“This has been one of the greatest experiences of my life”
29 July 2019
Rut Hanstveit, a Master’s student of global health, travelled from her home in Norway to Zambia, where she undertook a three-month long “observership” on the TREATS project.
Below, Rut shares her experiences on TREATS; the highlights and the challenges, and why the TREATS approach is so important in ending TB.
“I applied for the observership with Zambart [a research organisation forming part of the TREATS consortium] because I really wanted to see how a TB study is done in a high endemic setting. The aim of the TREATS project is to evaluate the effect of a combined TB and HIV intervention on a large population sample, by recruiting participants from remote locations, screening for both diseases and then offering treatment. The study aims to see if this approach can significantly reduce the prevalence of TB and help to end the disease.
“In my time in Zambia I learned how a TB prevalence study operated both in the field and in the lab. A typical day out in the field would start with me jumping into one of the Zambart cars and setting off to the local sites with the field staff. At the sites, assistants would go out into the communities using a door to door approach, telling people about the study and encouraging them to come and get tested for TB for free.
“Each site includes a tented waiting area for study participants and the OneStopTB clinic truck. The truck is designed to be taken into remote and difficult to reach areas, and is an all-in-one diagnostic, testing and treatment centre, with x-ray facilities and a GeneXpert machine (which is able to test for TB and whether the strain is drug resistant). I was very impressed by the practicality of having these facilities at the sites.
“The delivery of samples from the sites to the lab was more of a challenge because Lusaka has a bit of a traffic problem, which means that transportation by car can take a long time. Samples were therefore delivered to the lab by motorbike, with the temperature measured inside the sample case during the journey.
“Lab days would begin at 9:30am, when the staff started processing the sputum samples which had come in the day before. If any of the screening tests showed a positive result for TB or HIV, the patient was contacted by phone and asked to come to the site camp the next day for further examination by a medical doctor. They would then be referred for treatment.
“I was really impressed by the TB lab and how well it was developed, considering it was inside a shipping-container!
“This has been one of the greatest experiences of my life. During my three months with Zambart, I was met by an excellent, welcoming attitude. I feel very fortunate to have been allowed to observe the good work that TREATS staff are doing at all levels; at stakeholder meetings, at the lab and out at the sites. It was useful for me as a student of global health to see how research is done in action, and to understand how to do research in a more challenging setting, out in the field.
“Despite the challenges in gathering this research in challenging locations and making healthcare available for free, I saw that the TREATS staff are doing excellent and important work to improve health in places where people need it the most. This is an approach which can really improve public health and reduce TB and HIV. Along with more effort to improve living conditions for people in high endemic areas, it can be possible to end these diseases.”
The first TREATS annual review is now available
17 July 2019
The first TREATS annual review 2018 outlines the project’s key achievements so far and initial qualitative findings; building the foundations for a strong research project which will support the global ambition to end TB.
In the first year of the project, the TREATS Study Advisory Group was formed and Community Advisory Boards were established in Zambia and South Africa to provide communities with an active voice in the TREATS project design and help to share its findings.
In Zambia, the enrolment of participants for the infection cohort study – which will follow participants over two years to monitor TB incidence – began in July 2018. The target enrolment was achieved in all eight sites by November, with 4,111 households and 2,655 participants (aged 15-24 years) enrolled. Enrolment in South Africa also started in November, with 1,462 households and 322 participants enrolled.
One key element of the TREATS project is to evaluate the effect of the previous PopART intervention on routine TB case notifications, and on the behaviours and values of individuals, health workers and communities towards TB. The qualitative research performed by TREATS in 2018 has already revealed initial findings: for example, in all of the study sites, TB is now experienced as more manageable than it was in the recent past; and there is little awareness of the impact of TB on mental health.
“It is a unique opportunity to assess an intervention on a massive scale,” says TREATS Project Director Dr Helen Ayles in the review. “The TREATS consortium brings together a fantastic team of some of the best TB researchers and modellers, TB diagnostics companies and communications experts in TB. The study, I am sure, will involve many challenges. But it will also provide amazing data, and hopefully practical solutions to end TB.”
For more information on the first-year achievements and initial findings from TREATS, read the full annual review.
New TREATS building opened in Lusaka, Zambia
16 May 2019
TREATS has been operating at various sites in Zambia, including the Chawama First Level Hospital in Lusaka, which has accommodated the TREATS team since April 2018. Due to increased demand for space at the hospital, a brand new building has opened to house TREATS for the duration of the project.
The new building, commissioned on the 1 March by the District Health Office and Chawama First Level Hospital, is funded by Zambart and will belong to the Ministry of Health when the TREATS project ends.
Dr Mwila, representing Dr Consity Mwale, District Health Director, and Dr Shula, Chawama First Level Hospital Superintendent, attended the opening ceremony. The TREATS project team was represented by Dr Kwame Shanaube, Country Principle Investigator and Dr Modupe Amofa-Sekyi, Study Manager (incidence of infection cohort).
Dr Kwame Shanaube said: “Zambart has had a long standing affiliation with the Ministry of Health since starting out as a small research unit under collaboration between the University of Zambia and the London School of Hygiene and Tropical Medicine.
"In Lusaka district, this relationship is further enhanced by the strong ties we have formed with the District Health Office. Together we have maintained a strong relationship over matters related to public health and the overall wellbeing of our communities.”
In addition to TREATS, Zambart has worked on many successful projects in the area. As early as 2005, the ZAMSTAR study began conducting activities at Chawama hospital, followed by PopART which ran from 2013 until 2018.
Prevalence pilot in Kanyama
22 March 2019
The TB Prevalence survey kicked off with a pilot in Kanyama, from 4 – 8 February 2019. The purpose of this pilot was to ensure readiness for the upcoming intensive diagnostic phase (IDP), which will begin with the Lusaka sites: Chipata and Chawama.
Chali Wapamesa, study coordinator, explains how the pilot went:
“The first day was exhilarating. We began with the setup of the mobile field site, this consisted of building the tents, setting up all required furniture as well as the OneStop mobile clinic. Thereafter, we began preparing to conduct enumeration, unfortunately the rain poured down on us just as we were about to start. Nature taking its course! Nonetheless, we continued and began inviting participants for day one.
“The first few hours of the day were not as busy as we had expected, but to our surprise by the end of the day several participants had visited the mobile field site.
“The second day of the pilot was just as exciting, as we had now settled into our positions and the flow of participants through the mobile field site was smooth and transitioned easily from one tent to the next.”
“Overall, the pilot enumerated 528 individuals, of which 303 (57.9%) were invited and eligible. Over 50 sputum samples were collected and Gene Xpert test for TB were all negative.
“As well as TB screening, HIV counselling and testing, blood collection and non-specific C-reactive protein (CRP) testing were conducted. “The field teams worked hand in hand with each other to make sure that everything went well and that any challenges faced were discussed and addressed accordingly.
“All in all, the pilot was a success and we are ready to kick start the IDP!”
TREATS PhD students from Zambia attend LSHTM
25 February 2019
Two PhD students from Zambia, who are funded as part of the TREATS project, have been in London for a month to attend London School of Hygiene and Tropical Medicine (LSHTM) as part of their studies.
Modupe Amofa-Sekyi and Tila Mainga are studying PhDs in faculties of Infections and Tropical Disease and Public Health and Policy respectively. They have been funded as part of the TREATS project, and are studying the PhDs part time over four years.
Modupe said: “We’ve really enjoyed the opportunity to study at LSHTM. Having access to such great resources would be impossible at home, the classes have been brilliant and it’s nice to meet other students.”
The research they are undertaking for their degrees also contributes to the TREATS project, with Modupe working on the Infection Cohort looking into using blood tests to predict TB disease from infection, and Tila studying the mental health of people with TB.
Tila said: “After completing the PhD I would like to share what I’ve learnt with others in Zambia.”
Modupe and Tila are likely to return to London again as part of their studies, their only complaint was the terrible weather that gave them both colds!
Arrival of the first OneStopTB mobile clinic truck
4 February 2019
The first OneStopTB clinic truck has arrived at Zambart House in Lusaka, Zambia. The truck is an all-in-one diagnostic, testing and treatment centre, designed to be taken into remote and difficult-to-reach areas.
The OneStopTB truck will be used during the TREATS prevalence survey in the eight PopART selected communities to screen and test a total of 32,000 participants for Tuberculosis (TB). During field data collection, the mobile clinic will be stationed in each of the communities for three months.
Jeanette Hedstrom, TREATS Study Administrator, said: “Its arrival immediately drew everyone’s attention and the excitement was palpable at finally receiving the truck.”
The mobile clinic contains a built-in state of the art automated digital x-ray, which provides participants with results within two seconds, as well as a laboratory fitted with a GeneXpert machine, used to detect Mycobacterial Tuberculosis within two hours.
Jeanette added: “Colleagues from Delft, KNCV and HST were all present during the arrival and were just as excited to see the OneStopTB platform mobile clinic.”
A core team has been recruited to undertake the community screenings and tests in the mobile clinic, including: a team leader, radiographer, laboratory technician, data officer and a driver.
The TREATS prevalence survey is now preparing for the arrival of the second OneStopTB clinic truck, which is expected to arrive in Lusaka soon.
TREATS and King’s College London collaboration awarded funding to develop a new TB diagnostic
17 January 2019
Tuberculosis (TB) is the world’s leading infectious disease killer, with 10 million people falling ill with active TB disease every year. A critical part of the End TB Strategy is to not only treat and cure the millions with active TB disease, but also to be able to prevent people from developing active disease in the first place.
An estimated quarter of the world’s population are infected with Mycobacterium tuberculosis (M. tuberculosis), and on average five to 15 percent of those who are infected will develop active TB disease over their lifetime.
If those infected with M. tuberculosis can be identified, they can be given a course of treatment to stop active TB disease ever developing. In 2018, the World Health Organization (WHO) recommended scaling up access to testing and treatment for TB infection, especially among groups who are particularly at risk, such as small children and people living with HIV.
Currently, TB infection is diagnosed by a tuberculin skin test or interferon-gamma release assay. However, these tests cannot predict which people will develop active TB disease. The ability to predict where infection will lead to active disease would be a critical breakthrough in the management of TB infection and a key factor in eliminating TB worldwide.
Through a recent Medical Research Council UK Confidence in Concept Scheme award through King’s Health Partners, in collaboration with King’s College London, the TREATS team will try to address this knowledge gap.
In this proof of concept study, the team will investigate if extracellular vesicles in the blood (sacs released from cells into blood) can differentiate between individuals with M. tuberculosis infection, active TB disease and healthy controls. The ultimate aim is to develop a diagnostic test to identify individuals at risk of progressing from infection to disease. There is currently no valid test for this.
The study will take 12 months and will involve using samples collected as part of the TREATS incidence of infection cohort study in Zambia, as well as some new samples collected from patients who already have active TB disease. There will be approximately 150 participants in the study.
The PI’s of this study are Dr Lily Telisinghe from the London School of Hygiene & Tropical Medicine and Dr Rocio Martinez-Nunez from King’s College London.
The study findings are scheduled to be published in early 2020.
World AIDS Day 2018: Ending the TB/HIV epidemic
30 November 2018
There are 35.3 million people living with HIV in the world, of these one-third are also infected with Mycobacterium Tuberculosis (TB), the bacterium that causes TB disease.
In 2016, 1.7 million people died of TB. For people living with HIV, TB is the most significant co-infection – 40 percent of HIV deaths in 2016 were due to TB. Therefore, it is clear to see that TB and HIV are inextricably intertwined.
Today on World AIDS Day (1 December), we remind ourselves of the origins of our project that recognises this vital relationship between TB and HIV.
The Tuberculosis Reduction through Expanded Anti-retroviral Treatment and Screening for active TB (TREATS) project measures the impact of a household-level combined HIV and TB prevention intervention on the burden of TB at population level in South Africa and Zambia.
It came about as part of the largest ever trial of a combination HIV prevention strategy. This trial, called HPTN071 or Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART), is being conducted across 21 communities in Zambia and South Africa, covering around one million people in total
PopART involved universal testing and treatment (UTT) for HIV through house-to-house visits on an annual basis over four years – from 2014 to 2018. As part of this trial, all members of these communities are also screened for TB.
As Dr Helen Ayles, project director of TREATS explains, this is where TREATS came in:
“The scale of PopART meant that we were testing every member of the population for HIV, as well as screening every member of the population for TB. It was true active case finding.
“Establishing the TREATS project was so important as it allows us, for the very first time, to measure the effect of a combination TB and HIV intervention delivered to the entire population in seven urban, high prevalence communities, and to compare this with seven matched communities that did not receive this intervention.”
The main results from PopART, the effect on reducing new cases of HIV in the population, will be released in March 2019.
Helen added: “For me personally, the TREATS project brings together 20 years of research into a combined strategy – to end both TB and HIV at community level. It is a unique opportunity to assess an intervention on a massive scale. The TREATS consortium brings together a fantastic team of some of the best TB researchers and modellers, TB diagnostics companies and communications experts in TB. The study, I am sure, will involve many challenges. But it will also provide amazing data, and hopefully practical solutions to end TB.”
The TREATS consortium is made up of:
London School of Hygiene & Tropical Medicine
Imperial College London
University of Sheffield
KNCV Tuberculosis Foundation
The Health Systems Trust
International Union Against Tuberculosis and Lung Disease
Delft Imaging Systems
Dr Modupe Amofa-Sekyi, manager of the Incidence of TB Infection Cohort Study for Zambia, reflects on launching TREATS field work
19 September 2018
The Incidence of TB Infection Cohort Study is a key component of the TREATS project. Its aim is to assess the impact of a population level combined TB /HIV intervention on the incidence of infection of TB – in other words, the impact of this intervention on the rate of new TB infections across a community. The TB/HIV intervention, called PopART ran from 2013 to 2017, and involved universal testing and treatment for HIV, plus population level screening for TB, and treatment where needed.
The Incidence of TB Infection Cohort involves the four communities that were part of the PopART intervention and the four communities where standard care was offered during this time. A cohort of 300 young people, aged 15 – 24, will be recruited in each of these communities. Involvement is entirely voluntary. All participants must consent to take part in the study, and if they are under-18, they must also have the consent of their parent or guardian. During the participants’ first visit they are tested for TB infection and offered a rapid HIV test. They will be followed for two years after this initial test, and tested again to see if they become infected with TB during this time.
Through a comparison between the communities that received the PopART intervention, and those that received standard care, this study could help identify methods for reducing the rates of new TB infection.
Additionally, during the recruitment process and throughout the study, those who test positive for TB disease or HIV will be referred to the local health facility where they will be offered treatment and care.
In the field
Recruitment for the Incidence of TB Infection Cohort began on July 12, 2018. We launched with TB awareness-raising and information sessions in each community, to let people know about the TREATS project, its aims and processes. Interested individuals that met the age criteria were then invited to participate in the project. After this initial engagement, TREATS project staff located at the communities’ local clinics welcomed and enrolled the project’s first participants.
The enrolment process involved determining eligibility to take part, receiving formal consent, completing a questionnaire on risk factors for TB and HIV infection, recording height and weight, and collecting sputum samples for testing. Blood samples for TB infection testing were also collected. The participants were also offered HIV testing using rapid tests at per national guidelines, and were given the results immediately after testing. Participants will be informed of their TB test results as soon as they are received from the central laboratory at Zambart House.
Participants were asked to come back for follow up visits after 12 months and then after 24 months. They will also receive contact phone calls between visits at months six and 18. This process will enable us to track rates of new TB infection across a community, and will help us understand more about TB.
Conversations in the community
The TREATS project has been well-received by community members so far. TREATS staff going door-to-door found that most households were interested in the work and supportive of its aims. Parents were keen to let their children participate in the programme, acknowledging the need for new ways to approach preventing and treating the disease. Many expressed their appreciation for the work of Zambart in their community and had not forgotten PopART. Many also recalled the PopART uniforms and were able to relate with the TREATS branding. This provided a good link for TREATS staff to talk about how the two studies were relate to each other.
Most of the community members met by the TREATS team had direct personal experience of TB - either having TB themselves, or living with a family member who currently has TB and is on treatment, or could recall a family member who had died from TB. Many people understood the relationship between HIV and TB, but the majority knew more about HIV than TB. Specifically there were low levels of knowledge about the difference between TB infection and TB disease. In some communities there was also a significant misconception that if a person has TB, they automatically have HIV. There was also some stigma surrounding both TB and HIV.
Recruitment will continue until we achieve our target number of participants. It’s our hope that as we engage the community, we will strengthen our existing relationships which will enable us address some of the misconceptions and information gaps we have discovered - and break down the stigma we have found relating to TB and HIV.
Dr Helen Ayles, project director introduces TREATS - a revolutionary study for TB and HIV testing
23 MARCH 2018
In Zambia, where I have worked for the past 20 years, TB and HIV go hand-in-hand. From 2004 to 2011 I was one of the principal investigators of the ZAMSTAR study where we showed that by working in the community, going into TB patients’ homes and offering a combined package of TB and HIV diagnosis we could make a difference to TB at community level. Our problem was that the trial had borderline significance as we only directly covered about 6 percent of the population.
When we designed the HPTN 071 (PopART) study it was revolutionary. The intervention involved reaching out to the entire population -- visiting all homes in a community to provide a combination HIV prevention package, and linking to universal treatment for individuals living with HIV. With our previous experience in the ZAMSTAR study we could not ignore TB. And so PopART was designed with a community intervention that mirrored ZAMSTAR’s innovations, but modified according to the lessons we had learned. The scale of this intervention meant that we were testing every member of the population for HIV, as well as screening every member of the population for TB. It was true active case finding.
The TB side of the intervention was not popular with everyone. Many of the study team were much more familiar with working in HIV and so found the TB element of the study difficult to grasp. Our Community HIV Care Providers (CHiPs) also struggled as they were wholeheartedly focused on HIV --collecting sputum proved to be a new challenge. However we managed to win everyone round.
The TREATS project is so important as it will allow us, for the very first time, to measure the effect of a combination TB and HIV intervention delivered to the entire population in seven urban, high prevalence communities, and to compare this with seven matched communities that did not receive this intervention. It also allows us to measure several endpoints including: the incidence of TB infection in young people; the prevalence of active TB; TB notification and TB disease incidence in a random cohort of 18-44-year-olds. TREATS enable us to bring all this data together in order to understand the epidemiology of TB better.
Working in the field of TB is challenging. Our tools for diagnosing TB infection are limited -- this has hampered our understanding of the population dynamics of TB. And the tools necessary for large scale surveys, such as prevalence surveys, are expensive and difficult to use in this setting. The TREATS project will allow us to use the newest available tools to maximise additional scientific value. TB is also a feared and stigmatised disease. A social science component built into the TREATS project will help us understand what worked well and what worked less well in the intervention, and ultimately to better understand stigma related to TB. This will enable us to design better TB services for the future. Mathematical and economic modelling will provide generalisable answers for how we can most effectively undertake these large scale interventions in the future.
For me personally, the TREATS project brings together 20 years of research into a combined strategy -- to end both TB and HIV at community level. It is a unique opportunity to assess an intervention on a massive scale. The TREATS consortium brings together a fantastic team of some of the best TB researchers and modellers, TB diagnostics companies and communications experts in TB. The study, I am sure, will involve many challenges. But it will also provide amazing data, and hopefully practical solutions to end TB.