An interview with Dr Tichaona Nyamundaya, Senior Technical Advisor Program Coordination at the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) and Catalyzing Pediatric TB Innovations (CaP TB) implementation lead in Zimbabwe
We had the opportunity to speak with Tichaona about his work and find out more about differentiated tuberculosis (TB)/HIV service delivery models for children and families in Zimbabwe.
Can you tell us about the Catalyzing Pediatric TB Innovations (CaP TB) project and your job with this project?
The four-year project (2017-2021) is funded and supported by Unitaid and implemented by EGPAF. The project is aimed at contributing to the reduction in paediatric TB morbidity and mortality in nine sub-Saharan African countries (Cameroon, Côte d’Ivoire, DRC, Kenya, Lesotho, Malawi, Tanzania, Uganda and Zimbabwe) and India. We plan to do this by bringing comprehensive TB care closer to where children interact with the health system. We will introduce a range of innovations, including improved access to child-friendly TB drug formulations for treatment and prevention, new diagnostic technologies that are better able to detect paediatric TB and decentralizing sample collection that can help diagnose children who may not be able to produce sputum.
I lead the implementation of this project in four regions in Zimbabwe with the aim of optimizing the decentralization of paediatric TB care, from screening and preventive treatment initiation at community level, to optimizing treatment regimens for latent TB infection treatment and piloting new preventive treatment regimens for children.
Additionally, Zimbabwe is one of the first countries to have adopted the possibility to use stool as a specimen for childhood TB diagnosis. My aim is to support the Zimbabwe National Tuberculosis Control Programme in defining the optimal procedure to implement this potentially game-changing diagnostic specimen collection.
What role does differentiated service delivery (DSD) play in the CaP TB project?
Regardless of their HIV infection status, children are at higher risk of developing active TB disease compared with the general population due to their immature immune system. Children are also not likely to present to TB clinics as their symptoms may not be the classic symptoms of TB. For that reason, it is critical to ensure integration and decentralization of services to improve paediatric TB care. We have to change the “who”, “what”, “where” and “when” of TB service delivery in order to reach our childhood TB goals and get on the road to TB elimination.
All children below five years of age and children living with HIV should be screened for TB symptoms (cough of any duration, weight loss, fever or night sweats) at every client encounter. As part of CaP TB, we are supporting screening by a range of healthcare workers at every client encounter. Furthermore, we are bringing contact tracing to the household level and we support community health workers to screen children and other family members at home.
TB diagnosis is more difficult in children than in adults. We need differentiated strategies to ensure that children have access to TB diagnosis. For example, children often cannot produce sputum, which is the main way to diagnose TB in adults. For that reason, we need to ensure that healthcare workers are trained and supported to diagnose children in a way that works for children. This includes training healthcare workers to diagnose TB based primarily on clinical signs and symptoms, in addition to X-ray findings, if available. It also means training and supporting healthcare workers to collect sample types, like gastric aspirates, that can be used for diagnosis. In order for children to have access to TB diagnosis wherever they present, we need to decentralize this type of diagnosis and ensure that healthcare workers acquire TB diagnostic skills.
But it is not sufficient to solely improve screening and diagnosis of active TB. In order to significantly reduce the burden of TB in children, we also need to ensure that children receive TB preventive therapy. Under the CaP TB project, we are engaging with the Ministry of Health (MoH) to pilot another form of DSD: community health workers who have been trained to screen for symptoms of TB will dispense TB preventive therapy at community level for children who have no symptoms of TB, with subsequent referral of high-risk and symptomatic children for further evaluation.
How can TB and HIV programmes utilize DSD to reach more families, particularly children, in your setting?
Current TB/HIV service delivery models do not respond to individual child and family needs and expectations. DSD offers an opportunity to improve health outcomes of children and families affected by a range of geographic, economic, demographic and social factors by matching health service delivery to client needs and constraints. We need to integrate TB and HIV services to ensure that we are building a client-centred TB/HIV model. This includes making sure that children have access to TB services where they get their care for HIV. Through implementation of DSD, health service providers will be better equipped to understand the beneficiary’s perceived barriers to TB/HIV screening, testing and treatment.
What do you think is needed to scale up initiatives that are similar to the CaP TB project in your country and the region?
To scale up similar projects, it is important to share novel evidence and work closely with the MoH structures. We developed protocols approved by the institutional review board for scientific documentation and publication of data. These protocols will inform the scale up and normative guidance from the World Health Organization for the innovative interventions to be adapted or customized. This work will be carried out hand in hand with the MoH to best suit the contexts.
What do you want people to know about DSD approaches for TB and HIV in your region?
Differentiated service delivery is a client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of groups of people living with HIV and/or TB while reducing unnecessary burdens on both clients and the health system.
The CaP TB project is funded by Unitaid. For more information on Unitaid, visit https://www.unitaid.org/.
