A participant wears a mask at an event to promote infection prevention control (IPC) in Port Elizabeth, South Africa. The TB South Africa Project (TBSAP) provided strong support for IPC measures at the facility level. Photo credit: TBSAP

In March 2021, the USAID Tuberculosis South Africa Project (TBSAP) concluded a successful five years, rounding out 17 years of continuous technical assistance by URC to reduce the burden of tuberculosis (TB) in South Africa.

TBSAP provided technical support to the National Department of Health (NDOH) and to 14 of the 52 districts in South Africa. TBSAP contributed to a 27% decrease in TB incidence between 2016 and 2020 – from 834 to 615 cases per 100,000 people against an anticipated target of 655 in South Africa’s National Strategic Plan for HIV, TB, and STIs: 2017-2022.

TBSAP supported innovative and micro-targeted technical assistance interventions to reduce TB infections, increase the sustainability of effective TB response systems, and improve care and treatment of vulnerable populations. The project focused on closing gaps in the TB care cascade and find missing TB patients. To ensure sustainability and build local ownership for TBSAP’s work, the project focused on strengthening systems and building capacity of NDOH staff, non-government organizations, Ward-Based Outreach Teams, and the community health workers who will continue these efforts.

TBSAP was preceded by the TASC2 Tuberculosis South Africa Project beginning in 2004 and the TB Program South Africa beginning in 2009.

Key TBSAP achievements

Initiation on TB Treatment: The project drastically improved treatment initiation among people diagnosed with drug-resistant-TB (DR-TB), increasing 66% in 2016 to 93% in 2021. This closed the gap between diagnosis and treatment initiation in this especially at-risk group. Additionally, the project maintained high treatment initiation among people diagnosed with drug-sensitive TB, with rates reaching as high as 95% by the project’s end.

Introduction and Scale-up of Mobile Health Solutions: TBSAP was a leader in the development and implementation of mobile health (mHealth) solutions to improve TB case finding, treatment adherence, and improved outcomes. The use of innovative mHealth tools (such as ConnecTB) helped ensure effective monitoring, treatment support, reduced gaps in  the care cascade, and improved clinical management of TB patients at the community level. For example, the IPConnect suite of applications improves infection prevention control (IPC) in the facility setting, serving as a job aid for health care workers, and provides a facility-based IPC risk assessment tool. The suite of applications is used widely in South Africa: as TBSAP ended, IPConnect was being implemented in 14 districts across six provinces, placing IPC at the forefront of TB management at the facility level.

Improving TB and DR-TB Treatment and Care: The project supported the decentralization of DR-TB treatment sites; rollout of new diagnostics such as GeneXpert with faster results turnaround times; strengthening of communication between laboratories and facilities regarding rifampicin-resistant patients; tracking and tracing of patients lost to follow-up through local non-governmental organizations; and implementation of the Buddy Beat TB package, an educational, empowering, and fun support process for pediatric TB patients.

Institutionalizing Capacity for Continuous Quality Improvement (CQI): TBSAP directly and indirectly supported 1,247 facilities and 475 high-burden facilities with CQI across all of the project’s 14 districts, covering 88 supervisory structures, or clusters. CQI helped the NDOH introduce and roll out new oral treatment regimens, management of serious adverse events, accreditation for project TB training courses, and clinical systems mentorship. By December 2020, CQI coverage in supported districts had reached 100%, with 896 health care workers trained on CQI methodology. As a result of comprehensive CQI implementation, TB screening increased from 69% to 85% across all 14 districts, testing increased from 84% to 95%, and the treatment initiation rate remained above 95% through TBSAP’s implementation.

Scale-up of the FAST Intervention: The NDOH prioritized TB IPC to ensure reduced exposure and risk of TB infection for patients and health care workers. At project inception, major gaps were observed in the implementation and routine reporting on infection control interventions and challenges with timely and consistent screening, testing, and treatment initiation for those diagnosed with TB. TBSAP introduced the Finding cases Actively, Separating safely and Treating (FAST) intervention strategy and scaled it up to 82 sites by the project’s end, improving the implementation and monitoring of IPC practices and TB case finding at the hospital level.

A team at Kgabo Community Health Centre in City of Tshwane Health District, Gauteng, South Africa conducts a chart audit for a patient with drug-resistant TB. The TB South Africa Project (TBSAP) directly and indirectly supported 1,247 facilities and 475 high-burden facilities with technical assistance and direct service delivery support, including continuous quality improvement.

Infection Prevention Remains Relevant under COVID-19

TBSAP’s achievements continued despite enduring a year of the COVID-19 pandemic in South Africa, the country with the highest number of cases on the continent. In the 14 supported districts, the lockdown restrictions in South Africa contributed to a 37% decline in the headcount of patients presenting at facilities and a 31% decline in number of people screened comparing third quarter results in 2019 to the third quarter in 2020. Similar declines – which stand out from any past seasonal variation – have been seen in many other countries.

Despite these limitations, TBSAP’s provided strong support for implementation of IPC measures at the facility level – including capacity building of staff on IPC, IPConnect, and CQI to identify and overcome gaps. The project also conducted facility readiness assessments for COVID-19 and fit testing of respirators for health care workers. This is particularly important in the context of the COVID-19 pandemic, where capacity developed is now supporting South Africa’s ongoing fight against both the pandemic and HIV and TB.