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(1) What research and best practices inform this strategy?

(a) It is informed by the United Nations Programme on HIV and AIDS (UNAIDS) global ’90-90-90’ fast-track strategy, aimed at bringing about an HIV free generation by 2030 (UNAIDS, 2014). It has been adapted in the South African context to include Tuberculosis (TB). The Western Cape Province has committed to drive the implementation of the 90-90-90 strategy with the aim of achieving its key indicators, set out below:

Table 1:  HIV and TB 90 90 90 strategy

(b) in what ways will this be tailored for the context of the Western Cape?

The Western Cape Department of Health has adopted a systems approach of providing an integrated health service to reduce all conditions that are contributing significantly to the burden of disease in the province, aligned to the Western Cape Healthcare 2030 (PDoH, 2013) strategy for health service re-orientation.

Strategic Alignment to the Provincial Strategic Plan (2019-2024)

The Western Cape Government Provincial Strategic Plan (2019-2024), provides a strong basis for intersectoral and citizen-centric work, with the Whole of Society Approach (WoSA) as a key principle. The plan also recommends the Life Course Approach, which proposes segmenting interventions across a persons life course, based on the various key stages of life. This further aligns to Universal healthcare Coverage where the population is assured access to health care.

The Service Transformation Strategy is underpinned by:

Community-Oriented Primary Care (COPC)

Community-Oriented Primary Care is a continuous process by which health care is provided to a defined community on the basis of its assessed health needs through the planned integration of public health practice with the delivery of primary care services.  The Western Cape Department of Health is currently implementing COPC learning sites in the metro and rural areas. This approach emphasizes the need to co-create with community structures and stakeholders to improve the social determinants of health, and thus the health outcomes of the population.

The Western Cape has also adopted the National Strategic Plan on HIV, STIs and TB 2017-2022; The aim with this inclusive strategy is that all priority services must be managed.

(c) when will the strategy be launch officially and (d) what are the proposed milestones for its achievements; 

The 90-90-90 Strategy was originally launched in December 2014, and its target for completion was set for December 2020. Amidst the emergence of COVID-19 and due to its prioritized focus there has been a significant decrease in patients accessing HIV and TB services within the province and thus a decrease in the data was noted. In light of this, the National Department of Health with the support of UNAIDS, has thus extended the achievement of these targets to December 2021.

The Western Cape Province, in response, has developed new catch up plans for HIV and TB as part of our ramped-up efforts to address the TB epidemic, and to ensure that this province reaches our 90-90-90 goals. This has further been filtered in both Metro and Rural Health Services, reintroduction of Primary Health Care (PHC) services plans.

(2) Whether the Province will use its own resources to deliver medication to those TB patients in vulnerable groups; if so, what are the relevant details;

The Province has internally funded NPOs, who are contracted to support the Department of Health in community related activities by providing trained and skilled Community Health Workers (CHW). These CHW’s are a part of the Department’s Community Based Services component. Their function is to track and trace within the community, undertake home visits, to support the client and their families and to deliver medications within a controlled and supervised process. Their responsibilities are vast and their significance within the health services structure is greatly noted.

We are currently assessing the possibility of extending the delivery of medications, as we did during Covid-19, to TB patients.

The department currently facilitates medication pick-ups at central points within communities, in secured venues ie. Halls, religious places. These Differentiated Models of Care, not only provides a means for decongesting facilities and cost efficiencies but rather aims to provide patients with agency to choose the best option of accessing care and medication, be it in the facility, community or via a private entity, so that patients are able to continue taking their treatment.

Externally funded partners (USAID, CDC, Bill and Melinda Gates Foundation, Medecins Sans Frontieres) have been imperative in supporting the Department of Health in the home delivery projects and innovations in differentiated Models of Care.

(3) (a) What additional support will drug-sensitive TB patients receive

The current key focus for Tuberculosis:

• Re-introduce TB services in PHC facilities and hospitals - considering the second wave of COVID-19
• Enhancing TB services in the Community

The emphasis for Tuberculosis is: Prevention, testing, treatment and adherence within a comprehensive, integrated model.

• TB included in standard HIV and chronic care management, Integrated Clinical Stationery, PACK guidelines, standard training
• Including TB screening in the COVID-19 screening tool– approved by both Metro and Rural Health services
• All clients to be screened for TB and symptomatic clients tested at health facilities
• Dual COVID 19 and TB screening of symptomatic clients
• Dual testing of COVID 19 and TB symptomatic testing – with nasopharyngeal swabs for COVID 19 antigen / PCR tests and sputum for TB GeneXpert
• Strengthen Community screening for TB by CHWs
• Household contact tracing for TB by CHWs
• Continuous analysis of baseline data at community, facility, district and provincial level and feedback to hotspot areas.
• Behaviour change communication campaign using leaflets, digital platforms, radio
• Continuous Monitoring & evaluation
• Finding the TB missing cases (TB Room Nurse), by utilizing the NHLS TB results, check PHCIS TB data system and recall clients not commenced on treatment.
• Improved safety net for patients with other comorbidities [weekly visits by Community Based Services (CBS) Professional Nurse (PN)] 
• Best practices of COVID-19 home medicine delivery project can be expanded to TB

(b) How many of those patients have been identified in the Western Cape and (c) what proportion does represent of the total number of TB patients in the province? 

Tuberculosis data presentation is attached for further perusal at Annexure A