submitted in December 2003 dramatically changed the situation. The HEART [11] programme enabled Sinikithemba to scale up the number of patients on ART and at present this number is over 900, making the programme one of the biggest in the province of KZN. The HEART programme has also made it possible to offer ART to pregnant women, which has reduced the transmission to about 5%, compared to the National estimate of around 18%.

The HEART Programme at Sinikitemba in 2004

By the end of 2003 it was clear that many of the patients at Sinikithemba on ART were doing well. This made the work of the staff at the clinic very exciting, inspiring and encouraging. However, along with that, was the sadness and frustration of not being able to adequately help many patients who really needed to be on these life saving medicines but who were unable to afford to pay for it, due to the high cost of ART. Many people with HIV came to the clinic desperate for help and the staff felt very concerned and motivated to find a way to try and help more patients. Encouraged by EGPAF, [12] McCord Hospital joined a multi-country collaboration and a funding proposal was written in December 2003 under great pressure and in a very short time, to the PEPFAR fund. We believe that it is nothing short of a miracle that this was successful, and we give thanks to and acknowledge God in this project. The result was the establishment of the EGPAF HEART programme, aiming to provide ART at sites in 4 countries: South Africa (McCord Hospital), Zambia, Cote d'Ivoire and Tanzania.

The Strategic Objective of the HEART project at McCord Hospital is to rapidly scale up the treatment and care of HIV infected people, and to start as many people as possible, on ART, in accordance with the South African National Guidelines [13] and the Operational Plan [14].

An intensive planning process was undertaken in May and June in order to create a new HEART Operational Plan. In July, the new plan was implemented with the following core components:

• A Family Centered Care model, where family members were to be given priority in receiving treatment.
• A refocus of the core business of Sinikithemba to be an ART centre, rather than a general HIV clinic.
• As part of this streamlining process, a pre ART "screening" clinic was set up to do HIV testing (VCT), screening (CD4 counts) and psycho-social assessment, at an adjacent location.
• A new "Batching System" to be implemented in which patients are enrolled in group ('batches"), in order to provide streamlined comprehensive care. This involves a 3 week process to enroll patients for ART, in which patients come once a week for intensive training and preparation for starting ART. The process is as follows:

• This new system necessitated the creation of a monthly calendar which made it easier to predict the flow of patients in the clinic.

We have had to employ more staff, namely: A counselling co-ordinator to oversee the counselling service, more counsellors, nurses (to be trained in ART clinical care) as well as a nurse educator, doctors, a new clinic administrative manager and more reception / clerical staff, a dedicated full time pharmacist, and staff to assist with the monitoring and evaluation (M&E).

Computer System: The new "TrakHealth" computer system went "live" in July. It is a comprehensive electronic computer record which all staff need to use (receptionists, counsellors, nurses, doctors, pharmacists). It has been a challenge to implement it, because it has had to be "customized" for the HEART programme. A lot of progress has been made, but it is still an ongoing work in progress.

Paediatric Clinic: The increased number of children on ART has been a very exciting development. The comprehensive multidisciplinary team is working well, with strong emphasis placed on the psycho-social needs of the children.

Progress to date: In June 2004: 379 patients were on treatment

• July 2004: 45 new patients started
• August 2004: 61 new patients started
• September2004: 81 new patients started
• October 2004: 116 new patients started
• November2004: 85 new patients started
• December 2004: 85 new patients started
• January 2005: 93 new patients started
• Total (adults & children) currently on treatment: 921 (31 January 2005)
• Number of children on ART: 93

The Challenges and Obstacles with Project HEART

• Keeping track of our patients & batches, especially as the numbers increase. This involves tracking and following up those who do not come for appointments or follow up and finding out the reasons. The logistics of bookings and appointments and patient flow in the clinic are a challenge: how to ensure that patients get streamlined, appropriate and optimal care without waiting for too long or becoming frustrated with the clinic systems. This requires a system in which patient numbers can be predicted and anticipated and appropriate numbers of staff are available.
• Caring for very sick patients who want to start ART and at times not having immediate "slots" available in the programme, and grappling with the ethical and logistical issues of whether to "fast track" these patients, at the expense of others.
• The ongoing challenge of getting the computer system right and training all the staff to use it reliably, accurately and consistently.
• Monitoring and evaluation is a major challenge, which should improve as the computer system and the users of it become more reliable.
• The organizational structure of Sinikithemba needs to be redefined as the number of staff increases and the focus shifts.
• Staff: we have increased our number of staff and attention needs to be paid to the following:

• ongoing training
• retaining staff
• communicating with the expanding staff complement

Conclusion

Being able to provide ART as part of a standard package of care and at no extra cost for drugs or lab tests, has enabled many more patients to access these life saving drugs.

Sinikithemba now has one of the largest clinic cohorts of patients on ART in the province of KwaZulu-Natal. This, coupled with our ability to do analysis of our clinical data, provides an invaluable experience base, and enhances our capacity as a training site for doctors, nurses and others who want to learn about HIV management and the use of ART.

Many lessons have been learned as a result of our large patient cohort on ART, one of which is the importance of disclosure. We are hoping that with our family-centred approach with the HEART programme, in which infected family members will be given priority for ART, that this will encourage more disclosure and reduce stigma further.

We are looking into the option of establishing satellite sites which McCord Hospital can support. The aim would be to refer patients who are stable and on treatment for ongoing monitoring and care at a satellite site closer to the patient's home.

Dr. Janet Giddy, MBChB, DipPHCEd, MFamMed, is the HIV programmes Co-ordinator at McCord Hospital, Durban, South Africa. She is a Family Physician with experience in Rural Medicine, Obstetrics, Primary Health Care and education of health workers and medical students. She has published on rural health as well as human rights issues.  She is married and a mother of 4 children.

NOTES

1. Joint United Nations Programme on HIV/AIDS and World Health Organization (WHO) AIDS Epidemic Update December 2002.

2. World Watch 2000.

3. UN AIDS statistics.

4. Actuarial Society of South Africa 2000 model — ASSA model.

5. National HIV and Syphilis Antenatal sero-prevalence survey in S. Africa 2002. Dept of National Health.

6. Actuarial Society of South Africa 2000 model — ASSA model.

7. The impact of the HIV/AIDS epidemic on Hospital services in South Africa — report produced for the WHO. Jinabhai et al November 2002.

8. VCT — Voluntary Counseling and Testing.

9. ART — Antiretroviral Treatment.

10. PEPFAR — U.S. President's Plan for Emergency AIDS Relief. President Bush promises 15 billion dollars for the next 5 years for HIV care to 14 countries most affected by HIV/AIDS, most of which are in Africa.

11. HEART — Help Expand Antiretroviral Treatment.

12. EGPAF — Elizabeth Glaser Paediatric Foundation.

13. National Antiretroviral Treatment Guidelines. National Department of Health, South Africa 2004.

14. Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, November 2003.

passages | http://quod.lib.umich.edu/p/passages/