A New Approach to Detecting TB Cases among People Living with HIV in Malawi

MARCH 2009 — Malawi is a prime candidate for intensified (or proactive) TB case-finding among people living with HIV, since the country's rate of TB case detection is low, at 46 percent and HIV prevalence is high, at 12 percent. HIV/TB co-infection is a serious problem in Malawi and other countries in sub-Saharan Africa, where TB ranks as a leading cause of death among people living with HIV.

Family Health International is working to increase intensified TB case-finding in Malawi's Mangochi and Zomba districts through the USAID-funded TB CAP project, developing a questionnaire that contributes to TB screening and engaging volunteers in carefully recorded sputum collection and in referrals to diagnosis and treatment. Many of these volunteers are themselves living with HIV or are former TB patients.

A questionnaire, sputum-collection points, and referrals
FHI developed a short and simple questionnaire and trained volunteers from four community-based organizations to use them during monthly peer-support meetings for people living with HIV and with household contacts of TB patients receiving home-based care.

Respondents are asked whether they have experienced weight loss, chronic coughing, fever or night sweats, fatigue and tiredness, loss of appetite, or lymph-node enlargement. People whose answers suggest they may have TB are then referred to health facilities for diagnosis and treatment or are advised to go to sputum-collection points to submit specimens. They no longer need to travel a long distance to do this, since sputum-collection points are now conveniently located in rural communities.

Potential TB patients who go to the collection points are met by volunteers who record their names and give them small cups into which to deposit the samples they cough up. The cups are inscribed with names or identifying numbers and taken by the volunteers to the nearest community health center with TB microscopy.

FHI has assisted this part of the process by procuring 60 bicycles that the volunteers use for transporting the specimens. This ensures that those referred to sputum collection receive their results quickly and those with active TB disease begin treatment as soon as possible.
"We are empowering individuals with knowledge of TB symptoms and signs to self-refer to health facilities if they feel they have developed TB. We are also screening people living with HIV for TB using a simple questionnaire during peer support meetings within their communities," says McPherson Gondwe, FHI Senior Technical Officer. "This has increased the number of TB cases detected early and started on treatment."

Results
Between January and December 2008, FHI trained 247 volunteers in TB control. A total of 1,717 people living with HIV were screened for TB; of these 97 (6 percent) were detected with smear-positive TB and started on TB treatment. A total of 1,385 TB suspects submitted specimens to sputum-collection points; of these, 245 cases of smear-positive TB were detected, 243 people were put on treatment, and two died before starting treatment.

 "I am proud of the increasing number of TB cases getting detected and started on TB treatment, and I'm proud of the number of people accessing HIV testing and counseling services and numbers being started on ART," Gondwe says. "These people may either have presented late to health facilities or simply may have died without accessing TB or HIV diagnosis and treatment."

PHOTO:  (Top) Trained volunteers packs sputum specimens for transport via bicycle from community collection points to healthcare centers. (Bottom) More than 15,000 people have been reached through 29 TB CAP "open days" such as this one held last year in Mankanjira, Managochi District. (FHI/Malawi)

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