Tugela Ferry, KwaZulu Natal, South Africa

KwaZulu Natal province in South Africa has one of the highest rates of HIV infection in the world. Closely linked to this HIV epidemic is one of the world’s most severe TB epidemics. Yale first began work directed at the integration of TB and HIV treatment and care in KwaZuluNatal in 2000. In 2005, while investigating the advantages of integrated TB and HIV care in Tugela Ferry deep in rural KwaZuluNatal, Yale School of Medicine clinician and researcher, Gerald Friedland, along with collaborators at Albert Einstein College of Medicine, uncovered the largest global cluster of cases of extensively drug resistant (XDR) TB, a form of TB with few treatment options and high mortality. Since then, drug resistant TB has been recognized as a global epidemic, which threatens both TB and HIV programs and populations. Since 2002, Yale and collaborating institutions have provided clinical support and an array of research activities, capacity building and technical assistance to improve prevention, diagnosis and treatment of HIV and TB and confront the convergent epidemics of HIV, TB and XDR TB.

Organizational Structure of Philanjalo in Tugela Ferry

The Yale program in Tugela Ferry, KwaZuluNatal, has been situated within the AIDS Program in the Section of Infectious Diseases and the Department of Medicine Office of Global Health. The Yale associated Tugela Ferry Care and Research Collaboration (TFCARES) was organized in 2006 and is currently incorporated as an umbrella organization supporting efforts in KwaZuluNatal directed at confronting the entwined epidemics of HIV and drug susceptible and resistant TB. Participating institutions include the Yale School of Medicine, Albert Einstein College of Medicine, Philanjalo (a local HIV and TB oriented NGO), the KwaZuluNatal Department of Health, the Nelson R. Mandela School of Medicine and the University of KwaZuluNatal.  As an international collaboration of healthcare professionals and researchers, Yale and TFCARES is committed to clinically relevant, ethical research, educational capacity building and high-quality, compassionate and comprehensive care and treatment for adults and children with and at risk for HIV/AIDS and tuberculosis in Sub-Saharan Africa.

Philanjalo,  the primary local South African partner, serves as host organization for clinical and research activities and for all visitors. Philanjalo has developed and operates a 32-bed inpatient step-down facility for care of HIV and TB patients, supplies community based HIV and TB focused health care services, and employs all staff associated with research endeavors. Through the collaboration with Philanjalo, COSH and the provincial KwaZuluNatal government, Yale and TF CARES has provided senior and junior faculty, medicine and pediatric residents through the Johnson and Johnson Scholars Program, medical students through the School of Medicine and nurse midwife students through the School of Nursing.

The clinical care, educational, research, capacity building and technical assistance activities have been funded by charitable foundations and government agencies including, The Irene Diamond Fund, The Doris Duke Charitable Foundation, The Johnson and Johnson Foundation, The Gilead Foundation, The KwaZuluNatal Department of Health, PEPFAR (through Columbia University ICAP), the National Institutes of Health and the Howard Hughes Medical Institute.

Since initiating HIV and TB integration and the identifying of XDR TB in Tugela Ferry in 2005, Yale and TF CARES have made substantial progress in improving and strengthening TB and HIV care and in confronting the intertwined epidemics. But the challenges are great and remain to be met.

Clinical Opportunities in Tugela Ferry, South Africa

Clinical Care in Tugela Ferry is focused on the 350-bed Church of Scotland District Hospital (COSH), a rural government district-level 350-bed hospital, typical of many in rural Sub-Saharan Africa, The hospital, combined with the 15 outlying outpatient clinics, and clinical services provided by Philanjalo, the local South African NGO, forms the backbone of care for the 180,000 traditional and impoverished Zulu people who live in the beautiful Msinga area of KwaZulu Natal, 2 and ½ hours from the city of Durban. COSH inpatient services consist of male and female adult medicine and TB wards, pediatric, surgical and psychiatric and OB/GYN wards. Outpatient services consist of a modern HIV/antiretroviral (ARV) clinic and a TB DOTS program. Philanjalo’s step-down inpatient unit, a nearby specialized program and hospital dedicated to treating drug resistant TB, as well as an active community based home care program are all part of the clinical facilities and services the patients rely on. COSH medical staff consists of ~ 8-12 doctors all of whom are generalists and many, superb clinicians, teachers and extraordinary role models. The doctors who staff the hospital, along with hospital and clinic nurses serve as the primary health care for the people of the area.

The COSH ARV clinic was the first site providing antiretroviral therapy in the public sector in KwaZuluNatal province and has initiated treatment for more than 10,000 adults and children since 2004. Johnson and Johnson Scholars from the Yale/Stanford Global Health Program, representing institutions throughout the U.S., work in the adult and pediatric ARV clinic, casualty department, step down inpatient unit and TB and general hospital wards. For those interested in clinical work in Tugela Ferry, it is critical to appreciate that the South African medical organizations are very strict and clinicians must obtain a South African temporary license. Registration takes a long time, so submission of licensing forms is required no less than 6 months in advance of visiting and working in Tugela Ferry. The staff of the clinic, assisted by the efforts of the Johnson & Johnson scholars, actively manage all aspects of HIV care, including opportunistic infections (particularly TB), ARV initiation, and complications of therapy. Started in 2001, the Philanjalo step-down inpatient unit augmented the Philanjalo Home Based Care model in use from 1999. Prior to the national ARV rollout in 2004, the unit’s primary mission was to supply end-of-life care. Since the rollout, it has served as a step-down for patients who are too sick to return home, but not sufficiently ill to require hospital services. Often their patients are in the process of initiating ARV or TB medications and require education or observation prior to being discharged home. The Philanjalo Clinical Manager, rounds on the unit several times per week, often joined by the J&J scholars or other visiting physicians.

TFCARES has also played a key role in supplying technical assistance, enabling the development and implementation of the district decentralized Community Based Multiple Drug Resistant (MDR) TB Treatment Program at nearby Greytown Specialized TB Hospital. This weekly clinic supplies follow-up to the ~200 patients in the district currently at various stages of treatment for MDR TB, most of which is provided at home with daily visiting nurses and other staff. The model is innovative and avoids lengthy hospitalization distant from homesteads and contrasts with other provinces that have often required forced detention for the duration of the patient's 24 months of care. The model emphasizes respect of the patient, and tries to balance their needs and well-being along with public health needs of the community.

Educational Opportunities in Tugela Ferry, South Africa

Multiple educational activities are available through the Yale and TFCARES programs on site in Tugela Ferry. For residents, J&J Scholars learn through a combination of hands-on clinical work and organized activities. Most generally work in the antiretroviral (ARV) clinic for the duration of their rotation. Residents work side-by-side with experienced clinicians who are immediately available to answer questions. A doctors meeting is held on Tuesday and Thursday mornings and consists of informal educational exchange in a morning report style conference, where clinical case discussion and/or didactics take place. All doctors attend, so it is the main venue for administrative matters as well. Each Scholar is expected to prepare and present one formal talk during the stay in Tugela Ferry. The primary role of the visiting J&J scholars is clinical care. The bulk of the six week rotation time is filled with patient care and education although it is possible to learn about the research activities to determine future interest in such activities. Educational materials and internet access are available for use and self motivated learning is encouraged.

Research Opportunities in Tugela Ferry, South Africa

Yale and TFCARES research studies focus on the integration of HIV and TB care and treatment and have demonstrated the benefit of this strategy, as well defining and creating and testing innovative strategies to confront the convergent epidemics of TB, HIV and drug resistant TB. We provided the initial description as well as the most comprehensive clinical and epidemiologic characterization of XDR TB to date, including studies of transmission in hospital and community settings and clinical outcomes. We have performed studies of new TB diagnostic tests and strategies among adults and children and developed new community based strategies to treat MDR TB and to identify HIV and drug susceptible and resistant TB earlier in the course of disease through intensive case finding (ICF). In addition, we work collaboratively with basic and translational scientists at US and South African universities, to determine epidemiologic, mycobacterial and host immunologic factors impacting on disease transmission, incidence, prevalence, course and outcomes.

The research programs and staff are generally separate from staff providing clinical care and services. Students, and post graduate trainees and faculty interested in research activities are welcome and encouraged. Because of the nature of the research process, we expect a long duration of commitment to research projects.

Through rigorous on the ground and collaborative studies, we endeavor to provide new scientific and clinical knowledge and the evidence base for sound clinical and public health policies and practices directed against TB, HIV/AIDS and drug resistant TB. We have made numerous invited and submitted presentations at local, national and international meetings in the US, South Africa and other countries. We have published a large number of original research studies and reviews in the peer reviewed medical literature. The evidence provided by these collaborative efforts has resulted in improved health care programs that have been incorporated into provincial, national and international guidelines and health policies regarding HIV and drug susceptible and resistant TB.

Contacts 

Questions?  Please contact Dr. Sheela Shenoi.