Tugela Ferry, South Africa

Tugela Ferry is located in Msinga subdistrict of KwaZulu Natal province and is among the most impoverished regions of the country. This is a rural region, characterized by poor access to water, low literacy levels, and subsistence farming. KwaZulu Natal province in South Africa has one of the highest rates of HIV infection in the world, which drives one of the world’s most severe TB epidemics. Yale’s Dr. Gerald Friedland with collaborators at Albert Einstein College of Medicine, while investigating the advantages of integrated TB and HIV care, 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, both multiple drug resistant TB (MDR TB) and extensively drug resistant TB (XDR TB) have been recognized as global epidemics that threaten public health. 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. Today, MDR and XDR TB are at low levels in Tugela Ferry due to the efforts of the Department of Health supported by technical assistance from Yale and other partners, though remains a major problem in other regions. Although global efforts have resulted in decreasing HIV and TB incidence, in South Africa 20% of adults 15-64 years are living with HIV, and TB remains among the top ten causes of death annually in South Africa.

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. Yale is committed to patient-oriented and ethical research, educational capacity building, and high-quality, comprehensive care for adults and children in sub-Saharan Africa.

Philanjalo, our local South African partner, serves as host organization for clinical and research activities and for all visitors. Philanjalo operates a 32-bed inpatient step-down facility, supplies community-based HIV and TB focused health care services, and employs all staff associated with research endeavors. Since 1999, the Philanjalo has been offering community-based testing and treatment support services, and subsequently developed an inpatient unit. Prior to the national antiretroviral rollout in 2004, Philanjalo primary mission was to supply quality end-of-life care. Since 2004, 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 antiretrovirals or TB medications and require education or observation prior to being discharged home. Through Yale’s collaboration with Philanjalo, the local government district hospital (Church of Scotland Hospital), and the South African Department of Health, Yale has facilitated clinical rotations and research experience for senior and junior faculty, medicine, ob/gyn, and pediatric residents and fellows, medical students through the School of Medicine and nurse midwife students through the School of Nursing.

Clinical care in Tugela Ferry is focused at the 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 16 outlying primary health care clinics, and clinical services provided by Philanjalo, forms the backbone of care for the 180,000 traditional and impoverished Zulu people who live in the beautiful Msinga area of KwaZulu Natal, ~3 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 HIV clinic was the first site providing antiretroviral therapy in the public sector in KwaZuluNatal province and has initiated treatment for more than 25,000 adults and children since 2004. The Yale/Stanford Global Health Scholars, representing institutions throughout the U.S., work in the HIV clinic, emergency room (casualty), TB wards, medical wards, OB/Gyn, and pediatric hospital wards. The US Global Health Scholars actively manage all aspects of medical care. Aside from the main hospital wards and the HIV clinic, other opportunities include visiting the Philanjalo adult inpatient unit, the Khayalisha pediatric unit, and the MDR TB treatment program at Greytown TB Hospital (one hour away).

Multiple educational activities are available through the Philanjalo-Yale program on site in Tugela Ferry. Trainees learn through a combination of hands-on clinical work and organized activities. Most generally work on the hospital wards and in the HIV clinic. 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 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 at least one formal talk during their rotation in Tugela Ferry. 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. Educational materials and internet access are available for use and self-directed learning is encouraged.

The Yale-Philanjalo collaboration strives to generate evidence to improve the clinical outcomes of people with or at risk for TB and HIV. To that end, our research interests include: integration of TB and HIV services, using community-based strategies to diagnose and link patients to clinical care, supporting medication adherence and retention in care, integration with noncommunicable disease care, addressing gender disparities in health care, characterizing the impact of alcohol and substance use on TB and HIV outcomes, and implementing preventive services including TB preventive therapy and HIV pre-exposure prophylaxis. Trainees interested in research activities are welcome and encouraged.

Through rigorous 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 and HIV. We regularly contribute to and present at international meetings. We have published a large number of original research studies in the peer reviewed medical literature. The evidence provided by these collaborative efforts has been incorporated into provincial, national and international guidelines and health policies.