GF Jooste Hospital is a secondary level district hospital in the Cape Metro that takes on complex cases referred to the hospital by primary healthcare facilities.

Anova supports four of GF Jooste’s HIV programmes, namely: the Infectious Diseases Referral Unit, the TB Discharge Unit, the HIV Counselling and Testing Unit and the HIV Neurology Clinic.

ART

The Infectious Diseases Referral Unit (IDRU) at Jooste Hospital was established in August 2004 and continues to provide a vital service to local primary care clinics, and to the Department of Medicine located within the hospital. Anova funds three of the five medical officers within the unit, and provides infrastructure support.

The referral unit runs a rapid access clinic, which is open every working day. The clinic supports nine local antiretroviral clinics and 16 local TB clinics, and is the main focus of care for complicated HIV/TB patients in the local health sub-district. Jooste Hospital serves the areas of Cape Town with the highest HIV and TB prevalence locally, and a readily accessible specialist service means that primary care clinics are able to refer patients early in the course of their disease. In addition, telephone advice is readily available from experienced doctors in the referral unit, and primary care staff are encouraged to make use of this service.

The IDRU is a problem-based service, which provides outpatient investigation and management of complex clinical problems. Jooste Hospital is unique amongst local secondary level hospitals in the range of onsite diagnostic services, which enable extensive and rapid investigation. The radiology department has X-ray services, ultrasound scanning and a CT scanner staffed by two consultant radiologists. The onsite laboratory performs haematological and biochemical tests, and has a rapid turnaround time, meaning that results are obtained while patients are still present in the clinic, thereby minimising time to definitive diagnosis and management. The referral unit aims to investigate and treat patients as outpatients, thereby reducing emergency department visits and hospital admissions. It is also a popular service with patients, where the alternative of a prolonged hospital stay causes many social and economic problems.

Over the years specific expertise has been developed in several areas. These include:

• Drug-induced hepatitis, which is a common adverse effect of TB drugs and several antiretroviral drugs, particularly in severely immuno-suppressed HIV patients. The IDRU is the only service locally that is experienced in outpatient management and drugs rechallenge. Inpatient care involves hospital admissions of 14-21 days. Patients who are ill enough to require initial admission can therefore be discharged early from hospital, while those with milder degrees of hepatitis are referred directly from primary care to IDRU.
• HIV renal disease: We continue to see and investigate many patients with renal impairment, and have excellent links with the local tertiary renal unit, enabling ready access for renal biopsy. There is a severe shortage of renal replacement therapy in the state sector, meaning it is vital to investigate and manage patients with renal disease early in its course, and slow or reverse progression to end-stage renal failure.
• Immune reconstitution inflammatory syndrome (IRIS): As many patients locally are still starting HAART with low CD4 count nadirs, IRIS continues to be common. The IDRU has considerable clinical experience in investigating and treating patients with suspected IRIS due to the work of Dr Graeme Meintjes.
• Patients deteriorating or not improving on TB treatment: This continues to be a common reason for referral, with patients needing extensive investigation, including review of the initial TB diagnosis, consideration of drug resistance, and investigation for additional opportunistic infections.
• HIV neurological disease: Neurological complications are very common with HIV infections, and the cause of considerable mortality and permanent disability. A doctor with extensive experience in neurology provides clinical support to the IDRU.
• HIV neuropsychiatry: A psychiatry registrar (funded by a PEPFAR grant to the Department of Psychiatry at Groote Schuur Hospital) attends the IDRU on a part-time basis. Psychiatric problems may be caused by HIV infection, or be unrelated and cause problems with adherence to HAART and other medical treatment. Patients can be directly referred to this service by local clinics, and the medical wards.

HCT

The GF Jooste VCT Unit was established in October 2008 and provides opt-out HIV testing based on the ACTS (Advise, Consent, Test, Support) model that significantly decreases the time required for HIV testing.

Counsellors and nurses identify patients requiring an HIV test through bed-to-bed folder checks (in patient areas) and group counselling of outpatients. This form of “provider-initiated” HIV testing broadens the cover of HCT to patients where the reason for admission or consultation is not directly HIV related. Prior to the inception of the programme, HCT was offered only to those patients suspected of having HIV. This expanded method means more patients at risk of contracting HIV are tested and consulted.

The unit targets at-risk patients by focusing its attention on the termination of pregnancy clinics, hospital wards and casualty areas. The HCT Unit also uses rapid HIV tests to ensure that results are available within 15 minutes to one hour. This is a significant improvement as previously, results were rarely available on the day of testing. In addition, bloods for CD4 tests are taken on the same day as testing. Blood specimens are sent to an off-site lab for processing. In addition to expanding the reach of HCT in the hospital, the HCT Unit provides patient follow up. As Jooste is a secondary level facility, HIV-positive patients are down-referred to primary clinics for HIV care. Before the creation of the HCT Unit, no follow up of HIV-positive patients was done. The HCT Unit now ensures CD4 tests for all positive patients are done and performs follow-up patient calls to improve arrival rates at ART clinics for those with CD4 counts below 200. Clinic calls are also made to check on patient arrival.

Over the past year, the VCT Unit has achieved outstanding results, with dramatic increases in the number of patients testing for HIV.

TB

TB is usually treated in out-patient, primary care settings, such as clinics. As GF Jooste Hospital is a secondary level facility, patients who are diagnosed at the hospital are referred to their local TB clinic for ongoing treatment. But few patients actually present to their referred clinic or follow the prescribed treatment regimen. Previously at GF Jooste, a register was kept with referrals and notifications, but the system relied solely on already overburdened doctors to fill out the referral forms and return them. As a result of incomplete or missing registers, most TB patients were missed because treatment in clinics could only be initiated with a complete doctor’s referral. This also meant that many cases were simply never recorded. Over a three-month period in 2008, only 13 TB patients were noted, painting a picture that was a far cry from the reality, in a hospital where the majority of the 90 patients in the medical wards each day are TB patients.

Thus, in 2008 when a mortality study showed that 80 percent of HIV-positive patients who died at the hospital had never accessed life-saving ART, and that TB was the leading cause of death in these HIV-positive patients, GF Jooste’s TB Discharge Unit was established. The TB Discharge Unit was thus established to improve TB referral and treatment.

Further investigation showed that amongst the main reasons TB goes unaddressed in HIV-positive patients are the high disease burden, the lack of hospital beds and the low knowledge levels amongst patients. Often these patients are discharged or transferred to other facilities without any concept of what TB means or what the treatment entails.

The TB Discharge Unit aims to educate each patient diagnosed with, or strongly suspected to have, TB before they leave the hospital. Three lay counsellors have been trained extensively to perform active TB case finding, TB education, and to make referrals to clinics. They form a self-managing service, and are now providing TB education training to other counsellors at other facilities, including Groote Schuur. Education occurs in a PEPFAR-funded training facility, or by the bedside if patients are too ill to attend the sessions. Patients are educated about the germ theory of disease, risk factors for TB infection, as well as how to prevent TB, its symptoms, treatment and side-effects, managing HIV and TB co-infection, good nutrition, and the risks of MDR and XDR TB. The service includes VCT and CD4 counts to people who have not tested for HIV or people who have not accessed HIV care. The patient’s understanding is assessed at the end of the counselling session and given adherence aids and information leaflets and is again briefly re-counselled before discharge to make sure they understand the treatment regimen and plan to attend their local clinic.

Most importantly, thanks to the Unit, patients now understand what TB is, and are educated and supported while they are in the hospital. Counsellors speak to patients in their home language and also interview them extensively to ensure they get support for risk factors that could cause them to default on treatment.

By linking discharged patients to clinic care, this new system has also improved the arrival rates of patients at clinics. Previously, only 44 percent of patients arrived at clinics for further TB treatment after they had been discharged from hospital. A year after the TB Unit was established, an average of 81 percent of patients arrived at TB clinics after follow-up calls. A further 10 percent of patients were traced and had either passed away, been readmitted, or moved.  This meant that only nine percent of patients were in need of follow-up by DOTS supporters at the clinics.  

While the Unit was founded by a part-time manager, professional nurse, and three counsellors, it is now transitioning to a counsellor-run service supported by infectious disease consultants. By educating the counselling staff about programme management, data capture and computer skills, the counsellors are able to share management responsibilities for the unit, making it a sustainable approach.

The counsellors are all members of a discharge improvement team that is improving patient flow at Jooste and coordinating the discharge of patients. Patients are now being referred regularly by doctors for discharge counselling before they leave hospital.

Earlier this year, the unit hosted visitors from the provincial TB Directorate who were interested in observing the service and wished to replicate it in other provincial hospitals. 

HIV and Mental Health

HIV-infected patients commonly present with neurological problems that may be complicated and difficult to manage. They are particularly vulnerable and in need of special care due to confusion, as they are frequently unable to provide an adequate medical history or co-operate during examination. Assessment therefore requires considerable time – which is usually not possible in a busy clinic. Neurological problems lead to a series of other issues, especially when patients lack social support. This may include failed adherence to treatment and failing to keep future appointments. Patients also often do not benefit from available grants because they are too confused to manage the application.

The HIV neurology clinic attempts to address these problems. Within this dedicated neurology service, patients are now assessed thoroughly by a dedicated doctor experienced in neurological disorders. Appropriate investigations are performed and treatment is started without delay. The unique referral system that has been established between the Infections Diseases Referral Unit at GF Jooste and the neurology department at Groote Schuur Hospital allows for rapid further assessment of patients requiring tertiary care. As a result, many patients who might have been misdiagnosed or inadequately managed are now receiving optimal care.

The neurology clinic also runs a dedicated tuberculosis meningitis (TBM) service for HIV-infected patients that ensures that patients are started on ART at the appropriate time.