In light of World TB Day today, the Clinton Health Access Initiative, Inc. (CHAI) recognizes the somber truth that TB is the leading infectious disease killer today. While the global TB community has made huge strides to reduce TB mortality by half since 1990, there is still a long way to go.[1] The Global Plan to End TB has framed intermediary 90-90-90 targets for the period of 2016-2020, which seeks to have 90 percent of all people with TB diagnosed and treated, and ensure that 90 percent of key populations are reached.[2] CHAI and our partners around the world continue to work toward these goals to end TB.
As a part of this work, CHAI works to improve access to TB diagnosis and treatment among miners and ex-miners, who are highlighted as key target populations under the 90-90-90 framework. Ex-miners are considered a key population at increased risk for TB, given high rates of silicosis (a lung disease caused by exposure to silica dust in sectors such as mining) and HIV, two diseases that significantly increase the risk of developing TB.[3] This especially high burden of disease among ex-miners in Lesotho was documented in a prevalence study, which found that 30 percent had current TB disease or a past history of TB, 1 in 4 had silicosis, and 22 percent were HIV-positive.[4]
In response, in 2014, CHAI conducted a qualitative research study on health challenges of ex-miners in Lesotho. This study found that ex-miners tend to be older men over the age of 50, who have worked primarily underground in the gold mines in South Africa for long periods of time, on average 26 years. These men are not only are at high-risk for TB, but also have poor knowledge of the disease and exhibit poor health-seeking behavior. The lack of transport resources was highlighted as a major barrier to seeking health services.
Given the high-risk profile and poor health-seeking behavior of the ex-miner population, CHAI recognized the need to reach them in their own communities to be screened for TB and HIV, rather than waiting for them to present for care at their local health facility. Such an approach, known as “active case finding,” is a critical measure needed to reach the global goal of 90 percent case detection rate.
To conduct this community-based active case finding, CHAI has partnered with Mineworkers Development Agency (MDA), an organization in Lesotho with a deep reach into the ex-miner community, and Jhpiego, a clinical partner in Lesotho which has made great strides in providing “male-friendly” HIV services, to ensure that ex-miners are reached tested for TB and HIV when appropriate. This work has involved identifying community hotspots of ex-miners through analyzing MDA’s existing databases, developing an effective method to mobilize ex-miners, and promoting MDA events where TB and HIV screening services, along with health education activities, are offered.
This project, “High Impact Health Services for Ex-Miners Project in Lesotho,” kicked off on February 8, 2016, when 217 ex-miners gathered at the Community Council in Rothe, Maseru to be screened for TB and tested for HIV. Though there were doubts in the planning phase about whether or not ex-miners could actually be mobilized to voluntarily turn up for health services, turnout was unexpectedly high; screening activities had to be extended to a second day to accommodate demand. Since the launch, anywhere between 190 and 610 ex-miners have been mobilized on a weekly basis to be screened for TB and HIV across Maseru, Leribe, and Mafeteng districts in Lesotho in an intensified effort to reach this population. The ex-miners have queued in long lines, waiting their turn to access the different stations that were set up for TB screening and sample collection, HIV testing and counselling (HTC), and Isoniazid Preventive Therapy (IPT) initiation.
“Mobilization entails contacting community council members and chiefs and briefing them about the project and its objectives,” explains Isaac Shafiq, Occupational Health and Program Coordinator, MDA, Lesotho.” We then request them to convey the information to our target group: ex-miner population and the community members. We also have house-to-house mobilization—where the MDA Mobilizer/Screener has one-on-one talks with the target group and briefs them about the project and the scheduled cluster day. The reaction has either been positive when we approach them and at other times people are interested in knowing their health status, while there are always a few ex-miners who only want compensation and are not interested in anything else. We feel that the mobilization is beneficial since we bring health services to the doorstep of the ex-miners and there is a lot we can take forward, as MDA, in terms of supporting the ex-miner population. What I have noted from the uninterested ex-miners is that due to the high levels of poverty and due to the fact that they no longer feel they are useful in the community since they are not working, they do not feel the need to get TB screening done let alone adhere to medication if they are TB positive. So we still have a lot of work in giving them a purpose through livelihood projects and a lot of counseling.”
With the support of Aquity Innovations, CHAI, MDA, and Jhpiego aim to screen 6,500 ex-miners for TB and HIV. In addition, the project has set ambitious 90 percent linkage-to-care targets to ensure that at least 90 percent of all people diagnosed with HIV and TB, or who are eligible for IPT through the project are properly linked to care and initiated on treatment, in line with international targets defined by Stop TB Partnership and UNAIDS. The project is using a two-pronged push and pull approach to ensure this linkage takes place. As a “pull” approach, CHAI incentivizes with mobile money payments, conditional on the patient presenting to the health facility for care. As a “push” approach, CHAI uses data collected on mobile phones to identify and track, in real-time, patients requiring linkage to care.
CHAI estimates that this project can reach approximately 10 percent of the living ex-miner population in Lesotho. However, in order for these efforts to be truly successful, they must be brought to scale: nationwide coverage of TB and HIV screening for ex-miners. In addition, a crucial element that requires attention for the ex-miner population is silicosis screening. However, silicosis screening requires trained readers of chest x-rays for silicosis and lung function testing, sorely lacking resources in Lesotho. Scaling TB and HIV screening and building capacity for silicosis screening services is crucial to improving the overall health outcomes of the ex-miner population in Lesotho.
In order to scale this and similar initiatives targeting key populations, the global TB community needs to efficiently deploy resources to better understand the specific barriers to increased detection of TB among these populations and to design and execute smart solutions to address these barriers at scale. This will be a crucial step to achieving the 90-90-90 targets.
[1] http://www.who.int/mediacentre/news/releases/2015/tuberculosis-mortality/en/
[2] http://www.stoptb.org/news/stories/2015/ns15_052.asp
[3] http://www.stoptb.org/assets/documents/global/plan/GlobalPlanToEndTB_TheParadigmShift_2016-2020_StopTBPartnership.pdf
[4] http://onlinelibrary.wiley.com/doi/10.1002/ajim.20767/abstract
