ICMM Good Practice On HIV-TB-Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria
Contents
Foreword 1 1.1 1.2 1.3 1.4 1.5 3 3.1 3.2 3.3 4 4.1 4.2 4.3 4.4 5 5.1 5.2 5.3 5.4 5.5
2 THE MANAGEMENT PLAN PROCESS 2.1 Overview STEP 1: SCREENING STEP 2: SCOPING STEP 3: SITUATION ANALYSIS STEP 4: STAKEHOLDER ANALYSIS STEP 5: POLICY, PRIORITY, GOAL AND OBJECTIVE SETTING STEP 6: OPTION APPRAISAL STEP 7: PROGRAM DESIGN, BUDGETING AND REPORTING STEP 8: PROGRAM IMPLEMENTATION STEP 9: MONITORING AND EVALUATION 2.2 Roles and responsibilities 2.3 Improving implementation HIV/AIDS PROGRAMS Overview Prevention Treatment and care Program planning and implementation TB PROGRAMS Overview Prevention TB detection Treatment and care Program planning and implementation
INTRODUCTION Why the guidance? How to use the guidance Overview of the diseases Impact of mining on the spread of disease The business case for managing the three diseases
INTEGRATED MANAGEMENT OF HIV/AIDS, TB AND MALARIA Overview Dual linkages Integrated control
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6 6.1 6.2 6.3 6.4
MALARIA PROGRAMS Overview Prevention Treatment and care Program planning and implementation ANNEX A: Supporting Information
ANNEX B: Roles and Responsibilities
ANNEX C: Project Phases and Associated Program Tasks ANNEX D: Acronyms/Abbreviations and Glossary ANNEX E: References and Useful Resources
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Foreword
As well as having potentially devastating human and community costs, the cost of HIV/AIDS, tuberculosis and malaria can be significant for a mining and metals company. Data on direct and indirect benefits suggest that preventative and treatment measures, although incurring an additional cost, have important bottomline benefits. These include increased productivity, decreased overall costs of health care, lower rates of employee turnover, reduced employer liability, improved employee morale and increased access to funding for development. In addition, these three diseases are highly topical and attract media attention, which, if negative, can damage a companys reputation. The positive publicity from good health programs and securing the social licence to operate far outweigh their costs. This guidance provides a systematic management process that determines the level of intervention required for HIV/AIDS, TB and malaria, culminating, where appropriate, in the implementation of a health program with associated monitoring and evaluation. In all cases it is clear that the context within which the project or company is operating is vitally important in determining the program to be followed, and that the commitment of management to the program is key to its success. Specialist input is a crucial element in the risk assessment process and also in the design and evaluation of a program. Each disease has uniquely different prevention, treatment and control mechanisms, as described in the guidelines. The programs have the following main elements: HIV/AIDS programs consist of reaching out to employees and communities, counselling and testing, prevention and treatment, creation of an enabling environment free of stigma and adherence to the key International Labour Organization principles. TB programs encompass different types of intervention to control transmission and improve health, such as active and passive screening and testing, 'directly observed therapy, short course', and links with HIV programs. Integrated control of malaria consists of providing vector and environmental management (primary control), reducing individual risk (secondary control), and limiting the adverse effect of infections (tertiary control).
It is accepted that these three diseases are, globally, the major causes of communicable diseaserelated mortality. Integrating their management is supported by recent evidence that suggests a strong association between all three, with HIV/AIDS and TB programs already being managed together in many cases. Inmigration to the project area and the accompanying crowded informal housing, exposure of workers to dust that contains silica, an increase in working-age single men and commercial sex workers (with the associated risk of HIV infection) and a marked increase in the breeding places for malaria vectors as a result of human activities and environmental disruption can be contributing factors to the spread of the diseases. The mining and metals industry can play a key role in tackling these diseases for their employees, contractors and service providers, as well as extending the benefits to the surrounding communities. A direct link exists between a mines employees/contractors and the outside community due to, for example, shared living arrangements, social intercourse and the movement of malaria mosquito vectors across boundaries. In order to effectively manage these diseases, a partnership with communities and other organizations with similar goals is necessary and will significantly increase the scale and impact of any management program.
Experience has demonstrated that sustained effort on many levels and through many channels is necessary to bring about the social and behavioural change that will result in the long-term sustainability of health programs. Mining and metals projects have a finite life, and company interventions are likely to diminish when an operation closes, emphasizing the important role that partnerships have in determining the long-term improvement in quality of life. We refer the reader to ICMM's Planning for Integrated Mine Closure for tools that will assist the manager in designing activities to enhance sustainability post-closure. Strong corporate leadership is necessary, with a willingness to recognize the value of the health programs to the achievement of the companys business values. John Groom Chief Operating Officer ICMM
SECTION 1:
Introduction
Section 1. Introduction
1 1.1 WHY THE GUIDANCE? INTRODUCTION
1.2 HOW TO USE THE GUIDANCE
1.3 OVERVIEW OF THE DISEASES HIV/AIDS Tuberculosis Malaria
1.4 IMPACT OF MINING ON THE SPREAD OF DISEASE Abbreviations used ACT artemisinin combination therapy AIDS acquired immune deficiency syndrome DOTS directly observed therapy, short course ELISA enzyme-linked immunosorbent assay GRI Global Reporting Initiative HIV human immunodeficiency virus ICMM International Council on Mining and Metals TB tuberculosis
1.5 THE BUSINESS CASE FOR MANAGING THE THREE DISEASES Overview Within the Workforce Community Programs
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1.1 WHY THE GUIDANCE? Globally, HIV/AIDS, tuberculosis and malaria are major causes of communicable diseaserelated mortality and disability. While the link between TB and HIV/AIDS is well known, recent evidence suggests that there is a strong association among all three diseases, with people infected with HIV being more susceptible to malaria and with malaria increasing the concentration of HIV in the blood by up to sevenfold. Combined, therefore, the impact of these three diseases can be severe. In the context of the significant exposure of the mining and metals industry to HIV/AIDS, TB and malaria, and in light of the association between these three diseases, the International Council on Mining and Metals has developed good practice guidance on the management of the three diseases within the workplace and the communities where its members operate. Specifically, this guidance seeks to improve competencies to manage the three diseases at an operational level and to encourage an integrated approach to addressing the impact of the three diseases. HIV/AIDS 1.3 OVERVIEW OF THE DISEASES This section provides a summary of the more detailed information on each of the diseases that is provided in Sections 4, 5 and 6. Stages of the Disease: HIV infection can generally be broken down into the four distinct stages. (See Table 1.1.) 1.2 HOW TO USE THE GUIDANCE The guidance should be used as a practical and accessible tool in the management of HIV/AIDS, TB and malaria throughout the lifecycle of a project. It is designed to enable a projects staff (e.g., mine managers) to ask the right questions in order to guide effective health interventions and to seek appropriate technical expertise where necessary. Spread of the Disease: The virus is transmitted when blood, semen or bodily fluids are exchanged, for example, through unprotected sexual intercourse, through the sharing of needles during intravenous drug use, from contaminated blood during a blood transfusion, or from an infected mother to her child during labour or breastfeeding.
AIDS is caused by infection with the human immunodeficiency virus. HIV targets and infects immune system cells (CD4 cells) that normally provide protection against illness. As the virus replicates itself, it damages or kills the CD4 cells, thus weakening the immune system.
Table 1.1: Stage 3 1 4 2
Signs of the Disease: The signs of HIV/AIDS change as the disease progresses through its different stages. Only an HIV test can determine that a person is infected. The most common test for HIV is the antibody test called ELISA, considered to be more than 99% accurate. A negative result should be confirmed with a second test three to six months after the last possible exposure to HIV, as the immune system can take 3 to 12 weeks to develop antibodies. False negatives are possible during this window period. Treatment of the Disease: There is currently no cure for HIV. However, antiretroviral drugs, which suppress the virus, are used in its treatment. Anti-retroviral therapy is only started once Stage 3 or 4 of the disease is reached. TB is an infectious disease caused by a bacterium or bacillus known as Mycobacterium tuberculosis. Spread of the Disease: TB is usually spread when people with active lung disease (open disease) cough, producing tiny droplets that carry the bacilli into the surroundings to be inhaled by others. TUBERCULOSIS Stages of the Disease: The establishment of bacilli in the lungs does not necessarily mean that the infected person will go on to suffer active disease. If the person is otherwise healthy, the bacilli may be sealed off in small numbers and remain dormant. People with latent TB infection are not infectious.
Name of Stage Clinically asymptomatic infection Symptomatic HIV infection AIDS
Primary infection
Four Stages of HIV Infection
Description
Stage 1 lasts for a few weeks, often accompanied by a short flu-like illness. A person is highly infectious during this stage. Stage 2 lasts for an average of 10 years and is free from major symptoms, although there may be swollen glands. Stage 3 sees the development of major symptoms as, over time, the immune system becomes severely damaged by HIV. At first there are mild symptoms, but these worsen as the immune system deteriorates. TB may be reactivated and malaria infection may become more severe. Stage 4 brings the onset of opportunistic infections and the potential for cancer to become increasingly severe, leading to the diagnosis of AIDS. Untreated, AIDS invariably results in death within two years.
Healthy people with latent infection have a 10% chance of suffering active TB over their lifetime, the risk being highest in the first two years after infection and in instances where the infected person already has some damage to the lungs or to the immune system. People infected with both TB and HIV have a 10% annual risk of developing active TB. Signs of Active Disease: The classic symptoms of active TB in the lung are chronic cough, weight loss and night fevers with heavy sweating. Nonetheless, people may become infectious before showing or complaining of symptoms. People with undetected TB are a major source of infection for others. HIV infection complicates matters because people with both TB and HIV infection may not show the typical signs of TB. Although most TB affects the lungs (pulmonary TB), TB can infect many other parts of the body (extra-pulmonary TB), particularly in individuals who are coinfected with HIV. Although most people can be cured of their active TB with appropriate treatment, silicosis and HIV infection greatly increase the risk of recurrent tuberculosis, which may produce cumulative lung damage and result in work incapacity. Depending on the stage of HIV-immune compromise, the virus increases the risk of other opportunistic infections and results in a poor outcome for TB treatment. MALARIA Malaria is found mainly in the tropics but can also occur further north and south on the Asian, African and American continents, putting nearly half the worlds population at risk from the disease. Treatment of the Disease: TB is a treatable disease. In people being treated for the first time, the recommended regimen is six months of anti-TB drugs given under direct supervision (known as directly observed therapy, short course, or DOTS). Of increasing concern worldwide is multiple drug-resistant TB (i.e., resistance to two or more of the front-line drugs) and extensively drug-resistant TB (i.e., resistance to second-line drugs).
Malaria is an infectious disease that is caused by the Plasmodium parasite. There are four different species of malaria parasite that cause disease in humans: P. falciparum (which causes severe cerebral malaria), P. vivax, P. malariae and P. ovale.
Active disease in adults can result from the reactivation of latent infection or infection with a new strain of TB (re-infection). Factors that increase the risk of TB in working adults include silica inhalation and silicosis, tobacco smoking and HIV infection.
Spread of the Disease: The parasite is only transmitted by the female Anopheles mosquito, termed the vector of malaria. When the female Anopheles first emerges she is uninfected; it is only when she bites an infected human that she herself can become infected with the malaria parasite. A human is then infected with the parasite when bitten by a female Anopheles mosquito that has infective parasites residing in her salivary glands.
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Signs of the Disease: Signs and symptoms of malaria are non-specific and flu-like, with fevers, muscle aches and pains, tiredness and fatigue, gastrointestinal symptoms and headaches. Diagnosis and Treatment of the Disease: Diagnosis uses a combination of tests including rapid diagnostic tests similar to a home pregnancy test, as well as a blood smear that is examined under a microscope for parasite-infected red blood cells. Treatments typically use a short-acting drug based on a Chinese plant (Artemisia annua) combined with a long-acting drug in a combination therapy called ACT (artemisinin combination therapy). ACT is considered the most effective treatment for all forms of uncomplicated malaria. Non-immune staff can be provided with emergency standby treatment packs that contain ACT in the event that they develop a fever or any other suggestive symptoms and cannot obtain adequate medical diagnosis and care within 12 hours. 1.5 THE BUSINESS CASE FOR MANAGING THE THREE DISEASES 1.4 IMPACT OF MINING ON THE SPREAD OF DISEASE The mining industry can play a key role in tackling these three diseases. However, mining can result in significant in-migration to the project area, with the resultant development of informal housing and/or overcrowding (key factors in the spread of TB); exposure of workers to dust that contains silica (in the case of TB); an increase in working-age single men and commercial sex workers and associated risk of HIV infection; and a marked increase of breeding places for malaria vectors as a result of increased human activities and environmental disruption. While addressing these diseases in the workplace secures key business benefits, there are also strong arguments for widening the net of health care to include the communities surrounding mining projects.
Overview Responsible companies recognise that their activities have the potential to impact on the health of the communities in which they operate and vice versa and that they have an obligation to manage the potential impacts effectively. Employee and community health care programs are therefore often prominent in corporate social investment portfolios of progressive companies. However, while also being the right thing to do, a proactive approach to the management of these diseases can have a direct positive impact on the financial performance of the company. Significant quantitative and qualitative data suggest that companies working to address HIV/AIDS, TB and malaria in the workplace experience a variety of direct and indirect bottom-line benefits through preventive and treatment measures. These benefits include the following: Lower rates of employee turnover Reduced employer liability Improved profitability due to increased productivity and decreased costs of health care A workforce diversity reflecting a range of age groups, sexes, talents and skills Improved employee morale Access to international funding for mine development Company reputation and secured social licence to operate.
Programs should thus aim to address the three diseases both internally, thus protecting the workforce, and externally, managing the disease in the communities that are the source of labour or are affected by the project. External programs should be done in partnership with other key stakeholders. Within the Workforce There are varying estimates of the loss of productivity and profitability to the global economy each year owing to sickness and associated absence in the workforce. In 2003, Business for Social Responsibility noted that: Production lines, management structures and cohesion in the workplace are also directly undermined by increased absenteeism from sickness, caring for ill family members and preparing for and attending funerals. Greater staff turnover leads to knowledge and skill loss among employees. The costs of staff turnover are predicted to be as high as half a year to one year's pay for each person needing replacement in some countries (Business for Social Responsibility, 2003). There are also the immeasurable costs resulting from the loss of tacit knowledge and organizational memory. Lower morale due to illness and loss of co-workers threatens the stable environment needed to sustain mining projects. Some of these negative aspects can be mitigated by good health programs.
TB reportedly leads to a decline in worker productivity in the order of $12 billion annually, and it has been reported by International SOS, that each uncomplicated episode of malaria results in an estimated average two to five days of sick leave for semi-immune workers and more among those suffering from chronic health effects from repeated malaria infections. Furthermore, there are an estimated 30,000 malaria cases annually in travellers and expatriates, with the average cost per medical evacuation for a case of severe malaria being $50,000 (International SOS 2007).
While estimates may vary, what is certain is that with increased numbers of employees falling sick due to HIV/AIDS, TB or malaria, companies are faced with rising costs of health insurance, health care, sick leave/absenteeism and funeral benefits. They also have to bear the costs of recruiting and training new staff. The widespread nature of HIV, in particular, can threaten economic prosperity by putting national economies at risk, deterring investment and decreasing output for foreign exchange. Projects in malaria areas can suffer a loss of productivity through an inability to recruit skilled expatriate labour owing to the perceived health risks, as well as profitability through the costs of medical evacuations.
Photo courtesy BHP Billiton
some US companies have estimated costs between $3,500 and $6,000 per year for each worker with HIV/AIDS studies of South African firms indicate that cost savings due to investment in prevention and education programs are as high as 3.5 to 7.5. times the cost of the intervention.
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The advantages of taking an integrated, community-based approach to health care are as follows: Increased productivity: The workforce will include and possibly reside in the surrounding communities, and poor community health will affect human capital and worker productivity. Cost: The cost effectiveness of community health programs, together with strategic partnerships, ensures that larger investments can be made and the program sustained beyond the life of the mine. Community health outreach programs are often an essential criteria in evaluating funding requests by different agencies. Social licence to operate: Large health-related burdens of many rural and poor communities with little access to good health care facilities means that health care support is highly valued. Effective community outreach programs will build good relationships and reassure shareholders and prospective investors. Health impact assessment: The negative impact of mining activities on communities can be effectively mitigated by company health programs. Reporting: Community health programs will enhance any reporting in terms of the GRI.
Prompt diagnosis and effective treatment early within the diseases lifecycle can ensure significant cost savings. Early interventions also reduce the possibility of transmission to other workers, with associated cost savings.
Community Programs The relationship between a mining company and its local community generally extends beyond the business one of procuring resources, services and materials to one of capitalizing on mutually beneficial activities to realise the short- and longterm benefits of co-existence. In the case of the three diseases considered here, a direct link exists between a mines employees/contractors and the outside community, due to living arrangements, social intercourse and the movement of malaria mosquito vectors across boundaries. In order to effectively manage these diseases, partnerships with communities and other organizations with similar goals are necessary and will significantly increase the scale and impact of any management program.
In most instances, the benefits of addressing these diseases within the community far exceed the small additional cost to a company of extending its health service into the surrounding community.
Corporate social responsibility should be a standard part of company policies and procedures and should support the highest standards of health, safety and environmental management. Companies should take a proactive, integrated approach to disease management that includes a community-based control and prevention strategy. This approach is reflected within the International Finance Corporations Performance Standard 4, which addresses the management of a projects health impacts on local communities, as well as in the Global Reporting Initiative, which contains a number of indicators relating to community health. ICMM members have committed to report against the GRI.
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SECTION 2:
The management plan process
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Section 2. The management plan process

2 2.1 OVERVIEW STEP 1: STEP 2: STEP 3: STEP 4: STEP 5: STEP 6: STEP 7: STEP 8: STEP 9: 2.2 ROLES AND RESPONSIBILITIES 2.3 IMPROVING IMPLEMENTATION Working with External Partners Obtaining External Funding Working with Contractors, Service Providers and Suppliers Program Sustainability Abbreviations used AIDS acquired immune deficiency syndrome ESIA environmental and social impact assessment HIA health impact assessment HIV human immunodeficiency virus IFC International Finance Corporation ILO International Labour Organization KAP knowledge, attitude and practices KPI key performance indicators M&E monitoring and evaluation NGO non-governmental organization TB tuberculosis TOR terms of reference UNDP United Nations Development Programme WHO World Health Organization THE MANAGEMENT PLAN PROCESS SCREENING SCOPING SITUATION ANALYSIS STAKEHOLDER ANALYSIS POLICY, PRIORITY, GOAL AND OBJECTIVE SETTING OPTION APPRAISAL PROGRAM DESIGN, BUDGETING AND REPORTING PROGRAM IMPLEMENTATION MONITORING AND EVALUATION 16 17 17 22 22 24 25 25 26 27 27 28 28 28 31 32 34
This management plan process is relevant for existing projects that have not yet adequately addressed the three diseases, as well as for new projects, although in the latter instance the process is likely to be linked to the environmental and social impact assessment process and associated health impact assessment component. Figure 2.1 and Figure 2.2 provide a summary of the management plan process. To meet the objective of screening, two key questions need to be asked: 1. Answering this question involves the following tasks: Is the Company Required to Manage the Disease? Task 1: Undertake a legislative review of the country within which the company is operating or plans to operate. STEP 1: SCREENING Objective: To decide whether one or more of the diseases needs to be addressed or managed.
2.1 OVERVIEW This Section outlines a series of nine generic and systematic steps that can be followed to determine the type and level of intervention required for HIV/AIDS, TB and malaria, culminating, where appropriate, in the implementation of a health program with associated monitoring and evaluation. Sections 4, 5 and 6 provide disease-specific guidance to the nine steps described here. Box 2.1: Step 1: Step 2: Step 3: Step 4: Step 5: Step 6: Step 7: Step 8: Step 9: Screening Scoping Situation Analysis Option Appraisal Stakeholder Analysis Priority, Goal and Objective Setting Program Implementation Monitoring and Evaluation Program Design, Budgeting and Reporting The Management Plan Process
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Task 2: Determine whether the company has a policy requiring the management of all or any of the three diseases and, if it does, assess the implications of this for the particular project.
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Task 3: Determine whether the company is a signatory to or has adopted any leading practice agreements, conventions, policies or initiatives that require management of all or any of the three diseases. If the company has, assess the implications. 2. In the absence of any legal or company requirements to manage the disease, the company needs to consider whether the disease poses a risk to the project. This requires consideration of the following: The location of the project and the associated prevalence and incidence of disease(s) in the area The nature of the project and the phase of mine life The nature of the surrounding communities and their associated level of socioeconomic development and access to adequate health care The size and nature of the (intended) workforce, stratified by permanent and contract staff and community, migrant and expatriate staff, together with a consideration of their prevailing health levels Transport and travel routes of employees and transportation services required by the project. Health information can be obtained as a desk-top exercise, using various Web resources, as well as through a larger literature review. Assessing whether the project poses a risk for increased disease transmission is equally important as assessing whether the social environment is a risk to the project. If such an increased risk is identified, management of this impact will be required. This is discussed in more detail in Sections 4, 5 and 6, within each of the disease sections. Is There a Disease Risk Posed to and/or from the Project?
Photo courtesy Xstrata
Figure 2.1: An Overview of the Management Plan Process STEP 1: SCREENING STEP 2: SCOPING STEP 3: SITUATION ANALYSIS STEP 5: PRIORITY, GOAL & OBJECTIVE SETTING STEP 9: MONITORING & EVALUATION STEP 6: OPTION APPRAISAL STEP 7: PROGRAM DESIGN, BUDGETING & REPORTING STEP 4: STAKEHOLDER ANALYSIS
PRE-FEASIBILITY, FEASIBILITY & CONSTRUCTION PHASES ALL PHASES PLUS OPERATIONAL AND CLOSURE PHASES RISK MANAGEMENT: What needs to be done? Develop a health baseline.
RISK ASSESSMENT (Exposure): Do we need the program?
Decide whether or not one (or more) of the diseases needs to be addressed/managed. Select the most appropriate disease management intervention. Implement & manage the program.
Increase understanding of the nature/ extent of the disease & associated risks/issues. Define program budget & resources and set key performance indicators & targets. Assess the program against baseline, objectives, targets, KPIs etc.
STEP 8: PROGRAM IMPLEMENTATION
Participate in a process of information sharing, problem solving & identification of potential partners. Set priorities, identify available resources and define achievable goals and objectives.
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No action yes Nature/extent of key/strategic issues Prevalence/incidence of disease(s) Impact(s) of disease(s)/issues on project and vice versa Up- and down-stream risk factors in community(ies) and workforce Priority areas for health program Nature of stakeholder affected by disease(s) and planned health intervention; can influence disease management and program implementation Consultation/engagement structures Effective strategy of interaction Issues, concerns and involvement Non-key or nonstrategic issues Describe and monitor Key/strategic issues Potential at risk population(s) Potential health care partners Information needed to understand risk Terms of reference for Steps 3 & 4 determine
Develop in-depth understanding in affected and control areas
STEP 1: SCREENING Is there a requirement to manage the disease? Is there a risk posed by HIV/AIDS and/or no TB and/or Malaria to the project, or of the project to the community? diseases with low risk Monitor
Figure 2.2: The Management Plan Process - Summary of Key Considerations
No program
Develop in-depth understanding in affected areas
no
Key or strategic issues
STEP 3: SITUATION ANALYSIS What is the health baseline within the project area and affected communities?
STEP 2: SCOPING What are the risks of the disease? How should health program/s be defined?
STEP 4: STAKEHOLDER ANALYSIS Who are the stakeholders affected by or interested in the health program/s?
diseases with medium to high risk
Policy/ legislation Prevalence/incidence of disease Characteristics of community(ies)/stakeholders Size/nature of workforce Transport/travel routes
yes
STEP 5: PRIORITY, GOAL & OBJECTIVE SETTING determine ensure consider ensure Input indicators (financial, equipment, drugs, human resources) Process indicators (staff training) Output indicators (no. of cases seen) Outcome indicators (incidence reduction) Continuity and adaptation Consideration of developing research and technologies Understanding of roles, responsibilities and accountabilities Sensitivity to stigmatization Legal requirements/ accurate costing & scheduling/required resources/ procedures Community/ partner alignment Stakeholder consultation Locally appropriate and supported Technically/financially/politically feasible In partnerships and/or associations
STEP 6: OPTION APPRAISAL
STEP 9: MONITORING & EVALUATION
STEP 7: PROGRAM DESIGN, BUDGETING & REPORTING
Disease project policy Overall program/ national goal Specific objectives for managing/ controlling/ avoiding increase of disease/s
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If screening identifies a need to manage one or more of the diseases, then a scoping exercise needs to be carried out. This step terminates in the definition of the terms of reference for a situation analysis (or baseline study) described in Step 3. The following questions should be addressed: What are the key issues that need to be considered and are there any strategic issues that require early attention? Who is the potential at-risk population (including construction workers) both within the project and within surrounding communities, and how should they be consulted and/or included in the health program? Who are the projects potential partners in health management and how could they be involved? What information is needed to understand the key issues better and to develop appropriate management plans? The development of a health baseline should allow for a refined understanding of the following: The nature and, in some instances, the incidence and/or prevalence of the diseases in the project area The projected impacts of the three diseases on the project The upstream risk factors for disease in the affected communities and the workforce The at-risk population The relevant priority areas to be addressed as part of the health program. STEP 3: SITUATION ANALYSIS Objective: To develop a health baseline of a projects workforce and affected community. Box 2.2. Scoping Activities Key Scoping activities include: A desk-top literature review A preliminary site visit with key specialists A review of existing reports and relevant information A review of potential resources available for a baseline survey Preliminary consultation with key stakeholders in order to understand their needs and capacity A gap analysis to determine what data are already available and what data gaps need to be filled in The development of the TOR for Steps 3 and 4.
STEP 2: SCOPING Objective: To get a better understanding of the nature and extent of the disease(s) and associated risks or issues and, in doing so, define the way forward for the development of the health program.
The baseline should also lay the foundations for a health program that is appropriate to the local context, as well as create data against which to monitor and evaluate subsequent interventions. If the project is at the feasibility phase, then the situation analysis is likely to form part of the baseline development stage of the ESIA/HIA process. The factors that potentially need to be examined are listed in Box 2.3. Box 2.3. Baseline Information Required The baseline information that is potentially required for an ESIA/HIA process includes: Demographics, such as population size, gender distribution and age distribution of the workforce and host community Burden of disease (the level of morbidity and mortality caused by a disease, within a given area or target population) and epidemiology of HIV and/or TB and/or malaria in the community and workforce General standard of living within the study area, with the identification of vulnerable groups Existing health services in terms of type, mix, quality, location, access and equity Socio-economic status (variably defined as a mix of income, material assets, status indicators, education, occupation) Workforce housing, accommodation type and location Ethnicity, if it influences health Access to clean water and sanitation Gender equality and female literacy rates Food consumption and nutrition Policy environment and political factors, such as levels of support for social services and health care services in the area Government capacity to provide services Details on existing workforce and/or community programs targeting the three diseases.
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The above information can be gathered through the techniques outlined in Table 2.1, supplemented by detailed literature and/or data reviews and consultation with key stakeholders.
Photo courtesy Anglo American/Vismedia
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Leading practice would ideally involve situation analysis to be carried out in the affected area and in a matched control or non-affected area.
Stakeholders need to be systematically identified as early in the planning process as possible. Ideally, stakeholder consultation should commence during the scoping step in order to ensure that their knowledge and opinions are considered when identifying key risks and defining how to develop the management plan and associated TOR. Stakeholder consultation is also an essential element throughout the management planning process.
Stakeholders can be divided into two key groups, each of which will have a bearing on the health program: Stakeholders that are affected by the disease and the planned health intervention (e.g., community residents, employees) Stakeholders who have an influence on the management of the disease and the successful implementation of the health program (e.g., NGOs, national and/or local authorities, community leaders, health staff, funding agencies).
Annex A (Table A1) provides a list of key stakeholders who could be involved in health program development, with an outline of their associated interest in and/or relevance to such a program.
STEP 4: STAKEHOLDER ANALYSIS Objective: To participate in a process of information sharing, joint problem solving and identification of potential partners.
Table 2.1:
Workforce KAP survey Geospatial mapping Household survey Literature review Health facility survey
Workforce screening program Vector mosquito surveys Malaria prevalence surveys HIV sero-prevalence survey Insecticide sensitivity testing
Note: An HIV sero-prevalence survey and workforce HIV screening program cannot be enforced.
Data Gathering Techniques
HIV/ AIDS X X X X X X
TB X X X X X
Malaria X X X X X X X X X
If a company does not have a policy on the management of one or all of the three diseases, then such a policy should be developed, based on the findings of Steps 1 to 4. Policy formulation should be undertaken in consultation with a medical advisor familiar with the three diseases. Program priorities will be guided by the choice of options discussed in Sections 4, 5 and 6. The most urgent priorities should be based on: Protecting the project and the project workforce from the impacts of the three diseases Managing and controlling the existing transmission of the three diseases Ensuring that the project does not contribute to an increased transmission of the three diseases. The overall program goal should be clearly stated. Specific objectives can be developed for each of the options. Performance indicators can then be defined for monitoring and evaluation (see Step 9). STEP 6: OPTION APPRAISAL Objective: To select the most appropriate disease management intervention. Clear objectives and goals with measurable outputs should be defined through an iterative process, with priorities and resource constraints taken into consideration. Program goals and objectives need to be clear and be put in place early in the process. There may be different strategies or programs that can be implemented, depending on the phase of the mining project (see Annex C for more detail). During option appraisal it is essential that senior management supports the process and understands the various options. These should be assessed with the following in mind: Feasibility (technical, financial, political) Impact on health outcomes for the three diseases Performance against the basic health sector goals of cost-effectiveness, equity, efficiency and sustainability Partners that could be pursued for each option Priorities, goals and objectives must be defined in the broader context of local, regional, national and international objectives and targets (e.g., ILO, WHO, UNDP, Global Business Coalition and others already committed to tackling these three diseases). National governments may have well-developed disease mitigation strategies with defined objectives and targets that are often themselves aligned with broader multilateral objectives and targets. By aligning goals, objectives and targets within this context, program sustainability will be enhanced and program partnering success improved.
STEP 5: PRIORITY, GOAL AND OBJECTIVE SETTING Objective: To set priorities based on Steps 3 and 4, identify available resources and then define achievable and practical goals and management plan objectives.
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Inclusion of contractors Outsourcing of portions of the program, while still retaining overall responsibility Potential for a tripartite partnership for workplace programs in order to ensure support from employees, as well as from government, where appropriate. There is no generic formula for the three diseases that fits every context, and it may be prudent to launch a pilot program. A phased approach is often suited to new countries of operation where local factors are not yet sufficiently understood. The process for designing a health program is the same as that for designing any other mine-related activity. There needs to be an understanding of legal requirements, accurate budgeting, carefully defined timelines, an appreciation of available resources and the establishment of procurement procedures for equipment, drugs and consumables, all feeding into a quality monitoring and evaluation system. Key considerations are listed in Box 2.4. Legal requirements may include notification of certain infectious diseases (especially TB); provision of a safe workplace with regard to protection from blood-borne pathogens such as HIV and malaria and airborne pathogens such as TB; licensing of the facility for drug procurement and dispensing; licensing of radiological facilities and accreditation of laboratory facilities; licensing of appropriately qualified staff; and compensation for work-related diseases. Corporate policy will determine whether there is a central allocation of funding for health care or whether funding needs to be found within the projects budget. A specialized budget (or an integrated TB/HIV or even TB/HIV/malaria budget) may be necessary. Program budgeting to achieve measurable targets is preferable to an allocation from general budgets that compete with other health care needs. Community health budgets and resource allocation should take into account the ability to operate and maintain equipment, which is often limited. Focus should be on building human resource capacity and not only on building new clinics in the community. For large or innovative projects, particularly in under-serviced areas or populations, application for external funding may be possible. The groundwork for such applications needs to be laid (see Section 2.3 'Working with External Partners'). For community programs it is vital that proper financial auditing is performed if the project itself does not have control of the finances. Box 2.4. Program Design Considerations STEP 7: PROGRAM DESIGN, BUDGETING AND REPORTING Objective: To define the program budget and resources and set the key performance indicators and targets with associated timelines.
Program implementation needs to constantly feed back into the defined sets of goals, objectives and targets. Senior management support is once again a key success factor for successful program implementation, as are appropriately skilled human resources. These key indicators are dealt with in more detail in Sections 4, 5 and 6. STEP 9: MONITORING AND EVALUATION Objective: To assess program success against the baseline, objectives, targets and KPIs and to make any necessary changes.
Setting up a proper process of monitoring and evaluation increases the potential for external funding, as multilateral funding organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria require proper M&E systems (1). Reporting of program M&E should take cognizance of the framework developed by the Global Reporting Initiative (against which ICMM member companies are required to report), with particular reference to the sector supplement documentation for mining and metals.
1 See the Global Fund's collaborative "Monitoring and Evaluation Toolkit: HIV/AIDS, TB & Malaria";' 2nd ed. 2006
Monitoring of KPIs is undertaken to make sure that performance is adequate and certain targets are met. This is done on a monthly, quarterly or bi-annual basis. Targets typically include: Input indicators such as financial, equipment, drugs, infrastructure, human resources Process indicators such as management of patients and staff training Output indicators such as number of cases seen Outcome indicators such as reduction in disease incidence and change in health outcomes.
Evaluation refers to the appraisal of the entire planning and implementation process, with regard to policy, goals and objectives and resultant outcomes. Evaluation allows for the re-assessment of strategy in terms of program effectiveness, efficiency, equity and sustainability. It can result in policy shifts and radical direction changes in the program. It is usually performed annually, either by an experienced in-house consultant or by an external independent consultant. Evaluation can also be used to make the business case to management and stakeholders regarding the value added by the programs and enhanced social licence to operate.
STEP 8: PROGRAM IMPLEMENTATION Objective: To implement the program and manage it against KPIs and targets.
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2.2 ROLES AND RESPONSIBILITIES The essential requirement for an effective health program or programs is the commitment of senior management (at corporate and project level) to the control of the diseases in the workforce (and to contributing to its management in affected communities, where appropriate), as well as cooperation with national control programs where they exist. This includes ensuring that contractors comply with company policy and procedures for any employees brought on site. A champion should also be appointed to manage or oversee both site and community programs and to ensure that these are integrated across the three diseases. In a smaller or temporary project (e.g., during exploration phase), a contracted medical advisor familiar with disease management will serve as a link between the company and the area health service. For either project, the health care professional needs to be regularly updated and re-trained on the latest disease management, which is constantly evolving due to new information and changing conditions, such as with drug resistance. 2.3 IMPROVING IMPLEMENTATION The company-appointed health service will be responsible for the maintenance of accurate databases in a format suitable to report to the government, the individual project and corporate management and for linking into the company/project occupational health, medical and human resources records in a manner consistent with the required confidentiality (where applicable). Information management support will be needed to ensure that the system is efficient and uses technology appropriate to host-country conditions. The health care staff will need to be conversant with international and national reporting guidelines (e.g., on cure and completion rates) and be able to convert these into a format that can be integrated into the information system.
On a large project with an in-company health service, medical professionals working with operations management, human resources management, procurement and information management will develop the various elements of the program. This will include regular reporting by the health service to senior operations management and to the corporate health care unit to ensure the program remains visible in the projects performance management and budgeting. For implementation of the health care component, a large health services operation will include professionals and, in some cases, auxiliaries trained in medicine, nursing, counselling, pharmacy and radiography. Annex B provides a list of the different tasks for each disease management program. Roles and responsibilities should be allocated for each of these tasks. Working with External Partners The effectiveness of health programs and their long-term sustainability can be significantly enhanced by working with external partners, including funders, contractors, service providers and suppliers. The key benefits and obstacles to these partnerships, and criteria for program sustainability, are discussed in this section. Although mining companies and projects can individually make a major contribution to the health and well-being of the communities they are associated with, it is often preferable for them to partner with other organizations that have similar goals in
order to significantly increase the scale and impact of any program. Partnerships are motivated by the realization that the company response will always be limited, however good, if there is no participation in the broader community-wide and sectorwide activities. Some of the benefits of a partnership are outlined in Box 2.5. The kinds of expertise and support that mining companies are able to bring to a partnership are summarized in Box 2.6. Box 2.5. Key Benefits of Partnerships (Source: IFC, 2004) Key benefits of partnerships include: Pooling of resources and expertise (e.g., funds, staff time, expertise, local knowledge and technical equipment) A wider response and perspective involving different types of organizations and sectors Avoiding duplication and maximizing the different organizations capabilities Reduced dependence on the mining company, thus increasing the chance of greater sustainability Opportunities to build capacity among partner organizations Shared lessons and experiences An improved understanding of community needs A more co-ordinated response, including referral between organizations More innovative and effective programs Optimal allocation of resources and opportunities for the leveraging of resources Improved access to local communities (particularly if there has been a history of poor community relations) Improved credibility of mining companies within the target community As an essential outcome, improved support and services for those affected by the disease/s. Box 2.6. Expertise Brought by Mining Companies Expertise brought by mining companies includes: Leadership skills and governance expertise Policy and strategy development Communication and marketing Logistics expertise and distribution capacity Strategic and long-term planning Business administration Technical knowledge of disease control and management Employee training and development Application and use of information technology.
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The key challenges to the success of partnerships have been found to be: Unaligned motives Inadequate terms of reference Poor understanding of roles Lack of trust Lack of disclosure and confidentiality Competitive dynamics Different organizational structures Unclear exit strategies Unequal power relations Poor information sharing Lack of capacity among partners.
There are a number of different types of partnerships that can be considered. These are: Public/private/NGO partnership combinations or tripartite partnerships between government, business and labour Operational partnerships, generally around a specific program Policy and strategy partnerships, which typically deal with new challenges that cut across sectors Advocacy partnerships to promote action on key issues, such as an individual disease.
Partnerships can take many forms, from formal agreements to less formal collaborations and networks. Written agreements usually specify the purpose and duration of the partnership, the formal governance structure, roles and responsibilities as well as exit arrangements. For the mining sector, the ability of the appropriate partner to take over the management and continuation of the health programs at mine closure is a key element in ensuring their long-term sustainability. This hand-over should be planned well in advance and implemented in a systematic manner. Golden rules for initiating partnerships include: Agree on specific commonly defined goals for the partnership Identify appropriate people and organizations to work with to achieve goals Know and understand the partner Have clearly identified roles and responsibilities Identify champions to keep the momentum going Agree to shared governance Define the details of a collaborative relationship.
Potentially any of a companys stakeholders, including other companies, could be a partner. Categories of possible partners and pointers around their potential areas of responsibility, plus examples of international NGO and funding partners, are provided in Annex A, Table A2 and Box A1.
Obtaining External Funding
Numerous organizations focus on providing project funding for health programs in prevention, treatment, care and support. Each funder has its own requirements for partnering on projects and initiatives. A list of general funding criteria from a number of sources is provided as a guide in Box 2.7. Box 2.7.General Funding Criteria Draft and present proposals in accordance with each donors funding requirements/ guidelines. Know the amounts the donor is prepared to give, as there are often minimum and maximum amounts. Ensure that the company is in contact with the correct person and follows the correct application procedure. Ensure that the donor will accept the proposal. In many cases, donors will not accept unsolicited proposals. Ensure adequate time to source funding, as this is a time-consuming process. Many donors accept proposals all year-around but only review/discuss proposals once or twice a year while others have defined application deadlines. Have clearly defined goals and objectives in the proposal, supported by measurable indicators. Goals should be broad and overarching and reflect the aims of a variety of activities, national programs and collaborators working together, not just an individual project. Objectives need to be set for each goal, describing the intention of the programs for which funding is sought and providing a framework under which services are delivered. Donors may require that the company be registered with particular formal bodies (e.g., the Global Business Coalition serves as a focal point for the private sector in gaining access to the Global Fund). Most donors want to be assured of project sustainability. In this regard they look favourably upon well-structured and defined partnerships, additional funding sources, a historical record of performance and a monitoring and evaluation strategy. Have a well-developed monitoring and evaluation process. Donor reporting requirements differ substantially and can place a heavy burden on the project team. Ensure that the correct structures are in place to manage the financial and non-financial reporting requirements.
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Table 2.2 provides a list of examples of sources of external funding. Table 2.2: Organizational Type Private Foundations Private Companies/ Corporations Bilateral Agencies International Development Agencies Multilateral Agencies Non-governmental Organizations (local and international) Host-country Governments (national or local) Examples of External Funders Examples of Donor Agencies
World Bank and regional development banks (e.g., European Bank for Reconstruction and Development, Inter-American Development Bank, African Development Bank, Asian Development Bank) United Nations Children's Fund, Oxfam, Red Cross, Hope International, CARE, Family Health International
Working with Contractors, Service Providers and Suppliers Contractors are, in many cases, responsible for many of the day-to-day activities of a mine; during various phases of a projects life, they can outnumber the company/project employees. A companys capacity to operate effectively, as well as its profitability, is dependent on a network of contract, supplier and service enterprises; however, the effect of the three diseases on the ability of these associated organizations to deliver their services is often not clearly identified. Small contracting companies, service providers and suppliers, or those operating in a less formal manner, may find it challenging to develop their own health care programs, even if the potential impact of the disease on these enterprises is substantial. These companies have limited resources or may move from one region to another frequently, making a sustainable program difficult to implement. Larger mining companies can assist in a number of ways, such as through extending their education, disease prevention and health care programs to their contracting
Bill and Melinda Gates Foundation, Henry J. Kaiser Foundation, Rockefeller Foundation Departments of Health, Community Development/ Social Services; Lotteries Board
Companies that do business with your company (such as suppliers, service providers and contractors); other companies from the same or another sector
European Union; United Nations Development Programme; Global Fund to Fight HIV/AIDS, Malaria and TB; World Bank Group; International Finance Corporation; United Nations; European Commission External Aid Program; OPEC Fund; African Development Bank; Asian Development Bank
United States Agency for International Development, UK Department for International Development
company(ies). At a minimum, advocating and advising contractors on appropriate actions and information on the companys workplace policies and programs should take place. This capacity-building approach requires minimal resource demands. Partnerships with contractors, service providers and suppliers to address the impact of the three diseases will reinforce workplace health programs, enhance community and sector responses and contribute to broader community health targets. The key challenges to a successful partnership outlined earlier apply equally to contractors, service providers and suppliers. However, the effectiveness of these partnerships can also be threatened by several additional issues: The minimum practical standards for partnerships with contractors, service providers and suppliers are outlined in Box 2.8. Annex A (Box A2) provides an example of a malaria prevention clause included as part of a contractors contractual responsibilities. Temporary nature of the relationship. Service agreements are renewed on an annual or bi-annual basis. Contractors, for example, often complete their contract and move on to the next one. This results in a lack of continuity of service provision and can lead to problems around follow-up and continuation, with the program collapsing when the contractor leaves. Reliance on existing programs. Smaller companies often rely on wellestablished programs with effective structures before they can provide an intervention of some kind. If these are not in place, this company may not be able to participate. No culture of extended health care. Smaller companies do not have the resources to undertake large health initiatives and may only concentrate on their immediate employee needs. These companies would have different objectives and standards and would not necessarily have a policy for an extended type of support (e.g., into associated communities) nor would a structured program be in place. Proper engagement between mining company and service provider does not take place. Where a clear agreement and awareness of the standards and programs that should be achieved does not exist, the service company will not necessarily meet the expectations of the mining company.
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Program Sustainability The long-term sustainability of community health programs is a challenge when mining projects have a finite life and company interventions are likely to diminish when the mine closes. In the case of HIV/AIDS, experience has demonstrated that sustained effort on many levels and through many channels is necessary to bring about the social and behavioural change that will make the difference. The planning and delivery of health programs based on a partnership approach, with a strong role for local communities, has been the most successful model. The shared vision between the partners should be the long-term improvement in quality of life of employees and associated communities. The concept of sustainable development for health programs requires: Strong corporate leadership based on the full acceptance of the principles of sustainable development and long-term business objectives An understanding that the employees health cannot be adequately protected from communicable disease unless health programs are extended to the broader community A broad definition of community, with programs based on consultation, consensus and capacity-building Input from the host community into program design and implementation of community health programs Skilled human resources involved in implementation and associated capacity building A partnership model where the company seeks to work with a variety of partners in support of community and host-government obligations for community health (thus ensuring that the company does not build expectations that it is the sole provider) Comprehensive and prioritized objectives for the diseases being managed
Box 2.8. Minimum Practical Standards
The minimum practical standards for partnerships with contractors, service providers and suppliers are as follows: Clear engagement on expected obligations and accountabilities around health care, preferably encompassed in a formal agreement Use of existing health care programs and sharing of the knowledge, expertise and resources (including policies and procedural documentation) of the mining company Commitment of contractor, service provider or supplier to participate in the program as intended and allow their employees to make time for training and other initiatives Monitoring and evaluating the performance of contractors, service providers or suppliers in an integrated program with that of the mining company Agreements to certain requirements that extend to the initial employment of staff, such as appropriate baseline medical examinations and record keeping Ensure that contractors and service providers have adequate medical insurance for their employees.
An effective delivery system as part of a comprehensive program with prevention, control and eradication being equally important objectives Recognized value of the health program to the achievement of the companys business values and goals A clear project champion and committed leaders, supported by company and partner senior management Long-term commitment from funders and partners, through the project cycle and beyond the life of mine.
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SECTION 3:
Integrated management of HIV/AIDS, TB and Malaria
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Section 3. Integrated management of HIV/AIDS, TB and Malaria

3 3.1 OVERVIEW 3.2 DUAL LINKAGES HIV/AIDS and TB HIV/AIDS and Malaria 3.3 INTEGRATED CONTROL HIV/AIDS and TB HIV/AIDS and Malaria INTEGRATED MANAGEMENT OF HIV/AIDS, TB AND MALARIA
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Abbreviations used AIDS acquired immune deficiency syndrome ART anti-retroviral therapy ARV anti-retroviral HIV human immunodeficiency virus IPT intermittent preventive treatment MDG Millennium Development Goal PLWHA people living with HIV/AIDS TB tuberculosis
Estimated HIV prevalence in new TB cases, 2005
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3.1 OVERVIEW The geographical distribution of HIV/AIDS, TB and malaria commonly overlaps, partly due to the interplay that occurs between the diseases and partly due to circumstance. The interaction of these three diseases threatens already overloaded health services and consequently has an adverse impact on the health of affected workforces. Lack of human resources and fragmented management makes the control of each disease separately less effective. Furthermore, a lack of integration exacerbates the existing strain on human resources and promotes segmentation within a health service. In order to optimize the control of each disease, workforce programs need to be integrated where possible. For community health programs, the situation is more complex and context-specific and will largely depend on national government policy.
Integration allows increased efficiency and effectiveness by maximizing human resources and infrastructure and providing more coherent management. In addition, it takes into account more effectively the overlapping risk factors for the diseases and the concurrent clinical presentations. For example, managing risk factors for TB such as overcrowded single-status housing and inadequate awareness and education may also reduce risk factors for HIV, such as around unsafe transactional sex. Patients may also increasingly present to a company medical service with more than one of the three diseases.
[15-49 years, %]
Reproduced with permission of the World Health Organization 2006
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Due to the nature of the diseases, TB and HIV/AIDS are more closely linked than either with malaria. Integrated programs will therefore focus preferentially on these two diseases. The effect and linkages between TB and malaria are more tenuous and have not been well studied. The linkages between HIV and malaria are clearer, as explained in this Section. Due to the fact that the HIV and TB pandemics have converged and affected Africa most severely, much of the discussion is confined to evidence that has been collected from the African context. There are, however, parts of Asia that are also now significantly affected by all three diseases. 3.2 HIV/AIDS and TB When the immune system is compromised by HIV, organisms (in particular TB) find it easier to infect the body and to reactivate and cause disease that may have been lying dormant within the body. Furthermore, HIV also increases the risk of rapid TB progression soon after infection or re-infection with TB (Corbett et al., 2003). This results in a dramatic increase in the incidence of active TB and TB-related deaths in areas with high HIV prevalence. For instance, in Africa 16 35% of HIV-positive individuals with TB not receiving anti-retroviral therapy die from TB, whereas only 49% of HIV-negative individuals with TB succumb. Introduction of ART can reduce the incidence of TB in HIV-positive individuals by 80% or more (Corbett et al., 2006). DUAL LINKAGES
Co-infection with TB and HIV may possibly be associated with the faster progression of the HIV disease due to increased stimulation of the immune system. Furthermore, other diseases that occur at the same time, termed inter-current diseases, particularly sexually transmitted diseases, may further exacerbate susceptibility to and infectiousness of HIV. Overall, HIV infection dramatically increases the incidence of active TB infection by about eightfold. However, in late-stage HIV/AIDS this risk can increase by up to 20fold (Corbett et al., 2006). The following illustrates the increased risk of TB in people living with HIV/AIDS:
If a person is HIV-negative and infected with TB, there is a 1020% lifetime risk of developing active TB, but If a person is HIV-positive there is a 1015% risk of developing active TB per year (Corbett et al., 2003).
Furthermore, according to data from AngloGold Ashanti, in a typical South African gold mine with 4,000 employees it is estimated that there are about 3,000 new cases of active TB per 100,000 miners (so about 120 new cases) per year. Compare this to the TB incidence rate in the Americas of only 46 per 100,000 for the year 2000 (Corbett et al., 2003). HIV is increasing rates of TB in all types of mines (not only gold mines), but most significantly in those with high HIV prevalence. Table 3.1 demonstrates the TB risk stratification according to various risk factors found in South African gold miners.
It must also be noted that silica dust exposure in the absence of silicosis also increases the risk of TB. HIV/AIDS & Malaria The interactions between HIV and malaria are not yet completely clear, and in some instances they are quite subtle. Recent evidence indicates that during acute malaria infection there is an approximately sevenfold increase in the number of circulating HIV viruses (HIV viral load) due to an already overloaded and damaged immune system having to cope with the second infection. HIV transmission is significantly increased during viral load peaks that occur during acute infection and in Stage 4 of the disease (see Table 1.1). Consequently, it has been estimated that an acute malaria attack, by causing an increase in viral load, results in a 2.45 increased probability of HIV transmission per coital act (Abu-Raddad et al., 2006).
(Source: G. Churchyard, personal communication)
In communities where the burden of TB is high, at least half the TB cases that occur are the result of the progression to active disease following TB infection acquired within the previous year or two, regardless of HIV status. The undiagnosed cases of infectious TB in the community are the driving force for ongoing TB transmission, which is an important determinant of the rate (incidence) at which TB occurs. However, HIV-positive TB patients are less infectious and progress more rapidly to disease, diagnosis and treatment or death than HIV-negative individuals. Therefore the affect of the rising number of HIV-infected TB cases on TB transmission is uncertain. TB in HIV-positive individuals is associated with a transient increase in HIV replication, which may lead to an increase in viral load. This increase in viral load may result in a more rapid progression to HIV disease and death and may also be associated with increased transmission of HIV for reasons similar to those outlined for HIV/AIDS and malaria.
Until recently it was thought that HIV was not associated with an increase in drugresistant TB. However, recent data suggest that HIV may indeed be associated with drug-resistant TB, particularly among those that have previously been treated for TB (K. Weyer, personal communication).
Table 3.1: Variable Silicosis
HIV positive
TB Risk in South African Gold Miners
Increased Risk of TB 4.4 2.7
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Photo courtesy AngloGold Ashanti
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The exact clinical impact of HIV on malaria is still subject to ongoing research and is not clearly defined except in HIV-positive pregnant women, where current evidence strongly suggests that malaria attacks are more frequent and more severe both for the mother and the foetus. In adults and non-pregnant women the evidence is not as clear, but it seems that especially in areas of unstable (highly variable) transmission, malaria is both more frequent and more severe, while in areas of high-intensity stable transmission, malaria is more frequent but not necessarily more severe. HIV infection does appear to increase the likelihood of malaria transmission through increased parasitaemia (numbers of malaria parasites in the blood). HIV/AIDS appears to increase susceptibility to malaria. HIV/AIDS increases the risk of severe malaria and death in pregnant women. HIV/AIDS appears to increase the risk of severe malaria and death in children and adults in areas of unstable malaria transmission, and possibly in areas of stable transmission, although further research is needed. HIV/AIDS potentially increases the transmission of malaria due to increased numbers and duration of malaria parasites in the blood. Malaria attacks increase the HIV viral load about seven-fold. Malaria appears to increase the progression of HIV to AIDS. Malaria attacks potentially increase the transmission and incidence of HIV. Malaria may exacerbate anaemia caused by HIV/AIDS and result in an increased need for blood transfusion to counteract severe malaria anaemia. There are potential interactions between malaria treatment drugs and drugs used for treatment and prevention in HIV/AIDS, making medical management more complex. Certain drugs (sulphamethoxazole/ trimethoprim) used for prophylaxis against opportunistic infections in HIV/AIDS may result in increased resistance to similar drugs (sulphadoxine/ pyrimethamine) used in the treatment of malaria. HIV/AIDS may also reduce the effectiveness of anti-malaria treatment, particularly in pregnant women and children, although this relationship is not entirely clear. Therefore, the interplay between HIV/AIDS and malaria contributes in part to the spread of both diseases (and indirectly therefore to the spread of TB). A visual representation of the potential interactions between the three diseases is given in Figure 3.1.
The following links between HIV and malaria are either evident or appear evident but need further research:
Figure 3.1: Potential Interactions between HIV, TB and Malaria

Effect of TB and malaria on prognosis and spread of HIV Decreased survival after HIV infection due to high disease specific mortality Potential accelerated HIV progression due to frequent/ intense immuno-stimulation Increased HIV infectivity and transmission rates due to increase in plasma viral loads
Progressive immunosuppression and increased viral load Intercurrent infections
HIV-infection
Source: Adapted from Corbett et al, 2002.
Exposure to TB and malaria Intensity of exposure affected by: Geographical variation Socio-economic factors Public health control measures An individuals preventative measures
Effect of HIV on TB and malaria Increased rates of disease as exposure more often results in clinical disease Increased case fatality rates Increased transmission rates lead to more frequent disease episodes
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3.3 INTEGRATED CONTROL Where the three diseases co-exist, it is advisable to integrate the control of all diseases using a common platform. (See Box 3.1.) This includes the links and collaboration between the various programs that are specific to each disease, and between community programs and workforce programs (with distinctions where necessary). HIV/AIDS and TB Box 3.1: Examples of Collaborative Activities Establishment of a coordinating committee and allocation of dedicated funds for HIV, TB and malaria activities. Development of a joint HIV/TB/malaria plan, using an integrated approach, that includes resource mobilization, capacity building and training, communication and social mobilization, community involvement and research. Surveillance of HIV prevalence among TB and malaria patients to determine the burden of HIV disease among these patients (this will help to understand the extent of overlap between the three diseases and will inform the rational planning of services). TB/HIV/malaria training for health care providers should be done jointly and should utilize a good-quality service provider to ensure comprehensive, high-quality TB/HIV/malaria prevention and care services within the project area.
Overview The twin pandemics of HIV and TB are closely linked in most countries. There are some exceptions to this: in Russia, China and parts of South America, either TB is prevalent and HIV is not or vice versa (due to the complex interplay of underlying risk factors). In settings where there is a high prevalence of HIV and TB, the Global Plan to Stop TB 20062015 advises scaling up collaborative HIV/TB activities in line with targets for universal access to HIV prevention and treatment. The aim of collaborative activities is to decrease the burden of both HIV and TB. The recommended activities should provide integrated, comprehensive HIV and TB prevention, treatment and care services that are readily accessible. However, it may be advisable in certain settings for existing, independent HIV and TB services to be maintained rather than combining them into one program, with integration rather achieved through expanded referral networks. (See Box 3.2.) Furthermore, active case finding for TB in high HIV prevalence settings is advocated to reduce TB incidence and death rates and potentially to slow transmission.
HIV-positive patients uninfected with TB would be particularly susceptible to acquiring TB infection in poorly managed and designed health care facilities due to cross-infection caused by inadequate ventilation and overcrowding and poor infection control. Recommended HIV/TB Collaborative Activities The following recommendations are made to strengthen collaboration between the services, with the goal of reducing the disease burden from both HIV/AIDS and TB. Decreasing the burden of HIV in TB patients: In high HIV prevalence settings, HIV testing and counselling should be offered to all people diagnosed with TB, with an opt-out option for those who request not to be tested. Opt-out testing involves limited pre-test counselling and therefore decreases the time required for testing
As multi-drug resistant TB is increasing, the ability to isolate TB patients with active and open infection is important, especially in projects where health services are relatively self-sufficient due to poor health infrastructure in surrounding communities. In these circumstances, health facilities should have an appropriate infection control policy, adequate ventilation and patient isolation capability. Furthermore, they should ensure first-and second-line drug susceptibility testing is performed on all new TB cases. Infection control in congregate settings also needs to be considered. For example, opening windows in hostels will help ensure adequate ventilation and reduce risk of TB transmission. Further information on TB detection and active case finding is found in Section 5.
Box 3.2: Integration of HIV and TB Programs
Establishing a mechanism for collaboration: In addition to the activities outlined in Box 3.1, collaboration can be achieved through people with TB and/or HIV/AIDS being engaged in planning, delivering and monitoring TB/HIV activities and through laboratory services being strengthened to ensure quality diagnosis and management of HIV-associated TB, multi drug-resistant TB, extensively drug-resistant TB, TB in children, the diagnosis and staging of HIV disease, and the monitoring of side effects of combined TB/HIV treatment.
In large mines, the HIV and TB control programs are typically run by the mine health services, but in separate clinics, with cross referral. In smaller operations, elements of both the TB and HIV programs are outsourced to NGOs or the public sector or managed through a medical scheme. Due to the segmentation of TB and HIV programs, collaboration between them is difficult, but it can be accomplished by ensuring adequate referral and monitoring systems.
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Decreasing the burden of TB in people living with HIV/AIDS: PLWHA should be screened regularly for active TB and should be offered TB preventive therapy if they do not have active TB. Furthermore, adequate infection control procedures should be implemented.
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and improves the efficiency and coverage of the roll-out of testing. HIV prevention methods such as condoms and treatment of sexually transmitted diseases should also be provided to TB patients, as should all the other elements of a comprehensive HIV prevention, treatment and care program. Table 3.2:
Indicator Decreasing the burden of TB in PLWHA Decreasing the burden of HIV in TB patients Decreasing the overall burden of TB and HIV in the workforce TB/HIV collaborative activities
Monitoring and Evaluation Table 3.2 provides a list of output and outcome indicators for assessing collaborative activities between HIV and TB. In addition, suggested targets are given for the output indicators that are aligned with Millennium Development Goals and targets, although a company may decide to define its own targets. HIV/AIDS AND MALARIA M&E for TB/HIV Collaborative Activities
Measure % of PLWHA attending HIV services screened for TB % of newly diagnosed and eligible PLWHA offered intermittent preventive treatment % of TB patients HIV tested and counselled % of eligible HIV-positive TB patients offered ART % of PLWHA diagnosed with active TB annually Mortality rate in registered TB patients, both during and following TB treatment % of the workforce who test positive in an HIV prevalence survey % of undiagnosed active TB diagnosed in a TB prevalence survey Rate of new HIV diagnosed in the workforce Rate of active TB in the workforce MDG Target 2010 100% 85% 75% 85% MDG Target 2015 100% 100% 100% 100%
HIV/AIDS and malaria are linked in most malaria-affected African countries. However, in Asia and Central and South America, where HIV prevalence may be much lower and malaria transmission more unstable, the links may become more tenuous. In medium- to high-risk areas for HIV/AIDS and malaria, integrated control is recommended. Recommended Malaria / HIV Collaborative Activities The following recommendations describe how to strengthen collaboration between the services, with the goal to reduce the disease burden from both HIV and malaria.
Outcome/Impact
Output
Establishing a mechanism for collaboration: As outlined in Box 3.1. Monitoring and Evaluation Table 3.3:
Indicator Decreasing the burden of malaria in PLWHA Decreasing the burden of HIV in TB patients Malaria/HIV Collaborative Activities
Decreasing the burden of malaria in people living with HIV: In areas where malaria is endemic and HIV is prevalent, HIV-infected individuals should be educated on the importance of measures to prevent malaria. Effective malaria treatment would reduce the impact of malaria on HIV-associated anaemia and on HIV viral load and subsequent HIV disease progression and transmission. All HIV-infected individuals should be offered insecticide-treated bed nets in addition to other standard preventive measures outlined in Section 6. Testing of workers presenting with fever: Fever is a common presentation for both HIV and malaria (as well as TB). Workers presenting with fever should be tested for malaria and HIV to ensure appropriate management of both. M&E for Malaria/HIV Collaborative Activities
Measure % of malaria patients HIV tested and counselled % of eligible HIV-positive malaria patients offered IPT in pregnancy % of eligible HIV-positive malaria patients offered ART Malaria incidence rates in PLWHA over time % of malaria patients accepting HIV testing MDG Target 2010 85% 85% 75% 100% 100% 100%
Decreasing the burden of HIV in malaria patients: Malaria patients should be routinely offered HIV testing. HIV-infected malaria patients should be enrolled in an HIV/AIDS treatment and care program once the malaria is fully treated. Malariaassociated anaemia often requires blood transfusions. In many developing countries, blood may be inadequately screened for HIV and malaria, further contributing to the spread of both diseases, especially HIV. Ensuring a safe blood supply would decrease blood transfusionassociated HIV transmission to malaria patients. In areas where malaria control includes the spraying of houses, this contact should be used to educate households regarding HIV and malaria prevention and to promote or offer HIV testing. Table 3.3 provides a list of output and outcome indicators for assessing collaborative activities between malaria and TB. In addition, suggested targets are given for the output indicators that are aligned with MDG goals and targets, although a company may decide to define its own targets.
MDG Target 2015
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Outcome/ Impact
Output
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SECTION 4:
HIV/AIDS Programs
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4.1 OVERVIEW
4.2 PREVENTION Raising Awareness Getting the Message Out Going Beyond the Workforce De-stigmatising the Disease Peer Education Review Occupational Health and Safety Procedures Condom Distribution Circumcision Voluntary HIV Counselling and Testing Prevention and Treatment of Sexually Transmitted Infections Blood Borne Pathogens Program Post Exposure Prophylaxis Program Prevention of Mother-to-Child Transmission Training of Managers and Supervisors 4.3 TREATMENT AND CARE Provision of Nutritional Program Anti-retroviral Treatment (ART) Program for Employees ARV Program for Family Members Adherence Promotion Preparation for Treatment Dispensing of Medication Ongoing Adherence Monitoring Promotion Opportunistic Infections and Cancers Employee Assistance Program (EAP) Provision of Laboratory Services Referral of/or Treatment of Complicated Cases Terminal and Home-Based Care 4.4 PROGRAM PLANNING AND IMPLEMENTATION STEP 1: Screening STEP 2: Scoping STEPS 3 and 4: Situation Analysis and Stakeholder Analysis STEP 5: Policy, Priority, Goal and Objective Setting STEP 6: Option Appraisal STEP 7: Program Design, Budgeting and Reporting STEP 8: Program Implementation STEP 9: Monitoring and Evaluation
Section 4. HIV/AIDS programs

HIV/AIDS PROGRAMS
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Abbreviations used AIDS acquired immune deficiency syndrome ARV anti-retroviral ART anti-retroviral therapy CSW commercial sex worker EAP Employee Assistance Program GBC Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria HIV human immunodeficiency virus M&E monitoring and evaluation NGO non-governmental organization PEP post-exposure prophylaxis PLWHA people living with HIV/AIDS STI sexually transmitted infection TB tuberculosis UNAIDS Joint United Nations Programme on HIV/AIDS VCT voluntary counselling and testing WHO World Health Organization
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4.1
A GLOBAL VIEW OF HIV INFECTION, 2006
OVERVIEW
KEY FACTS: According to the World Health Organization and the Joint United Nations Programme on HIV/AIDS, in 2007: 33 million people worldwide were living with HIV, with 22.5 million (68%) of them in sub-Saharan Africa 2.5 million people likely became newly infected with HIV 2.1 million people were likely to have died of AIDS Two-thirds of people with HIV, who require ART, had no access to the drug; and Less than 1 in 10 people at risk of HIV had the means to protect themselves.
Figure 4.1: Components of an Effective HIV Strategy REACHING OUT Raising awareness Providing information Effective communication Going beyond the workforce Peer education Targeting high-risk groups employees, families, communities, commercial sex workers, men who have sex with men, contractors, suppliers
CREATING AN ENABLING ENVIRONMENT Leadership training/capacity building Confidentiality De-stigmatizing the disease Employee buy-in Appropriate policies Support groups
Strong commitment and support Adequate health services Provision of a nutritional program ARV programs for employees and potentially for family members Adherence promotion Preparation for treatment Controlled dispensing of medication Monitoring of adherence Treatment of opportunistic infections and cancers Employee assistance program, including psycho-social support Provision of laboratory services Referral of/or treatment of complex cases or ill people Terminal care (home-based or hospice care)
TREATMENT AND CARE
PREVENTION
COUNSELLING & TESTING Encourage all to know their status Voluntary counselling & testing Pre- & post-test counselling Promote adherence
PREVENTION Good occupational health and safety procedures Promoting circumcision Distributing condoms Prevention of sexually transmitted infections Blood-borne pathogens program Post-exposure pathogen program Training managers & supervisors Preventing mother-to-child transmission
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Effective HIV/AIDS programs in medium- to high-risk settings have been shown to be cost-effective, especially with the huge decrease in the cost of drugs for the treatment of HIV. Globally, the rollout of anti-retroviral drugs has reached unprecedented proportions in most countries. In addition, many companies are now choosing to put workplace HIV programs in place, especially in medium- to high-risk settings, as it makes good business sense. The Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria is just one such example, with many prominent mining companies as members. An effective HIV prevention strategy cannot rely on only one type of intervention, and, as with malaria and TB, an integrated management approach must be used that involves a variety of different interventions. The basic principles for effective prevention of HIV among workplace employees and the community are summarized in Box 4.1. These principles should not be seen in isolation from overall national, provincial or sector HIV/AIDS strategies and programs. They are, however, valuable in guiding workplace policies and programs and community outreach programs with the goal of reducing HIV transmission. A basic approach and associated goals are summarized in Table 4.1. The principles, although not exhaustive, are elaborated on in this document in order to provide an outline of a model for comprehensive preventive action. Furthermore, and most important, supporting anti-retroviral therapy in mature HIV epidemic settings is now seen as a key and cost-effective strategy to support prevention, reduce transmission and keep employees productive. A summary of the key components of an effective HIV strategy is provided in Figure 4.1. 4.2 PREVENTION HIV transmission among employees can and should be prevented. To achieve this, a range of properly planned and consistently delivered interventions should be included in workplace prevention efforts. A strong commitment and concerted support from management, unions, employees and, where appropriate, the community, are prerequisites for the creation of a coherent prevention strategy. Box 4.1: Basic Principles for Effective HIV Prevention Reaching out to infected employees and the affected communities to provide information and improve communication and education Ensuring confidentiality of results Providing easy access to health and social services Providing a safe working environment for employees Participating in strategic community outreach programs Promoting and providing HIV testing to encourage all employees to know their HIV status Providing ARV treatment to employees.
The key elements of an HIV/AIDS prevention program are as follows: Education and awareness Peer education Training of line managers Occupational Health and Safety Procedure review Blood-borne pathogens program (forms part of health and safety review and provides ARVs for post-exposure prophylaxis) Condom distribution Sexually transmitted infection surveillance and treatment Consideration of male circumcision, promotion/facilitation Prevention of mother-to-child transmission Strategic community outreach programs, especially those targeting high-risk groups such as commercial sex workers (CSW).
Table 4.1: Basic Approach for HIV Prevention Strategy Management strategies Outreach or community programs Workplace programs Goal
Raising Awareness Awareness programs include information, education and communication activities that address the facts and fiction of HIV transmission and promote preventive measures, while at the same time seek to de-stigmatize the disease. Employees need to be aware that there is no personal risk from casual contact with colleagues living with HIV or AIDS. Awareness activities should inform employees about the real risks and educate them about ways to minimize their exposure. It is also important for people to understand the multiple impacts of the HIV infection on relatives, friends, casual encounters and the overall community. Messages could emphasize the costs that an HIV/AIDS infection can have for individuals and their families, including the reduction of income as a result of poor health and the consequences for children who lose their parents.
To manage and mitigate the impact of the epidemic by applying the 9 Step approach outlined in these guidelines.
To contribute to broader community, mining sector and societal HIV/AIDS responses.
To prevent new HIV infections in the workforce and to provide treatment, care and support for infected and affected employees. Furthermore, to improve the capacity of line managers and supervisors to manage people living with HIV/AIDS.
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Getting the Message Out To be most effective, information should be communicated in local languages. In areas where literacy rates are low, special consideration might be given to nonwritten forms of communication. There are many simple, effective and low-cost ways to raise awareness of HIV/AIDS among employees, as expanded in Box 4.2.
Good Practice Guidance for Mining and Biodiversity
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Going Beyond the Workforce Since activities undertaken outside company gates usually account for most employee infections, many businesses find it useful and necessary to extend their education and awareness efforts beyond the workplace. This includes working with their suppliers and contractors, as well as the local communities in their area of operations. Particularly vulnerable groups, such as women and young people, can be targeted through local schools, employees' wives and local women's organizations. High-risk groups such as temporary construction workers, migrant labourers, truck drivers, men who have sex with men, and commercial sex workers may require specifically adapted awareness messages. De-stigmatizing the Disease Discrimination in the workplace reinforces the stigmatization of people living with HIV/AIDS. At the same time, the workplace offers a unique opportunity to confront societal discrimination and stigma by dispelling myths and communicating that there is no need to fear people living with HIV and/or AIDS. These messages can be further reinforced by workplace-based anti-discrimination policies and programs that demonstrate that people can live and work with HIV/AIDS, often for many years. Encouraging an HIV/AIDS support group for employees or involving people living with HIV/AIDS in company awareness activities can also be powerful means of breaking down misconceptions and fostering understanding and acceptance. Peer Education Peer education is one of the most widely used strategies for raising awareness on HIV/AIDS. Peer education typically involves training and supporting members of a given group to effect change among their peers. A project coordinated by UNAIDS and several other partners in Jamaica identified principles and components that affect the quality and effectiveness of HIV/AIDS peer education programs. These include providing training for peer educators, compensating them in some way, involving them in the design of training curriculum and materials and linking the education program to other services, such as access to condoms, medical care and voluntary HIV counselling and testing.
Box 4.2: HIV/AIDS Awareness Raising Activities Posters, billboards and condoms in high-traffic areas throughout company facilities Messages included with condoms in pay cheque packages Posting the company HIV/AIDS policy in public places in the local languages Placing a Health Questions Box in the canteen or other convenient locations so that employees can anonymously submit questions on health and HIV/AIDS Public posting of Q&A by the nursing staff via bulletin boards or flyers Taking advantage of local resources by bringing in trained counsellors from local hospitals and participating in government and NGO initiatives, including World AIDS Day on December 1st each year
(Source: IFC, 2002)
Voluntary HIV Counselling and Testing A high percentage of those infected with HIV in the developing world are unaware of their HIV status. For example, fewer than 10% of African patients with TB are tested for HIV, while up to 38% of African TB patients are co-infected with HIV (Corbett et al, 2006). From a behaviour change and treatment perspective, this knowledge is critical, as it can reduce risk-taking behaviours such as unprotected sex and can channel HIVpositive patients into a treatment and care program. Furthermore, effective treatment and care of those who are HIV-positive will reduce transmission by reducing viral load. Therefore, a key aim of an effective program is for all employees to know their status.
Review Occupational Health and Safety Procedures While there is no risk of HIV being transmitted in the workplace through casual contact between co-workers, workplace accidents or injuries that cause bleeding can be a concern. At the most basic level, companies should review their existing occupational health and safety procedures and associated supplies and make changes or improvements where necessary to address concerns about blood-borne infectious diseases. Some simple guidelines can be posted in company clinics or at emergency first aid stations on shop floors to help reduce the risk of HIV infection in the event of a workplace accident. First aid boxes should include gloves for dealing with emergencies. Condom Distribution An important element of any HIV/AIDS prevention program is a reliable supply of free or affordable high-quality condoms. Ensuring condoms are available in the workplace addresses a primary limiting factor of their use the stigma associated with purchasing them. Condoms can be made readily available at a company's clinic or through self-service dispensers in bathrooms and in clinic waiting rooms. It is advisable to provide condoms free of charge at the beginning of any program and, later, to maintain one location for free condoms even if they are available through vending machines at other locations. If a company uses peer education as part of its awareness program, the peer educators can be given condoms for distribution to their co-workers. The female condom has also proved effective in certain situations because women have some control in their use.
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Circumcision Information on circumcision as an option to reducing a persons susceptibility to contracting HIV should be provided to employees and form part of any HIV awareness program. Based on three recently completed randomized control trials, WHO has issued a policy note recommending circumcision for HIV prevention in appropriate areas. It is, however, recognized that in some circumstances, cultural issues and, where suitable medical services are not readily available, the potential for secondary health issues will also be important considerations in the promotion of this option.
Photo courtesy Xstrata
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VCT has proved effective in promoting prevention for those who test negative and behaviour change for those who test positive.
Traditionally, mines have perceived VCT as a prevention strategy; however, VCT has an important role to play in channelling HIV-positive employees into treatment and care programs. The ultimate goal of VCT is to capture 100% of HIV-positive employees and have them enrolled in treatment and care programs.
Pre- and post-test counselling is a critical component of VCT programs. As opposed to client-initiated testing, provider-initiated opt-out testing is becoming increasingly advocated at health service provision points. Opt-out testing requires individuals to specifically decline the HIV test if they do not want it to be performed. As minimal pre-test counselling is provided, this approach provides considerable time and staffing cost savings and may increase coverage of testing. Furthermore, it is a WHO/UNAIDS-approved testing methodology, although the same principles of consent, confidentiality and counselling apply. It is important to note that the link between the VCT service and the treatment and care program can be either anonymous or not. If anonymous, the VCT service, when it picks up an HIV-positive employee, will provide the individual with a letter of referral to the treatment and care program, in the hope that the patient will enrol him or herself. Typically, a proportion of these individuals will not be enrolled and will therefore be lost to the follow-up. If the link is not anonymous (but still confidential), then the VCT service will provide the HIV-positive employee with a referral letter, as well as providing the treatment and care program with the details of the person concerned. Such an approach maximizes enrolment rates into treatment and care, provided the VCT service is still well accepted by employees. Although anonymity may maximize participation in VCT, as employees may feel it is more likely that the company will have no knowledge of their results, it typically undermines enrolment in treatment and care, with the converse potentially being true for a non-anonymous approach. Key components of a successful VCT program include confidentiality, employee buyin, access to VCT services, access to treatment and care programs and successful management of stigma in the workplace. Sufficient availability of trained counsellors is necessary for VCT. Fortunately, companies need not bear this responsibility alone. VCT offers a good opportunity for partnerships to develop between companies and government agencies or NGOs that may already offer these services. Experience shows that uptake rates for VCT can vary greatly. Much time and effort is required to market the VCT campaign, and employees who feel that there are significant benefits to testing (such as access to ARVs) will be more likely to come forward and be tested.
Prevention and Treatment of Sexually Transmitted Infections A strong positive correlation exists between sexually transmitted infections and HIV transmission. The presence of STIs within a company's workforce indicates high-risk sexual behaviour, and STIs increase both a person's susceptibility to HIV and the possibility of transmitting the virus through sexual intercourse. Even without the HIV epidemic, STIs are a common health problem among workers and pose a significant
public health risk that should be addressed in company clinics or in collaboration with government and NGOs. With regard to community programs, STI management programs among CSWs who operate in the host community can help prevent transmission in both the community and within the workforce. The Lesedi case study, provided online at www.icmm.com, is a good example of a mining company involved in a community CSW program. Blood-borne Pathogens Program This program should aim to protect all employees against blood-borne pathogens, including HIV, hepatitis B and hepatitis C. The program should define control measures, including universal precautions used to prevent occupationally acquired infectious diseases through exposure to blood and bodily fluids. The use of postexposure prophylaxis (PEP) is outlined below. Box 4.3: Guidelines to Managers/Supervisors in Managing HIV/AIDS Managers and supervisors should: Clearly understand their role in managing HIV/AIDS in the workplace and be able to identify situations where consultation and intervention are required Facilitate access to health care and be supportive of people who have disclosed their HIV status Manage all people with an underlying chronic illness consistently within the organizations guidelines. This helps reduce tensions in the workplace Obtain training to understand key issues and the basics of HIV/AIDS so that when confronted with employees with the disease, their performance can be managed coherently, effectively, legally and ethically
Post-exposure Prophylaxis Program All employees with potential exposure to blood or body fluids (e.g., medical staff and emergency response teams) should have access to post-exposure prophylaxis program packs on site or at the nearest hospitals. Some countries may require PEP to be provided for occupational exposures. WHO and the International Labour Organization provide useful guidelines on PEP, which change periodically depending on current evidence. Training of Managers and Supervisors Line managers and supervisors should receive training in workplace HIV management to improve program success. Guidelines for managers and/or supervisors to assist them in managing HIV/AIDS in the workplace are given in Box 4.3.
Prevention of Mother-to-Child Transmission With no intervention, up to 40% of infants will become infected with HIV in the womb, during delivery or via breast milk. Providing ARVs dramatically cuts the transmission rates for infection in the womb and during delivery, while bottle feeding cuts the transmission via breast milk. Some low-income medical benefit plans, while not offering comprehensive HIV/AIDS benefits, offer a special benefit (ARVs) to expectant mothers who are HIV-positive.
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4.3
Beyond awareness and prevention activities, some companies may choose to offer more comprehensive medical care, treatment and support programs for employees suffering from HIV/AIDS. Provision of drug therapies and the medical monitoring of HIV/AIDS patients can keep employees working and maintain their quality of life for as long as possible. ART provision is cost-effective. Care and support programs may also include counselling on coping skills, work difficulties and depression and can link people to support networks.
Provision of Nutritional Program A well-run HIV program would typically provide nutritional support with multivitamin and folate supplementation, a balanced diet that has been designed by a dietician and protein supplementation for TB patients. Good nutrition has been shown to keep HIV-positive individuals healthy for longer and to delay the onset of AIDS. Targeted nutritional programs should be made available to assist infected employees.
Anti-retroviral Treatment Program for Employees Developments in the area of anti-retroviral drug therapy are advancing rapidly both in the choices and pricing of the drugs. Leading-edge HIV medicine needs to be understood before embarking on a program as it has been found, for example, that certain therapies are causing the virus to become resistant to ARVs. Nevertheless, the correct use of ARVs both lengthens the life expectancy and protects the quality of life of a HIV-positive patient. In the workplace, ARVs can thus make a valuable contribution to both employee and company alike.
Perform proactive occupational health and safety reviews or occupational risk exposure profiles where the physical and psychological job demands are well understood. This will help prevent the employee from being a health and safety risk to others (e.g., a weak and fatigued person having to control a skip) or the job affecting the persons health (e.g., excessive heat aggravating the dehydration associated with AIDS-related diarrhoea). Training in universal precautions for all staff, but particularly for first aiders, is very important. Regularly review job placement of people with HIV/AIDS. There are many well documented cases where a very sick, poorly productive worker can be fully functional within three months of starting ARVs. Recovery and maintenance of renewed health are linked to high selfesteem. Recognizing someones recovery and placing the person in a job with the correct health fit has powerful therapeutic advantages. Seek advice and support from the human resources department or health personnel when in doubt about how to manage ill people. Take a leadership role in dealing with stigma and discrimination in the workplace. Should managers become aware of isolation and the victimization of people with HIV/AIDS in their departments, they need to either re-educate the staff themselves or call in the AIDS training team to deal with the behaviour. If this does not improve, discipline may need to be used. If the stigmatization is not controlled, it can lead to morale and productivity problems. TREATMENT AND CARE
ARV Program for Family Members An unresolved debate is whether a company should aim to provide benefits to family members when these members are not currently covered by medical aid. This is a matter for decision by the company concerned. Preparation for Treatment A brief period of education and other preparation for adhering to HIV treatment is extremely valuable and almost always possible without unduly delaying treatment. Use of peer educators is an especially effective approach. Typically two or three sessions of a half-hour to one hour each is needed. Dispensing of Medication Controlled dispensing of ARV medications, especially early in the course of treatment, allows frequent patient contact and monitoring of any problems with treatment during this critical phase. Opportunistic Infections and Cancers Later stages of the HIV infection are accompanied by a number of opportunistic infections and cancers. Prompt treatment of these infections improves the quality of life and functionality of the employee, as well as extending life expectancy. Ongoing Adherence Monitoring Promotion Adherence should be reviewed and reinforced at every patient contact. A nonjudgmental atmosphere should be promoted so that patients feel free to report lapses in adherence. Many patients overestimate their adherence, but self-reported non-adherence is relatively accurate. A standardized question method asking patients to report the proportion of medication doses taken correctly during the preceding three days has been widely used with variable results. Counting pills remaining in boxes or bottles is another monitoring method, although it correlates poorly with adherence. Viral load surveillance (amount of HIV in the blood tested periodically) is the most accurate measure of treatment adherence.
Adherence Promotion A 95100% level of adherence is critical to the sustained success of ART. This stands in contrast to other chronic diseases, for which 80% adherence is considered acceptable. The requirement for such a high level of adherence, combined with the complexity of ARV therapy, makes this treatment a great challenge to almost all patients, regardless of background, but especially for those also struggling with other medical or psycho-social difficulties. It is especially important to address adherence before treatment begins for two reasons: Patients new to treatment are most likely to make errors in the management of medications. Lapses in adherence when viral load levels are still high is most likely to lead to a selection of drug-resistant mutations.
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Photo courtesy Anglo American/Vismedia
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TB can occur at any stage of HIV. TB preventive therapy is logistically easier to give in the early onset of HIV disease and is possibly more effective than giving it at a later stage. Primary prophylaxis should be offered to prevent TB and other opportunistic infections, and, for certain diseases, secondary prophylaxis may be given to prevent a recurrence. Terminal and Home-Based Care When the patient presents with AIDS and the condition is terminal, they require specific care. This could include hospice or home-based care. NGOs and volunteer groups usually provide this service, although the quality of service may differ from region to region. 4.4 STEP 1: PROGRAM PLANNING AND IMPLEMENTATION SCREENING
Employee Assistance Program Counselling for employees, their families and their dependants on the risk of HIV/AIDS transmission and infection should ideally form an important part of an HIV /AIDS program. Out-sourcing counselling is a useful option as it can provide important confidentiality for employees. Provision of Laboratory Services Laboratory tests that monitor CD4 counts and viral loads are a key component of an ARV program. Laboratories capable of performing these tests should be identified and procedures should be put in place to standardize and manage quality of testing and reporting. Diagnostic tests for HIV and basic blood tests may be managed by a project site health service, but more sophisticated testing may need to be outsourced. The burden of the additional demand of HIV/AIDS on the health care system can be substantial, and for individuals or families it can be unsustainable. Some mining companies have developed or supported programs of home-based care for individuals and families in labour-recruiting areas. Caregivers are trained, and primary health care and palliative care is provided for the dying in Southern Africa, partnering with initiatives such as The Employment Bureau of Africa has extended this assistance to bereaved families and makes welfare support available for the incapacitated terminally ill persons, as well as for the orphans left behind.
Referral or Treatment of Complicated Cases Opportunistic infections that occur as a result of HIV/AIDS can present with complicated pathologies and may need to be managed in a sophisticated medical setting. This required level of health care facility should be identified and evacuation procedures should be put in place. The human resource implications need to be understood in relation to what is covered by medical insurance and what is not.
The potential threat of HIV/AIDS to a project, or from a project to the community, would be determined at the screening step. When available, HIV/AIDS prevalence data are provided by UNAIDS. A low prevalence (<2%) indicates that the likelihood of HIV/AIDS being a problem in the short to medium term is also low. If the operation is
being developed in a region of moderate (25%) or high (>5%) prevalence, the likelihood of HIV/AIDS being a risk to the operation is high. In such regions, research reviewing the impact of HIV/AIDS in the region should be available. Box 4.4 provides a list of mining activities that may increase the transmission of HIV/AIDS and thus make the disease more of a threat to the operation and/or the community. STEP 2: Box 4.4 Operational Activities that may increase the Transmission of HIV/AIDS Activities that result in in-migration of people due to either direct employment by the project or looking for potential work, and that alter the population profile (e.g., gender distribution) of the area Employment of a large number of workers (during construction and operation phase) who live without their families or away from their home communities, resulting in extensive casual sexual relations, including with commercial sex workers Employment of relatively well paid workers in areas of high unemployment and/or poverty, resulting in the engagement of company employees with commercial sex workers Creation of predominantly single-sex (male) working and living environments, and associated incidence of men having sex with men Transportation of materials and people over long distances Location of the operation within a country or region undergoing rapid economic change and lacking structured health, education and HIV/AIDS prevention programs. SCOPING
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Scoping should provide a basis for defining the size, urgency and complexity of the local HIV/AIDS situation and its potential impact on the operation. Conversely, the potential impact of the planned activities of an operation on the HIV/AIDS prevalence in affected communities should also be identified. Information can be obtained from international sources such as UNAIDS, national databanks and company data for existing operations. It is advisable at this stage to use the appropriate technical expertise to define the potential risks of HIV/AIDS. Based on this information, the right mix of expertise and intervention (such as behavioural, medical and management) required to manage the epidemic in the particular situation is determined. The nature of engagement with the local communities and the strategies to be used in preventing the introduction of HIV into
Some analysis (such as cost-benefit analysis) should be conducted to determine the extent of the problem. In medium- to high-prevalence settings, for example, actuarial modelling will be of great assistance in estimating the risk from the impact of HIV/AIDS on production as well as long-term group benefits (pension/provident funds and disability packages) and the burden of disease (number of people requiring treatment and number of admissions) on health resources.
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local communities or the potential increase of HIV prevalence in employee or community groups can then be specified. STEP 3 and 4: SITUATION ANALYSIS AND STAKEHOLDER ANALYSIS STEP 5: PRIORITY, GOAL AND OBJECTIVE SETTING
In the workplace, personnel data such as absenteeism, staff turnover and disability insurance claims, combined with health statistics from the company clinic (such as STI rates among employees), should be reviewed. This information may be complemented by a more qualitative assessment such as a survey of managers, foremen and employees to determine general attitudes and perceptions about the impact of the disease on operations and whether people feel they are at risk. For communities, the national Ministry of Health and NGOs operating in the area would provide relevant statistics. A survey of the local conditions may, however, be necessary. HIV/AIDS should be tackled in a manner that is based on its risk to the facility and the community rather than on external pressures, such as the media. A good situation analysis will help organizations make correct and defensible decisions on their allocation of resources. The attention to detail and the clarification of expectations are probably more important in dealing with HIV/AIDS than with the other two diseases. Typically, companies have two objectives in undertaking a workplace HIV/AIDS program: To limit the incidence of new infections among staff and the surrounding community, To manage the impact of existing infections on the company, staff and community. The situation analysis requires detailed information about the population who are working and surrounding the operation. Their strengths and vulnerabilities need to be defined. The details of these tasks are well explored in Section 2.
Reference to a corporate HIV/AIDS policy, if available, would greatly assist in meeting the objectives of Step 5. In the absence of a corporate policy, one would need to be developed with the assistance of appropriate medical expertise, although a number of guidelines do exist. Information from the situation and stakeholder analyses should be used to make the policy relevant for the local conditions.
Priorities should be based on the findings of the research conducted in the previous steps. If, for example, the analysis shows an epidemic in its early phase with few cases of AIDS, the priority should be on prevention. Alternatively, a well-established epidemic that will affect the productivity of workers would need to focus on the provision of medical treatment and care, such as wellness interventions and the provision of ART with the associated support services.
In order to achieve these objectives a company's program might set goals in three areas changing behaviour and increasing the use of preventive measures; improving medical care and support to persons affected by HIV/AIDS and other infectious diseases; and improving the capacity of line managers and supervisors to manage people with HIV/AIDS. STEP 6: Box 4.5: Points to be Considered in HIV/AIDS Programs As the roll-out of HIV/AIDS programs is often impaired by the fear of stigmatization or victimization, the choice between in-house and external providers needs to be carefully considered. The cost of error in HIV/AIDS tends to be greater than in other health interventions, and mistakes can lead to a significant amount of time and effort being expended in damage control or even halting of the programs. It is advisable, therefore, to use experienced service providers. The information from the actuarial review is often very useful in helping a company decide whether to offer ART through the company health service or medical scheme or instead to refer patients to state or NGO treatment programs. Funding of HIV/AIDS programs may come from various sources. Prevention and treatment programs can be funded by major NGOs. In certain cases, company medical insurance can be used to fund the ARVs and hospital expenses. Model 1: Model 2: Model 3: Model 4: Employer Provider Medical Aid Scheme Independent Disease Management Program Clinic Provider (see Annex A, Box A3 for more information). OPTION APPRAISAL
HIV/AIDS program options will be determined by the results of the previous five steps, including the size and life of the project and the availability and quality of local health services to treat HIV/AIDS. Some points relevant to HIV/AIDS programs are listed in Box 4.5. Companies may make HIV/AIDS care and treatment available to employees through totally state-provided health care, private/public/NGO partnerships, purely private (or company) health care interventions or a health insurance model. Often a mix of the HIV/AIDS program elements is put together in the options chosen. In South Africa, for instance, typically four models are available:
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Each of the options of care and treatment involves some level of financial cost to the employer. The effectiveness of the different options when enrolling HIV-positive members and providing high-quality care and treatment is rarely effectively communicated by providers of the services.
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Once a company has determined that the existing or potential risks of HIV/AIDS to its workforce or to the community are sufficient to warrant action, it should be recognized that a large part of the problem, as well as the solution, lies outside the fence of a company's operations and medical facilities. Resources in the wider community from which companies can benefit include NGO activities, public programs undertaken by Ministries of Health or national AIDS committees and initiatives launched by other businesses, employer associations or medical organizations. Partnerships can help private firms better analyse their risk factors, design and implement focused programs, leverage their resources, learn from the experience of others and ensure independence and confidentiality of employees' condition and care. HIV/AIDS programs should not be seen in isolation and, where feasible, they should be linked to other health and psycho-supportive programs, such as employee assistance programs and general life skills education. It should be stressed that there needs to be a focus on both the programs quality and effectiveness and the ever-changing situation in the world of HIV/AIDS. Scientific, demographic and even political changes can all influence how the HIV/AIDS program should adapt. STEP 8: STEP 9: PROGRAM IMPLEMENTATION MONITORING AND EVALUATION Program implementation needs to constantly feed back into the defined sets of goals, objectives and targets. Senior management support is a key success factor for successful program implementation, in addition to appropriately skilled human resources. The local circumstances largely determine how programs will be applied, as each situation is different. HIV/AIDS has more of a behavioural element than either TB or malaria, which requires sensitive management and good skills in training and communication. The higher media profile of HIV/AIDS should also be used to publicize the challenges and the achievements of the program. Table 4.2 provides a list of suggested key input, process and outcome indicators to monitor performance of a program. The choice of indicators will depend on the local context. It is highly recommended that the final choice of indicators be determined by an expert. If the HIV program is STEP 7: PROGRAM DESIGN, BUDGETING AND REPORTING
A useful exercise to develop an effective program is to follow the natural history of one patient, from the time of recruitment to the time of departure from the company, and define the resources required at each step of the process. Questions should be asked to determine the most effective (and cost-effective) way of managing that person at a particular phase of the disease. Gaps and overlaps in the service should be identified and optimized accordingly.
outsourced, it is vital that proper M&E is performed by the contractor. Contractors should also adhere with the M&E process to enable their programs to be assessed adequately. The frequency of monitoring depends on the incidence of prevalence of HIV and the type of program. Table 4.2 also provides suggested targets and frequencies for a high-risk setting. Table 4.2: Monitoring and Evaluation Indicators Indicators Condom distribution: Number of condoms available Number of condoms taken Number of condoms taken per 1,000 employees* Peer education activity: Number of peer educators trained and active as peer educators* Improved knowledge, attitude and behaviour practices: Knowledge, attitude and practices - focus group discussions, in-depth interviews and/or cross-sectional surveys covering HIV prevention, treatment and care VCT/testing: Number of people attending VCT counselling* Per cent of VCT-counselled people who took an HIV test* Number of people who took provider-initiated opt out testing* HIV policy in place and reviewed* Number and positions of staff contracted* Financial resources committed and spent* Infrastructure provided* Suggested Target 100% 1 per 50 employees Annually Monthly Monthly
continued over
Every 3 to 5 years
Frequency
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Output
Process
Input
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Indicators
Acceptability of program: Per cent of the workforce attending VCT* Per cent of those identified as positive who are registered in a treatment and care program* Per cent of people registered in a treatment and care program attending for treatment* Treatment effectiveness: CD4 counts: track number of patients on treatment at 6, 12, 18 and 24 months whose CD4 count is above 200/ml* Viral loads: Per cent of those started on treatment with a > 1 log reduction at 68 weeks after starting treatment Per cent of those on the program adherent to treatment, defined as a proportion at months 6, 12, 18 and 24 with undetectable viral load (<400 copies / ml)* 3 day pill recall (needs careful definition depending on the context) Absenteeism statistics (all causes): Per cent of workforce absent from work* Average duration of absenteeism Comparison of HIV population on disease management program against general work population Death statistics: Death rate stratified by natural causes and trauma Disability statistics: Per cent of workforce medically boarded* Per cent of workforce needing workplace accommodation due to medical incapacity* Actuarial model cost-benefit analysis: Enhancing model with updated, hard data such as incidence, prevalence, disabilities and deaths. Impact projections for the medium to long term provided to estimate impacts Economic impact of intervention and future cost benefit modelling Incidence of HIV: Technological advances may allow for reliable measurement of incidence. (Discussion with an expert and review of current technology is necessary.)
Suggested Target
>90% >90% >90%
100%
100%
100%
Frequency Annually Monthly Annually Annually Annually
* Good practice core indicators
Every 5 years Initially and every 2 years
Evaluation
Outcome
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SECTION 5:
TB programs
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5.1 OVERVIEW
5.2 PREVENTION
5.3 TB DETECTION Screening Tests for Active TB Screening Tests for Latent TB Infection 5.4 TREATMENT AND CARE Abbreviations used AIDS DOTS HIA HIV IGRA M&E MDR-TB NTP PPV TB TST VCT WHO XDR-TB STEP 2: Scoping STEP 6: Option Appraisal STEP 8: Program Implementation STEP 9: Monitoring and Evaluation
5.5 PROGRAM PLANNING AND IMPLEMENTATION STEP 1: Screening acquired immune deficiency syndrome directly observed therapy, short course health impact assessment human immunodeficiency virus interferon-gamma release assay monitoring and evaluation multi drug-resistant tuberculosis national TB control program positive predictive value tuberculosis tuberculin skin tests voluntary counselling and testing World Health Organization extensively drug-resistant tuberculosis
Section 5. TB programs
TB PROGRAMS
STEPS 3 & 4: Situation Analysis and Stakeholder Analysis STEP 5: Policy, Priority, Goal and Objective Setting STEP 7: Program Design, Budgeting and Reporting
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80 80
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5.1
Estimated TB incidence rate, 2005
OVERVIEW
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KEY FACTS: According to the WHO Stop TB Strategy: TB bacilli infect about one-third of the worlds population, with the majority of infections being latent rather than active TB. Someone in the world is newly infected with TB every second. About 510% of HIV-negative people who are infected with TB bacilli become sick or infectious at some stage during their lifetime, with the highest risk period for active disease being in the two years after they were originally infected with the TB bacillus. In HIV-positive people, however, the risk of developing active TB once infected increases dramatically to 1015% per year. This has led to an explosion in active TB in sub-Saharan Africa and the resurgence of tuberculosis in many developing countries.
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TB is a curable disease. But at the regional and country level it requires a strong national program for its control, the quality of which is a key factor in reducing the impact of TB on mining operations. Company TB programs should therefore always be developed in conjunction with national or regional programs and health services, with as much integration of the TB and HIV programs as possible. For mining companies in medium- to high-risk areas, active TB programs are typically justified and should be supported. It is good practice to involve employees in program development and implementation. Ideally this should happen through established employee representatives, for the reasons listed in Box 5.1. Box 5.1: Reasons for Participation of Employee Representatives in TB Programs While TB is curable, it requires a long period of treatment and excellent patient adherence, which is more likely if there is employee buy-in. Employees found with early infectious TB may not feel ill. Furthermore, they will need guidance and support in order to identify the potential symptoms and need for early treatment. Employees are likely to fear for their job security if they are identified with TB, and they require reassurance. The strong connection between TB and HIV may transfer some of the stigma of HIV to TB.
TB treatment should be made free to the patient, whether in-company or through area health services, because of the need for prolonged treatment periods and high levels of patient adherence to prevent the emergence of drug-resistant strains. Over and above the recommendations of a national TB control program (referred to as an NTP), there are a number of considerations specific to a mining operation that require additional measures. These considerations include the effect of: While the initial target of a company TB program should be its own employees and those of contractors, TB in the surrounding or labour-sending communities should be considered an important part of the extended mining environment.
The recruitment of workers from high TB incidence communities, including those coming on site as part of contractor operations The additional risk of TB conferred by silica dust at certain operations The additional risk of TB conferred by high HIV infection rates among employees or prospective employees The in-house spread of TB facilitated by camp or hostel accommodations (and of HIV to and from surrounding communities) In-migration caused by the mining operation and associated over-crowding and/or development of informal housing, resulting in poor living conditions and the increased spread of TB Occupational disease compensation laws requiring the reporting of pulmonary TB with or without pneumoconiosis. Leading practices for an in-company TB program in a high-prevalence TB setting are listed in Box 5.2.
5.2
TB prevention can be directed at two points in the cycle of infection and disease.
The first point of intervention is to prevent the passage of the TB bacillus from someone who is infectious to someone who is not yet infected. The focus of this first point of intervention is on finding and treating infectious cases (discussed further under Treatment and Care in section 5.4). The second point of intervention is to prevent persons infected with the bacillus (latent infection) from developing active disease. The focus here is on maintaining good general health and, in the mining context, trying to control two powerful risk factors for active TB silicosis and HIV infection. An additional control measure that has been shown to be effective is to give prophylactic (preventive) treatment to people infected with TB who are at high risk of developing active disease. Apart from treatment, there are a number of elements crucial in TB prevention that have particular relevance to the mining industry. These measures include: Adequate accommodation and facilities for employees to limit TB cross-infection, particularly the avoidance of cramped and poorly ventilated living and recreational facilities Where the company is responsible for the provision of meals, adequate nutrition for employees based on sound nutritional principles and designed by a dietician. Specific nutritional support should be provided to employees with active TB or HIV who are underweight The reduction of silica dust exposure at operations in order to reduce employee risk of active TB Health education for employees aimed at understanding TB and HIV. This education should include the importance of controlling occupational factors such as dust exposure but also at reducing smoking and heavy alcohol intake, which may contribute to TB risk
Box 5.2: Leading Practices for an In-company TB Program Education of the workforce on TB Active screening of employees Reduction of cross-infection in healthcare facilities and company housing Integrating TB and HIV programs Silica dust control Quality sputum microscopy services (preferably with fluorescent microscopy and 24-hour turn-around time) Sputum culture either onsite or offsite depending on quality of offsite laboratories and other local contextual factors, such as health service capacity, cost constraints, and MDR-TB prevalence Ensuring high cure rates critical to preventing drug resistance and ensuring overall program success Monitoring and evaluation essential for the reasons outlined in Section 2 Community outreach programs. PREVENTION
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An HIV program linked to the TB program Protection of health care staff from TB infection. (see Box 5.3)
Figure 5.1 provides a summary of the key elements of a TB control program. 5.3 TB DETECTION
Active screening or case detection for active TB refers to the regular examination of all employees and prospective employees (or community members) at risk of TB. This is contrasted with passive screening in which people are encouraged to present themselves to the health service if they have symptoms of possible TB. Deciding which tests to use for active case detection is complex, as there are many factors in the target population that influence the effectiveness of individual screening tests. These factors include: Prevalence of active undiagnosed TB Prevalence of HIV infection Prevalence of prior TB Age distribution of the population Whether the population is unscreened or highly screened.
Screening Tests for Active TB Detection of latent or active TB is not easy and relies on a number of different strategies. In high-prevalence settings, active screening programs are preferred to passive ones as they are more likely to detect infected employees.
Box 5.3: Measures for Protecting Health Care Staff Occupational risk assessment for exposure to infectious patients and specimens Modification or construction of health care facilities to maximize ventilation in waiting areas and wards Special air extraction and filtration units in high-risk areas Intensive education of health care staff about early symptoms of TB and about modes of TB transmission Entry and pre-placement medical screening of all health care staff Regular medical surveillance of health care staff with symptom checks and, where appropriate, immunological testing and/or sputum and/or chest radiographs Provision of appropriate protective masks to staff in certain high-risk settings, such as collecting sputum specimens Offering voluntary counselling and testing to staff, emphasizing the increased risk of pulmonary tuberculosis in HIV-positive staff working in health care settings Separation of congregation areas of known or suspected infectious TB cases and provision of surgical masks for coughing patients where appropriate Isolation wards and special procedures for handling MDR-TB or XDRTB in patients.
Figure 5.1: Key Elements of a TB Control Program

Prevent TB bacillus spreading from infected to uninfected individuals Prevent individuals with latent infection developing active disease Create the right environment Regular examination of all and prospective employees at risk from TB
Directly observed therapy, short course program
is the recommended international framework: Top management/ corporate commitment to internal and national programs and international benchmarks Good quality diagnosis with adequate facilities and employee education and confidentiality Standardized short-course chemotherapy under direct observation in controlled conditions, providing support for adherence (by company health service, if appropriate) Uninterrupted supply of quality-assured drugs Recording and supporting system capturing and reporting performance of individual patients and performance of the program against accepted benchmarks
ACTIVE SCREENING Choice of test Type of test
is context specific and requires specialist knowledge. Need to consider: Prevalence of active, undiagnosed TB, HIV infection and prior TB Age distribution of population Level of screening Cost and logistics needs to be sensitive and avoid false positives: Symptom check Chest radiograph Microscopic examination of sputum. Tuberculin skin tests for latent TB infection
OBJECTIVE
PREVENTION DETECTION

TREATMENT & CARE
Encourage employees to present themselves if they suspect symptoms of TB
Find and treat infectious cases Maintain good general health Control silicosis and HIV infection Provide preventative prophylactic treatment Provide adequate accommodation/ facilities Ensure good nutrition Provide health education Integrate HIV & TB programs Protect health care staff
PASSIVE SCREENING
INTERVENTION
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Screening tests in common use include symptom check, serial weight measurements, chest radiograph, microscopic examination of sputum for TB bacilli and laboratory culture of sputum. The purpose of case finding is to reduce the duration of infectiousness of any given case. Therefore in the first instance screening tests need to be sensitive that is, they should be able to pick up most cases of active TB in the population being screened. (See Box 5.4) It is also important for the screening program to avoid false positives, which would lead having to investigate large numbers of people who do not have active TB (or even treating such people unnecessarily). Positive predictive value (PPV) is the characteristic that describes the proportion of positives on any given screening test that has the disease. PPVs are influenced by how common the disease is in the population and are higher the more prevalent the disease. In a study among gold miners, symptom check alone had a low PPV (<10%), sputum microscopy and chest radiograph intermediate PPV (3040%), while culture had the highest PPV (> 90%). Symptom checks alone are therefore not sufficiently sensitive and should be used with other screening tests. Box 5.4: Sensitivity of TB Screening Tests In a highly screened population of South African gold miners, symptom check, chest radiograph and sputum microscopy were found to be of equally low sensitivity in detecting cases (2530%). Laboratory culture alone had a much higher sensitivity (77%). Combining test types increased sensitivity. For example, combining symptom screening with a chest radiograph increased sensitivity to 50%. The combination of symptom screening, chest radiograph and sputum microscopy increased sensitivity further to 65%. Adding sputum culture increased the sensitivity to 98%. In contrast, in unscreened general communities the sensitivity of symptom screening has been found to be higher, between 50% and 80%. (Source: G. Churchyard, personal communication)
In addition, cost and logistics will determine the final choice of program. The choice of screening tests is thus highly context-specific. As new or improved diagnostic methods are developed or become less expensive, case detection program protocols will change. Advice on leading practice should thus be obtained from a specialist familiar with local conditions and policies and with those of the areas or countries from which the workforce is recruited.
Screening Tests for Latent TB Infection Tuberculin skin tests are based on an immunological reaction to a derivative of the bacilli that is injected under the patients skin and monitored over 72 hours. When positive (shown by a red swelling of the skin), they indicate infection rather than active disease. They are useful for future prediction, such as in managing latent TB infection in populations with low rates of TB where there is a policy of treating any new TB infection that is detected. Where there is a specific policy of treating latent TB infection in groups at high risk of TB (e.g., HIV-infected individuals), TSTs may also be useful. It should be noted, however, that these tests have a high rate of false negative results in the advanced stages of HIV disease.
New tests of latent infection (e.g., interferon-gamma release assays) are being used to identify latent, recent and re-infections and to monitor response to TB treatment. Currently they do not have an established role in screening for or diagnosing active TB. More information is needed about their value in specific populations such as HIV-infected individuals. IGRAs are recommended for screening expatriates from low-prevalence TB countries before, during and after deployment to a highprevalence setting. The aim would be to treat new infections or latent TB before active TB develops. Screening in this instance should be performed at a minimum annually and ideally every six months. 5.4 The recommended international framework for TB treatment is the WHO-supported DOTS program directly observed therapy, short course. In any country this may be adapted by an NTP. This program is described in considerable detail in the documents cited in Annex E. Up-to-date protocols are available on the WHO Web site: www.who.int/tb/dots/en. Table 5.1 provides an overview of the key elements of a DOTS program as it applies to a company TB program, with associated company responsibilities listed. Table 5.1: DOTS Program Element Political commitment Standardized short-course chemotherapy under direct observation Good quality diagnosis particularly TB sputum microscopy in all suspected patients Uninterrupted supply of quality assured drugs Recording and supporting a system capturing individual patients and program performance Key DOTS Program Elements Equivalent Company Responsibilities TREATMENT AND CARE
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Top management/corporate commitment to a TB program, as well as to the NTP and international benchmarks (see Annex E, Useful Resources) Employee education to present early if they have certain cardinal symptoms, including policies protecting job security and confidentiality and the creation of a climate of openness about TB Support for NTP for diagnosis, or provision of in-company facilities for diagnosis as part of passive or active case finding Establishing conditions for employees to be treated for six months or more under observation, while minimizing economic loss or job security threat Support for employee adherence wherever treated e.g., with in-company treatment supporters Provision of chemotherapy by company health service, if appropriate Sourcing of drugs through NTP, direct commercial purchase, or via international agencies Notification to NTP Within confidentiality requirements, tracking all employees diagnosed with TB whether in-company or referred out Monitoring in-company program performance using accepted benchmarks and reporting of program performance to NTP.
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5.5
Company policy, agreements, adopted conventions and other initiatives may require a project to put procedures in place for dealing with TB. In addition, particularly in areas of medium to high TB prevalence, there may be health and safety legislation within the country that requires a mining company to manage TB risk in the workplace. This is especially pertinent for mining companies that operate on-site health clinics and where there is significant exposure to silica dust. Furthermore, this step in the management plan process requires an understanding of whether there is a risk posed by TB to the mining operation or project and/or whether the operation or project poses a risk of increasing TB transmission. Understanding the risk of TB to a mining operation: The risk of TB to the project will be determined by the number of employees with untreated TB at entry and the number of employees that develop TB during employment. The key indicator is the TB incidence rate. A specialist with occupational health or public health expertise will need to assist in the decision regarding whether the TB incidence rate is a risk to the mining operation or not. TB rates vary greatly by region and by social group within regions and have historically been a marker for poor living conditions and social pathologies, such as alcoholism. In a mining context, exposure to silica, hostel or camp accommodation and migrancy will contribute to an increased risk of infection or active disease among existing or potential employees. If the operation already has an active health service that collects data on TB among employees, the annual incidence rate in the mine workforce could be calculated. Failing this, an incidence rate across the industry as a whole may be available. In areas with poor health infrastructure and inadequate disease surveillance, accurate figures may not be available. In such cases, local government medical officers may be able to provide an assessment of the degree of risk that TB poses.
TB incidence rates are generally expressed as the number of new cases per 100,000 people (from the population giving rise to those cases, which could be the whole local population or just company employees). For example, incidence rates in the South African gold mining industry are of the order of 3,000 cases per 100,000 employees per annum. The WHO national estimate for Angola in 2005 was 269 per 100,000 p.a. and for Brazil, 60 per 100,000 p.a. Assessment of the significance of these incidence rates, in terms of the risk to a mining operation, will need to be carried out by an occupational health or public health expert, as there is no generic rate of TB incidence that equates to a specific level of risk to an operation.
STEP 1:
PROGRAM PLANNING AND IMPLEMENTATION SCREENING
Data on national or area TB incidence and other indicators relevant to the mining operation should be available from local or national health authorities or WHO (see Annex E). The screening assessment should include TB rates in the area from which the employees are recruited as well as rates in local populations with which employees will come into contact. Rates of local MDR-TB and XDR-TB should be obtained as well, as the spread of drug-resistant TB among employees would have significant consequences.
Determining whether the facility poses a risk of increased TB transmission: This question forms part of establishing the social licence to operate. For example, if workers are recruited from other, higher-incidence areas, there is a risk of TB transmission to local residents if ongoing contact with local communities is established. The same effect would be achieved where occupational factors, such as silica dust, greatly increase workforce TB risk. There may also be a danger of overloading area TB health services if there is a large increased burden of TB cases as a result of new mining operations. Answering this question requires some information on incidence among new employees and the TB risks inherent in the mining operation itself. For facilities in the operational phase, company data and reports that provide information on existing TB epidemiology in the workforce and affected community, hazard identification and risk assessment of silica dust for the facility will be useful for performing a data gap analysis and developing the TOR for Steps 3 and 4. The quality of data from national and regional data sources must be carefully assessed before using them for decision-making. Assessment of additional risk factors for TB: This would include the occupational hygiene assessment of silica exposures and an estimate of HIV prevalence in the workforce, as well as assessing other upstream risk factors for TB in the workforce and affected community as part of any literature review and/or HIA. Workforce screening survey: This involves screening employees for TB and can add useful information, particularly if the desktop assessment has not been able to get hold of reliable data. The screening survey can be used to measure the prevalence of past TB (whether reported by the employee STEPS 3 AND 4: SITUATION ANALYSIS AND STAKEHOLDER ANALYSIS STEP 2: SCOPING
The latest epidemiological information, new research and updated program and technical protocols are accessible via a number of Web sites and other data sources. These are detailed in Annex E. Section 2 outlines the key activities and information requirements that should be carried out as part of the situation analysis. At this stage, any planned health impact assessment must include a TB component as part of the process. In addition, four other activities specific to TB should also be examined.
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Photo courtesy Lung Health Image Library/Pierre Virot
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or apparent on the chest radiograph) and the prevalence of current active TB (undiagnosed TB detected by the screening plus employees arriving for TB treatment). STEP 5: STEP 6: PRIORITY, GOAL AND OBJECTIVE SETTING OPTION APPRAISAL
Workforce knowledge, attitudes and practices survey: This can provide useful baseline data on employee knowledge, attitudes and practices that relate to TB and can be conducted as part of a broader survey that includes HIV and malaria. It can be performed cost-effectively and efficiently through the occupational health service for operational phase projects. Section 2 outlines the key considerations for priority, goal and objective setting. In terms of specific guidance for TB, it should be noted that the setting of objectives should be linked to the level of TB program selected minimum, intermediate or gold standard (see Step 6: Option Appraisal).
Risk assessment: Finally, a projected impact on the facility will be determined by the estimated number of new TB cases among employees each year during the life of the operation. Other factors that need to be taken into account are whether these are new or re-treatment cases (influencing length of treatment and time off work) and whether they are complicated by other diseases or permanent health damage (influencing return to full work capacity). In addition, delayed diagnosis and treatment will influence the number of untreated TB cases in the workforce and the potential for the spread of TB to other employees, including in-company medical personnel. The risk assessment process will provide an estimate of the level of risk quantified by estimates of either potential sick days lost, costs incurred, or incidence rates in the workforce and community without any intervention. The risk assessment can qualify the risk to the facility and the community as low, medium or high. Objectives for the minimum package, for example, would include ensuring that all employees receive education about TB (and HIV) within one year of commencing the program and that TB in an employee is detected as early as possible for referral and treatment. Within the intermediate package, one objective would be to screen all employees annually for TB, while in the advanced package an objective could be to ensure that all HIV-positive employees received prophylactic therapy against TB. TB program options will be determined by the relevant TB incidence rates, the size and life of the operation and the availability and quality of local health services to treat TB. Based on these factors, there are three recommended options: minimum, intermediate or gold standard. These are outlined in Table 5.2.
Table 5.2
MINIMUM
TB Program Options
(Reliance on area health services)
INTERMEDIATE All of the above, PLUS:

(Closer links with local health services, including in-house resourcing)
TB Program options
Recommended Program Elements
GOLD STANDARD
(Full in-house health services)
Policy or statement on TB, including protection of employment rights and confidentiality Education of all employees about TB and HIV Support for passive case finding Liaison with area health services regarding return to work and work capacity of individual employees Linkage with HIV/AIDS activities, e.g., VCT DOTS program support in the workplace with the drugs delivered by the NTP Active case detection of TB (screening) Closer partnership with area health services for treatment, adherence support of employees and possible resource support In-company VCT programs In-company quality microscopy and chest radiograph service TB preventive therapy Education programs aimed at communities and local health care providers Treatment of dependents
See Section 4 on HIV In-company laboratory capabilities (preferably using fluorescent microscopy with 24-hour turn-around time), and radiography services In-company management information system M&E system for monitoring TB cases and meeting NTP notification including human resources and health care requirements, together with regular facilities; ability to maintain confidentiality program evaluation
Influencing Factors
All of the above, PLUS: Provision of DOTS in company health services Sputum culture and drug resistance monitoring
Education level of employees; in-company or area health education resources Quality of diagnostic services in area Existence and quality of area health services; ability of system to maintain confidentiality See Section 4 on HIV Sustainable company health care infrastructure Capacity of area health services In-company x-ray and laboratory facilities
Corporate policy, country legislation, national TB policy, international benchmarks
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Sustainable company health care infrastructure Laboratory capabilities but could use outside laboratory services provided quality control is good HIV and silicosis prevalence Wider stakeholder relationships Employee living and family situation including access by dependents to company facilities
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Program design and budgeting will be determined by the choice of options above. Generic considerations for this step are spelt out in Section 2; however, the following should be taken into account in TB program design: Legal compliance requirements: These may include specific notification of TB to state agencies; occupational health and safety duties, including protection of all staff against TB in the workplace; and compensation for occupational tuberculosis (in operations with silica exposure and health care facilities). Budgeting: Annex A, Box A1 provides examples of external funding sources that may be approached for assistance. Outsourcing: Services suitable for outsourcing might include HIV/TB education of employees, microscopy testing of sputum; x-rays for active case finding; drug storage and shipment. STEP 8: PROGRAM IMPLEMENTATION Drug procurement: Ensuring an uninterrupted supply of good-quality TB drugs is essential where in-company treatment takes place. Sourcing will vary with the country and size of operation. In many countries, the NTP will provide first- and second-line drugs obtained through the state tender. This can be backed up by procurement directly from pharmaceutical suppliers, for example to ensure a threemonth cushion. Combination drugs are useful for monitoring and enhancing adherence. TB program requirements are constantly changing under the pressure of the HIV epidemic and the escalating threat of drug resistance. Where there is a welldeveloped NTP, these changes are likely to be incorporated into that program. Program managers need to keep abreast of these developments and make use of updated training opportunities for health care staff. All new health care staff should have a TB induction and ongoing TB training. Table 5.3 provides an example of standard operating procedures for an in-company TB health program. These procedures provide a useful checklist for project implementation. There are a number of other key considerations specific to TB programs: Sick leave: TB treatment always involves extended sick leave. In some in-company treatment programs, hospitalization for the first two months of treatment (intensive Where second-line drugs required for the treatment of MDR-TB and XDR-TB are not available in-country, direct international procurement may require the approval of the in-country medicines control agency. The Global Drug Facility of WHO provides support for government and NGO TB drug procurement and quality assurance operations. The Green Light Committee of the WHO Stop TB Partnership assists in the procurement of second-line drugs for the treatment of MDR-TB and XDR-TB.
STEP 7:
PROGRAM DESIGN, BUDGETING AND REPORTING
phase) is recommended. HR policies and systems thus need to be sensitive to the treatment cycle and possible complications, such as further prolonged sick leave work incapacity or even death (particularly in HIV-positive employees). Table 5.3: Example of Standard Operating Procedures for In-Company TB Standard Operating Procedures Follow-up of positive TB sputum Direct observation of treatment TB treatment and sick leave Counselling of TB patients Awareness and management of TB at all levels of the health service Internal and external laboratory quality control for TB investigations Collection of sputum specimens for laboratory investigations Quality control of chest radiographs Reporting of TB to national TB control program Discharge of TB patients from hospital Transfer of a TB patient to an outside health service Permanent disability assessment following completion of treatment Investigation of patients with suspicious chest radiographs and periodical examination Food handler program for site caterer, with procedure for TB screening Procedures related to the compensation of TB as an occupational disease
Continuity of treatment: For employees being treated for TB, continuity is imperative. Continuity assurance should be a key indicator of any TB program. For example, employees being treated for TB who leave the company, whether temporarily (on leave) or permanently (incapacity), need to be linked up to appropriate health services in their area of residence.
Return to work: A clear return-to-work policy is needed for the employee with TB and because of possible anxieties among other employees. Constantly reminding all staff that TB is a curable disease is necessary to dispel stigma and misperceptions. Return to work will be linked to medical certification that the employee is no longer infectious and is not otherwise ill or incapacitated for his or her usual work. If permanent incapacity has resulted, the companys normal permanent incapacity procedures should be applied.
Transfer of medical records: For all employees, when medical records are kept incompany, provision needs to be made for the transfer of important information with the employee at exit (e.g., past TB treatment experience). The medical record is thus both an important input and output of the program.
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Monitoring and evaluation are essential activities. A failing program can actually do harm through incomplete treatment of TB cases and promotion of drug resistance. Regular monitoring should enable assessment of the TB program against clear indicators. Table 5.4 sets outs some possible indicators under the headings of input, process, output and outcome. Indicators should be chosen that are appropriate to the context or the program and with expert input. Table 5.4: Selected Indicators for Monitoring and Evaluating the TB Program
Policy and standard operating procedures in place Number and position of staff contracted Financial resources committed and spent Infrastructure provided All staff educated about TB Frequency of reporting by health care unit to senior operations management on TB Per cent of registered TB cases that are bacteriologically diagnosed (smearpositive) Per cent of registered TB cases for whom the treatment outcome is known Per cent who failed treatment or defaulted Example of indicator Per cent of TB cases completed treatmenton which drug susceptibility testing to first drugs was performed (in countries that have appropriate laboratory capability; second-line drug testing depends on results of first-line sensitivities) Per cent of new smear-positive TB cases cured* Per cent of new smear-positive TB cases that convert to smear-negative at the end of the initial phase of treatment Case fatality rate (% of registered TB cases who die from TB) Program Element Quality of TB program management Monitoring of key inputs Monitoring of key inputs Monitoring of key inputs Company commitment Integration into operations Quality of diagnosis of suspected cases Ability to secure treatment adherence Ability to secure treatment adherence Quality of monitoring and follow-up of employees transferred out Quality of monitoring for MDR-TB and XDR-TB Ability to secure treatment adherence; impact of HIV; minimization of drug resistance Minimization of drug resistance; minimization of impact of HIV 80% Standard/ Frequency Updated annually Quarterly Quarterly Quarterly Annually Monthly or quarterly
STEP 9:
MONITORING AND EVALUATION
>90% >90% >85% >85% <10% <5%
Output
Process
Input
Outcome
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SECTION 6:
Malaria Programs
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6.1 OVERVIEW
6.2 PREVENTION Environmental Management Chemical Management Awareness Bite Prevention Chemoprophylaxis Abbreviations used ACT DHS EST HIA HIV IRS ITN LLITN M&E MARA RBM RDT TB WHO STEP 2: Scoping STEP 6: Option Appraisal
6.3 TREATMENT AND CARE Diagnostic Tests Drug Treatment Emergency Standby Treatment Occupational Hazards: Pesticide Exposure STEP 8: Program Implementation STEP 9: Monitoring and Evaluation
6.4 PROGRAM PLANNING AND IMPLEMENTATION STEP 1: Screening artemisinin combination therapy demographic and health survey emergency standby treatment health impact assessment human immunodeficiency virus indoor residual spraying insecticide-treated bed net long-lasting insecticide-treated bed net monitoring and evaluation Malaria Risk in Africa Roll Back Malaria rapid diagnostic test tuberculosis World Health Organization
Section 6. Malaria programs

MALARIA PROGRAMS
STEPS 3 & 4: Situation Analysis and Stakeholder Analysis STEP 5: Policy, Priority, Goal and Objective Setting STEP 7: Program Design, Budgeting and Reporting
100 101
102
102
90 91 92 93 94 96 96 97 97 98 98 98 99
103
104
104
99 99
6.1
Malaria cases (per 100,000) by country
OVERVIEW
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KEY FACTS: According to WHO in 2007: Malaria causes over 1 million deaths annually, mainly in sub-Saharan Africa. Most of the deaths are in children under the age of 5 and pregnant women. More than 500 million people become ill with malaria annually. 40% of the worlds population is at risk of malaria infection.
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The public health and economic significance of malaria is great, and its control remains a major challenge. Development projects and activities that will modify the local ecology and involve significant population movements and environmental alteration should always be assessed for their potential to increase vector breeding sites, human-vector contact and the risk of malaria transmission. Planning for malaria control should be implemented as early as possible in the project lifecycle, for reasons that will be outlined in this section. The four main variables in malaria control are: human (the host), mosquito (the vector), parasite (the disease agent) and the environment. Control interventions should ideally target all four variables to maximize program success. Box 6.1: Key Elements in Malaria Control Availability of early, accurate diagnosis and effective treatment Selective application of vector control (adult/larval mosquito control and reduction in vector-human contact Effective monitoring and evaluation development of accurate and timely epidemiological information systems to assess strategy and allow for proper program monitoring and evaluation of the environment, vectors, parasites and human demographics and health. By allowing early detection of changes in transmission, rapid response and application of appropriate control measures can be implemented. Partnership and collaboration in community programs with key external stakeholders to ensure community collaboration and enhance program sustainability. For nearly 90 years some form of cost-effective intervention has been available for the control of malaria. However, any set of interventions has normally not been affordable in very-low-income communities, and effective coverage of the most vulnerable groups will likely require substantial assistance from external donors or sponsors. This section outlines the different interventions that might be considered, the likely effectiveness of each intervention and the basic procedures required to implement and sustain these interventions for the duration of a project and beyond.
Box 6.1 lists the four fundamental elements in a comprehensive strategy for malaria control.
Effective malaria management requires an integrated approach at all three levels. This is described below and illustrated in Figure 6.1.
6.2 PREVENTION Malaria management can be achieved at three risk mitigation levels: primary, secondary and tertiary. These measures are critical not only for a mine site itself but also for company offices, guest houses or staff accommodation situated in a malaria area. Furthermore, in addition to the site workforce, all other company employees, non-immune dependents and site visitors visiting a malaria area will need to be covered by adequate control measures. For example, all site visitors should be issued with an emergency standby treatment pack and information on malaria either on entry to or exit from the country of operation.
Primary: Vector control activities focused on reducing vector activity and density as well as vector-human contact. Environmental Management A cardinal rule in malaria control is to avoid the creation of conditions in which the breeding of mosquitoes can occur as a result of human activities. Breeding places may be created by, for example, excavation for road building, leaking water pipes and engineering works that interfere with the natural lines of water drainage. The correction of these types of errors is usually more difficult and costly than their prevention, and the physical control of breeding sites can often avoid the more costly, long-term methods of chemical control and dealing with medical emergencies associated with severe malaria. Engineering and design controls should be planned well before construction commences.
Primary prevention methods can be divided into site selection and source reduction approaches. Site selection: Planning for project accommodation location and design should take into account the anticipated impact on local malaria transmission and control methods to counter risk. Locating camp accommodation near a known mosquito vector breeding area or next to a community village in a malaria endemic area may make future malaria control interventions more costly and difficult. Choosing suitable sites for housing (temporary or permanent) is therefore important. Placing housing upwind from identified breeding sources is advised. It may be less expensive to convey water a greater distance from a source than to build near the water itself, thus avoiding the recurring expense for mosquito control.
Secondary: A strategy that involves the reduction of individual risk by using a full range of personal protection and behaviour modification measures. This includes raising awareness of, and education on, the risks of malaria; education on the benefits and use of bite prevention and personal protection measures, and making these measures available to employees; provision of mosquito-proof accommodation (e.g., screened windows and doors); and mandating compliance with appropriate anti-malarial chemoprophylaxis when recommended. Tertiary: At this level the effects of a malaria infection are limited through prompt, accurate diagnosis and effective treatment, even while working on site or in remote areas removed from health care facilities. The biggest risk to delayed diagnosis and treatment may occur when a person is away from the project site, thus the program needs to be designed to include the provision of support systems should a person acquire malaria while away from the work site. There are two primary malaria prevention methods: environmental management of vectors and chemical management of vectors.
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Establishing a buffer zone of one mile (1.6 kilometres) radius or more from known vector breeding areas and villages with endemic malaria serving as reservoirs of malaria is always advisable. Box 6.2 provides criteria for defining the malaria buffer zone.
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The chemical management of vectors can be divided into two categories: larval mosquito control and adult mosquito control. From an environmental and human health perspective, many pesticide chemicals have a potential adverse impact. However, safe and effective chemical management of vectors can be achieved if staff are properly trained and managed.
Larval mosquito control: Areas and items retaining water for a sufficient period of time (normally 610 days, depending on the ambient air and water temperature) can represent potential sites for mosquito propagation. Whether natural or artificial, such areas and items should be routinely inspected for mosquito larvae and made free of floating and emergent vegetation. In situations where larval habitats cannot be permanently modified or eliminated, or larvae destroyed by biological, mechanical or physical means, use of chemicals forms an important means of control. A wide variety of products are available that can target various types of water and are highly effective and safe when appropriately formulated and used according to labelled directions. Products include target-specific bacterial toxins (Bacillus thuringiensis israelensis), insect growth regulators and specially formulated, non-residual light oils applied either in water or on the water surface.
Source reduction: The physical reduction or elimination of vector breeding habitats can be an important means of controlling malaria. Source reduction practices are generally classified as either permanent modifications or recurrent manipulations of the natural or human-made environment. Chemical Management
Environmental modifications involve permanent changes made to the environment to reduce or eliminate breeding. These include land filling and levelling and appropriate drainage designs to limit or remove temporary or permanent bodies of standing water.
Environmental manipulation involves planned recurrent activities aimed at producing conditions unfavourable for breeding mosquitoes by manipulating their preferred habitats. Control can take many forms, depending on the breeding site and target species. Highly effective methods for reducing vector populations include periodic flushing, changes in water levels or salinity, intermittent irrigation, shading or sun-exposure of stream banks and ponds, vegetation clearing, well-maintained impoundments and introduction or encouragement of certain larval mosquito-eating fish and other predator species to promote an aquatic environment unsuitable for mosquito larvae.
Box 6.2: Defining the Malaria Control Zone Malaria mosquito vectors usually fly no further than 500 meters in search of a blood meal, although with the right environmental conditions (such as in strong winds) they can potentially travel up to 2 kilometres. Any malaria control zone therefore needs to extend out a minimum of 500 meters into a so-called buffer zone, but ideally a radius of at least 1.6 kilometres is advisable. For many projects this buffer zone extends into adjacent communities, necessitating community interventions in order to protect facilities within the fence.
Under certain circumstances, a variety of aerosol-based application methods of insecticides can be effectively dispersed in the air (called space spraying) to knock down and kill mosquitoes that come in contact with the airborne microscopic droplets. This method covers everything from individual user aerosol spray cans and mosquito coils to large, truck-mounted fogging machines that cover extensive areas in a short amount of time. Normally such methods are reserved to control the presence of unacceptable numbers of vector mosquitoes in order to prevent or control a malaria outbreak in the short term. However, unlike residual applications, fogging or ultra-low-volume provides only brief protection and must be repeated often. There is also a fair degree of initial expense for equipment and recurring costs for chemicals, along with specialised training. Long-lasting insecticide-treated bed-nets and other materials is currently one of the most commonly used and promoted intervention methods and has become an integral control tool in the WHO Roll Back Malaria program. In 2007 WHO made even stronger endorsement of LLITNs following recent evidence from trials in Africa. The insecticide impregnation of the netting either kills or repels adult mosquitoes. LLITNs usually retain their chemical repellent effectiveness for three to five years without the need for re-treatment. Surveys and interviews should be conducted to understand the current acceptance of nets, the patterns of use, community perception and understanding of the nets health value and the willingness to use them to prevent malaria. Nets should be factory pre-treated (e.g., Olynet, PermaNet, Interceptor) and provided either free of charge or made easily affordable to local people. Acceptance and practicality of insecticide treatment of other materials or fabrics (e.g., window and door curtains) should also be explored. Employees often serve as role models in poor communities, and education about bed-nets and the distribution of bed-nets to employees should be a priority.
Adult mosquito control: Approaches to adult mosquito control include indoor residual spraying, space spraying, insecticide-treated bed-nets and other materials. Indoor residual spraying is designed to reduce or break transmission by preventing or reducing mosquito-human contact. IRS involves the spraying of a residual insecticide onto a surface, typically the interior walls of a home or office. When mosquitoes make contact with the surface, they are either killed as a result or irritated to the point of taking premature flight, disrupting the normal feeding behavior of the vector. IRS does not necessarily provide individual protection from being bitten; however it can provide elements of both toxicity and behavioural avoidance that will greatly reduce bite frequency and risk of infection. Use of residual insecticides to kill mosquitoes that land on treated surfaces has a long history in malaria control programs. When combined with bed-net use, it provides a formidable barrier against malaria transmission. Selective insecticide spraying of interior house walls should be strongly considered in any integrated control program, especially in areas with a high risk of transmission and nearby local communities. The duration of action depends on many factors, including the nature of the sprayed surface, the specific chemical insecticide and its formulation and dosage. In some cases, IRS may not be an effective control measure based on the feeding behaviour of the local vector. If vectors tend to bite outdoors, then IRS becomes less effective.
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Employing the secondary prevention A-B-C-D strategy to educate employees and guide management is advisable as it is easy to remember (see Box 6.3): Box 6.3: Malaria A-B-C-D Strategy Awareness prompt Diagnosis
For the most part, malaria is a human-made disease in which the transference of the disease to humans is made easier or exacerbated by our behaviour or actions. Avoiding mosquito bites, which can include the use of repellents, is a prudent strategy for reducing infection from malaria and other insect-borne diseases. Ideally, responsibility for protection from vector-borne diseases should rest with the individual or family. General health information on malaria and personal protection measures should be distributed at point of induction into the workforce, posted around the work and living facilities and reiterated as often as possible (e.g., at weekly safety meetings). Information should enforce the conscientious use of personal protective measures. Bite Prevention Bite prevention is critical in avoiding contracting the disease and needs to be encouraged at all levels. Use of bed-nets should be encouraged, if not made compulsory. The use of treated nets will greatly increase effectiveness.
Physical exclusion of vectors is important for reducing risk. All accommodation and eating areas should be mosquito-proofed as best as possible. Windows and doors should be screened and periodically inspected for damage and repaired. Properly screened outdoor areas should be provided so that people can sit outside after dark. Further protection can be accomplished by limiting the amount of outside activity from dusk to dawn whenever possible.
B C
Awareness
Bite protection
Chemoprophylaxis
and treatment
Routine personal protective measures should be strongly promoted through camp education and every means of media available. People should be encouraged to wear long pants and shirts, closed shoes and socks, and an effective repellent should be made readily available (see Table 6.1), especially during night-time activities.
Mosquito coils and insecticide aerosol sprays should be used when mosquitoes are present in a room or have access to it. Treating clothing with permethrin can also serve as an effective bite protection measure, especially for employees working after dark in high-malaria-risk areas. Chemoprophylaxis 6.3 Table 6.1: Insect repellent type DEET 23.8% Soya Bean Oil Picaridin (KBR 3023) 9.3% IR 3535 (Alanine analogue) Citronella containing products TREATMENT AND CARE Insect Repellent Effectiveness Duration of effectiveness (minutes) 302 120 95 23 20 Chemoprophylaxis with an appropriate agent (according to the drug resistance profile of the region) has been shown to decrease the risk of infection by over 80%. In addition, in the event of breakthrough infection, chemoprophylaxis has been shown to reduce the risk of dying from malaria significantly through slowing of the parasite replication rate in the body. Doxycycline, Atovaquone/Proguanil and Mefloquine are currently thought to be safe for long-term chemoprophylactic use according to the Centers for Disease Control and Prevention in the United States. Box 6.4: Factors Affecting Prompt Diagnosis and Effective Treatment of Malaria Appropriately skilled and sufficient numbers of human resources Effective drugs and reliable drug supply Basic laboratory and diagnostic services Appropriate medical management guidelines Adequate access to health care facilities.
Regular chemoprophylaxis should be encouraged for those considered at increased risk (e.g., non-immune workers or expatriates, those involved in evening operations and night security details).
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Proper and safe treatment and care of malaria patients requires two main elements: accurate diagnosis and effective treatment. Achieving prompt diagnosis depends on factors listed in Box 6.4.
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Key considerations in the treatment and care of malaria patients include diagnostic tests, drug treatment and emergency standby treatment. In addition, the health and safety of workers handling potentially toxic pesticides must be actively managed. Diagnostic Tests It is important to note that in the workforce and at the site clinic, diagnosis should not be done presumptively. The malaria parasite needs to be detected in blood samples through either microscopy or rapid diagnostic tests that detect malaria parasites in the blood either directly or indirectly. Failing to do so can greatly underestimate or overestimate actual malaria infection, as well as result in inappropriate clinical management. Note: The WHO publishes a list of RDT manufacturers that have adequate evidence of good manufacturing practice and quality. Effective, affordable malaria treatment roll-out into poorer communities is of high importance and provides an important tool, in combination with insecticide-treated nets and IRS, in suppressing malaria transmission (Barnes et al., 2005). As treatment protocols change due to scientific advances, the latest WHO malaria treatment guidelines should be checked when designing a malaria management protocol.
In nearby communities, diagnosis is more difficult as resources for proper testing are not always available. Microscopy requires well-trained and committed staff and physicians who are capable of following strict management protocols and trust in the reliability of microscopy services. RDTs remain relatively expensive and require strict supply chain management and careful storage to ensure the kit is maintained within the recommended temperature range. Prolonged exposure of test kits to extremes in temperature (generally >30 Celsius, although some are able to withstand 40 Celsius) can result in a significant decrease in test accuracy. The most suitable test format and manufacturer quality assurances must be ascertained to meet local requirements. Note: WHO publishes a list of approved quality artemisinin-based drug suppliers as part of its Procurement, Quality and Sourcing Project. Emergency Standby Treatment EST is highly recommended for all non-immune employees, all at risk family members who travel and site visitors. It aims to provide the employee with a kit containing ACT for the treatment of malaria in the event that they fall ill and cannot get prompt medical care and effective treatment. Many expatriates come from countries where there is no malaria transmission. Health care providers in these
Drug Treatment Current leading practice in treatment is based on the use of artemisinin-based compounds combined with a long-acting drug (termed artemisinin-based combination therapy) for the treatment of most types of malaria. Many developing countries (and some others as well) do not provide residents with adequate access to effective and affordable malaria treatment. Furthermore, counterfeit and ineffective drugs marketed for malaria treatment are a significant problem in Africa and Asia. If there are any concerns about the quality of drugs, then a project may want to perform drug quality testing at an international testing centre. It is advisable that only WHO-approved manufacturers of antimalarial drugs are used.
countries often have inadequate knowledge of the diagnosis and treatment of malaria. 6.4 STEP 1: PROGRAM PLANNING AND IMPLEMENTATION SCREENING
There have been many instances of expatriates getting poor medical advice or experiencing serious delays in diagnosis and treatment, with potentially fatal consequences. By having EST available, death or significant disability can be avoided as there is a low risk of adverse effects in self-administering ACT in the event there is a delay or concern about the standard of care. This activity can potentially be supervised by using an online medical travel management and education system combined with a malaria hotline number available for the company through a medical service provider. It is not advisable that the EST kit contains a rapid diagnostic test as these are temperature-sensitive and storage conditions cannot be guaranteed by patients. In addition, failure to conduct or interpret the test properly can lead to false negative results, resulting in delayed treatment. The screening step will determine the risk of malaria and any requirements for its management and control. Web sites showing malaria risk, such as the Mapping Malaria Risk in Africa project site (www.mara.org.za), the U.N. Development Programme Web site, and geospatial maps produced of malaria transmission, provide a useful source of guidance when assessing the levels of risk posed from malaria to the project and from the project to malaria transmission. There are also useful sources of malaria-specific information from government data, the WHO Roll Back Malaria and Demographic and Health Survey information that can be used to guide screening. Government data vary in quality, but the DHS may provide standardized and serial data that include malaria and that are more objective and collected according to a set methodology. DHS data can be found at www.measuredhs.com. With regard to the risk assessment process, the following factors should be noted. Occupational Hazards: Pesticide Exposure Workers who are involved in insecticide spray programs and who handle pesticides that contain carbamates and organophosphates must be monitored for potential toxicity. The medical surveillance program should perform regular red cell and serum cholinesterase levels. It is important to choose an accredited laboratory that can conduct accurate cholinesterase testing to ISO15189 standards.
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Understanding the risk of malaria to a mining project: The risk of malaria to a project will be determined by the transmission levels of malaria in the surrounding communities, as well as the presence of malaria mosquitoes (Anopheles) in the surrounding environment. If there are few human settlements in the area, malaria transmission may be very low or even non-existent. However, if the Anopheles mosquito is present or climatic and environmental conditions are suitable for its establishment, human migration into the area has the potential to increase malaria transmission dramatically. Finally, the malaria immunity status of all employees and malaria transmission patterns of labour source areas must be considered. Labour sourced from a third country or area with high malaria transmission or where different malaria parasite species are present have the potential to introduce or change malaria transmission patterns in the project area. During scoping, the following sources of information might be useful: MARA maps DHS data Multiple Indicator Cluster Surveys data Malaria Indicator Survey data from the WHO RBM Web site National Burden of Disease data (if available) WHO Burden of Disease data (see relevant report from the Burden of Disease project) National Malaria Control Program data (if available) STEP 2: SCOPING
Malaria transmission is best determined through the incidence of new malaria infections; the prevalence of malaria parasites in the blood of local residents, in particular primary school children and children under the age of five; and various vector/parasite parameters such as the entomological inoculation rate and sporozoite infectivity rate. No measure of malaria epidemiology is perfect, and each has drawbacks and benefits. It is advisable to consult an expert to interpret malaria transmission data in order to determine risk more accurately.
When assessing risk it as also important to look at travel routes, especially for nonimmune employees and dependents. Malaria may be acquired in airports or during travel after dark. High-risk environments for malaria transmission in malaria areas include hotels or offices where adequate malaria prevention controls are not in place.
Understanding the risk that the mining project poses for increased malaria transmission: This is covered in Sections 6.1 and 6.2. To summarize, the following activities related to a mining project have the potential to increase malaria transmission: construction of ditches and graded roads; clearing of vegetation and changes in the type of vegetation; creation of bodies of standing water, such as environmental containment dams, water storage facilities, water truck filling areas; disturbance of natural water drainage by earthmoving activities; and increased migration of humans into the area and changes in human demographics and behaviours.
Literature searches and review through PubMed/MEDLINE and other online science database reference libraries Local and regional health reports and health facility data. STEPS 3 AND 4: SITUATION ANALYSIS AND STAKEHOLDER ANALYSIS
The quality of data needs to be carefully assessed and qualified, as some information sources provide insufficient or inaccurate detail (e.g., malaria diagnosed presumptively or areas with poor access to health care will not provide accurate data on malaria epidemiology). The following malaria-specific surveys should be carried out as part of the situation analysis: Health impact assessment and household survey: In concert with an in-depth HIA, a household survey should be included to explore background malaria knowledge and attitudes. This survey should be integrated with HIV and TB surveys and form part of a broader HIA. Geospatial mapping: This can provide useful layered visual information superimposed onto the project area that shows: Control zones Malaria transmission rates and other epidemiological information Vector larval habitats. Malaria prevalence surveys: This involves taking a small finger-prick of blood from volunteers. A preferred sampling of groups of children under the age of 5 and those between 6 and 15 years of age are best to measure local endemic transmission. Community sensitization is required to clearly communicate the intent and objectives of the survey. All persons found with active infections should be given full and effective treatment. Insecticide sensitivity surveys: This is best performed during the initial series of vector mosquito surveys to determine the prevailing chemical resistance patterns in local mosquito populations. The information collected will help guide decisions on the combination of insecticides to use either alone or in rotation.
Vector mosquito surveys: These surveys usually require one to three months of detailed observation and collection activities that are technically complex and require an entomology specialist to collect and identify adult mosquito species and determine feeding densities and behavioural patterns and to collect and identify larval species and define development (breeding) site characteristics. A specialized laboratory is often necessary to assess malaria infectivity in captured mosquitoes and to correctly identify adult mosquito species. Data may be needed from mineaffected communities, which, in some instances, may require consent or permission to enter villages, community sensitization and education before collecting samples or conducting interviews. Area health facility survey: This will provide valuable background disease data and determine the availability and quality of malaria treatment and care in affected communities. The survey would also be integrated with HIV and TB surveys and form part of a broader HIA.
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As malaria control field data traditionally include Global Positioning System data, these data can be loaded into the mapping software to create time-ordered patterns for analysis. Whether this is useful or necessary should be determined by an expert. In the event that a malaria policy does not exist, guidance on policy design for malaria programs can be found in the World Economic Forum document referenced in Annex E, Useful Resources. Policy should cover all contractors and may need to be adapted to reflect the local context as compared with a company-wide policy. Objective: The primary aim of malaria control is to reduce the impact of the disease on the health of the worker and mine-affected communities to the lowest possible level within available financial and human resources. This should be achieved in the context of other health priorities and in line with existing technology and feasibility. Priority setting: For community programs in particular (and to a lesser extent for workforce and site malaria control), priorities, goals and objectives should be aligned with national government malaria control programs and international Millennium Development Goals and objectives, in addition to catering to local priorities. The criteria in Box 6.5 should be considered during option appraisal. STEP 6: Box 6.5: Selection Criteria Intensity of malaria transmission and degree of stability Perennial or seasonal transmission Parasite species distribution Parasite drug sensitivity Vector species, mosquito ecology and behaviour, insecticide susceptibility Domesticated animal and human ecology Environmental parameters topography, hydrology and meteorology Factors or circumstances that may preclude the use of particular control tools. OPTION APPRAISAL STEP 5: PRIORITY, GOAL AND OBJECTIVE SETTING
Workforce high risk groups need to be identified and protected appropriately. For example, security guards who work outside at night may be a high-risk group and need additional protective measures, such as permethrin-impregnated work clothes, to reduce the risk of occupationally acquired malaria. Expatriates who come from non-malaria countries are not immune and are at high risk of severe malaria. This group also needs special consideration in terms of malaria prevention. For example, chemoprophylaxis use and EST provision are crucial prevention strategies for this group.
In some regions it may be possible to form partnerships with other private companies in the area, and this should be assessed as an option. For instance, other mining companies in the region may also be involved in malaria control, and collaboration and a pooling of resources may lead to increased cost efficiency and more effective options. It may be advisable to run a pilot project within the community to understand local factors influencing program success and sustainability as well as to build capacity before scaling up. Studies have shown the efficacy of environmental management programs involving organized community participation and education and promotional campaigns and their effectiveness. Provision of malaria control tools and trained community health volunteers can be an effective way to manage and sustain environmental and active/passive case detection programs outside the immediate project areas. Integration with other community primary health care initiatives may also help ensure sustained community participation over time. With regard to sustainability and cost, it is important for any community intervention that the project does not go it alone and that it is carried in concert with national government and in support of broader initiatives. Human resources can typically consume 6070% of a malaria control budget following the initial large capital outlay for vehicles, buildings, and spray equipment. The malaria control building, housing all site resources, should ideally be placed close to the clinic for good communication, but also reasonably close to the environmental control activities to cut down on travel distances. Areas that store pesticides and spray vehicle wash-down areas need to be bunded, with water runoff separated from the environment, as many of the pesticides used are extremely toxic to most aquatic species. STEP 7: PROGRAM DESIGN, BUDGETING AND REPORTING In general, there is no generic blueprint for malaria control that can be equally effective everywhere. The key success factor is that an integrated approach be used and a proper planning process is followed, as outlined in Section 2. Approaches have to be constantly modified to take into account local factors and changes over time.
There is increasing international focus on and funding for malaria, with renewed attention placed on IRS programs but also, in combination with environmental controls, increased ITN coverage and ACT rollout. These four interventions should be the main strategies both for site control and community control. IRS in the community requires considerable resources and needs to be well understood before or if a community IRS program is implemented. Other types of community interventions, such as ITN distribution, can be extremely cost-effective and suitable for company support.
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Large-scale spray programs require very careful planning, as logistical and training needs can be considerable. For example, all households should be notified and the community sensitized before spraying commences. Supply lines for chemicals and equipment in developing countries may take considerable time to set up, as there are numerous issues, such as requirements of the national environmental protection agency or other regulatory body for the licensing of unlicensed chemicals, lengthy
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chemical supply timelines and the need for special transport and storage conditions. (Many pesticides have a temperature range that needs to be adhered to, otherwise they lose effectiveness.) The personnel undertaking the spraying (spraymen) need proper training, as they are often working with chemicals that are potentially toxic to humans and the environment, and proper chemical handling is crucial. Recommendations on standard program implementation are contained in Section 2. A malaria investigation form should be completed for each malaria case. A dedicated data management system needs to be designed for the primary and secondary interventions to track parameters, with progress fed into a monitoring and evaluation matrix. In addition to an overall project malaria policy, the site malaria treatment and care program should have all procedures clearly documented and outlined to include: Medical treatment Malaria diagnosis Quality control of malaria slide preparation and examination Case investigation Periodic program monitoring and assessment Routine medical surveillance of workers handing and applying pesticides. Health care workers need to be trained and re-evaluated regularly on their knowledge of the diagnosis and effective management of malaria. STEP 9: MONITORING AND EVALUATION Table 6.2 provides an outline of the key M&E indicators for a malaria control program. The indicators suggested would encompass both workforce and community programs, and the choice of indicators depends on the program design. In addition, malaria that is most likely contracted due to a workplace exposure should be recorded as an occupational disease. For example, if workers employed outside after dark in a malaria transmission zone are found after case investigation to have most likely been inoculated during work activities (taking the incubation period into account), then the case should be recorded as an occupational disease. STEP 8: PROGRAM IMPLEMENTATION
Figure 6.1: Integrated Control of Malaria

Site Selection Buffer zone; distance from vector breeding areas/ populations with active malaria transmission. Malaria and personal protection information distribution. Source Reduction Environmental modification to reduce vector habitats; environmental manipulation to produce unfavourable conditions for vectors. Prompt diagnosis through blood sampling or rapid diagnostic tests.
Regular chemoprophylaxis for those considered at risk.
ENVIRONMENTAL
AWARENESS DIAGNOSIS
Control/ Reduction of Individual Risk Limiting Effect of Infection TERTIARY CONTROL (D)
SECONDARY CONTROL (A, B, C)
CHEMOPROPHYLAXIS
Vector Management
PRIMARY CONTROL
Larval Control Destruction through biological, mechanical or physical means. Adult Mosquito Control Indoor residual spraying, space spraying and long-lasting insecticide-treated bed-nets and other materials. Bed-nets (LLITN), physical exclusion, personal protection. Use of artemisinin-based combination therapy; emergency standby treatment.
BITE PROTECTION
TREATMENT
CHEMICAL
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Table 6.2: Selected Indicators for Monitoring and Evaluating a Malaria Program
Vector mosquito Number of ITNs received Number of ACT drugs received Volumes of chemicals received Number and frequency of Periodic insecticide susceptibility monitoring malaria prevalence surveys of target vectors Number of treatments from Type, product and malaria survey positive volumes of insecticide cases used Number of people with Number of ITNs malaria (stratified as distributed uncomplicated vs. severe) receiving anti-malarial treatment (stratified by type of treatment) Number of health facilities Number if ITNs with no reported stock-outs distributed to (running out of stock) pregnant women lasting more than a week in the last three months Number of people reached with home-based management of malaria Number of malaria blood Number of sites, frequency, and dosage of slides taken larviciding applications Number of malaria RDTs performed Distribution, coverage and percentage of functioning passive case detection posts; ratio of admissions or attendees to number of slides taken; average monthly slide outputs Number and per cent of Malaria prevalence in structures sprayed (IRS) community children <5 years and >5 to in relation to targets. 15 years of age Per cent of health facilities Refusal rate for structure spraying (IRS) with malaria diagnostic supplies and equipment Per cent of houses with Per cent of children <5 yrs old with fever/malaria screened windows receiving appropriate care within 24 hours by homebased management Malaria Parasite Number of EST packs distributed Per cent of severe malaria cases Number of people contacted by community outreach activities for malaria education
Human Staff numbers (stratified) within the program Malaria policy for the facility, signed off by all senior management Financial inputs in terms of capital expenditure, recurrent and fixed costs Malaria program operating procedures Pesticide medical monitoring program in place Number of meetings held Number of spraymen having completed IRS training Number of service deliverers trained in malaria case management Number of active case detection house visits, percentage of population covered. Number and per cent of non-immune workers diagnosed with malaria not on chemoprophylaxis Number and per cent of non-immune workers having completed the online malaria learning module Number and per cent of employees who have received malaria induction
Outcome/Impact
Per cent of malaria cases that are laboratory confirmed by microscopy or RDT or Malaria QBC All-cause mortality rate in children <5 yrs old
Number of laboratory-confirmed malaria cases and deaths
Output
Process
Input
Table 6.2: Selected Indicators for Monitoring and Evaluating a Malaria Program
Malaria Parasite Per cent of pregnant women receiving intermittent preventive treatment (IPTp) Per cent of children <5 yrs Per cent of pregnant women sleeping under old with fever/malaria an ITN the previous night receiving appropriate care within 24 hours Per cent of children <5 yrs Per cent of children old with malaria/fever <5 yrs old sleeping correctly managed at health under an ITN the facility previous night Reduction of vector mosquito density: measures of adult Anopheles indoor and outdoor densities; percentage of active larval habitats and densities (larvae per dip). Reduction of house-frequenting vector mosquitoes and infectivity: measures of adult Anopheles indoor resting density and malaria sporozoite infection rates. Vector mosquito Per cent of households with at least one ITN Per cent of severe anaemia (Hb <8.0 mg%) in children <5 yrs old Mean infant (<1 yr old) birth weight by month Per cent of low birth weight babies (<2.5 kg) Human All-cause mortality rate in target population
Outcome/Impact
Per cent of anaemia (Hb <11.0 mg%) in children <5 yrs old Per cent of children with palpable enlarged spleen (splenomegaly) Per cent of spraymen monitored for pesticide exposure every six months
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Annex A: Supporting information

International funders, such as Global Fund to Fight AIDS, Tuberculosis and Malaria Traditional healers Shareholders Corporates Private health service providers Non-profit organizations (e.g. NGOs and community-based organizations)
Table A1
Stakeholder
Government (Department of Health and potentially the Departments of Labour, Minerals, and other government departments interested in the three diseases) Labour organizations and trade unions International health agencies, such as WHO Academics and research institutions Community organizations and individuals (traditional or political)
Stakeholders in Health Program Development
Business organizations (e.g., the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria; the International Council of Minerals and Metals; the Global Reporting Initiative)
Co-funding of existing operations, ensuring sustainability
Compliance with legislation and National Treatment Programs (in the case of TB), public-private partnerships, sustainability of new programs Finding out community priorities; impact of the operation on health, resourcing of community programs/ facilities, provision of services; transparency; role of individuals in various programs Use of international recommendations for policy, public-private partnerships networking, management guidelines Sharing knowledge on best-practice initiatives; input into company-sponsored research initiatives; providing specialist input into health management program development Service cooperation; transparency; company accountability for impacts of their operations; sharing of knowledge gained May be involved in any prevention and care activities both in the community and the workforce Sharing knowledge on best-practice initiatives; joint initiatives to tackle shared health impacts/issues
Cooperation in education about prevention and treatment of disease
Costs, reputation, social licence to operate, demonstration of proper risk management
Job security, employee benefits, employee education/acceptability of program, avoidance of stigmatization
Interest of the Stakeholder in the Operations Health Program and/or Operations Interest in the Stakeholder
To demonstrate a sector-wide and business response to the three diseases to society; to support a network for public-private partnerships; to provide a focal point for accessing external funding for community programs.
Government NGO
Multilateral funder Suppliers and contractors Membership organizations Trade unions
Mining company or other company
Community members Local private health service providers
Business associations
Table A2
Potential Partner
Potential Partners and Typical Responsibilities Responsibilities
Support and policy framework, facilitate external stakeholder participation, provide labour, provide access to funding Provide external funding, monitoring, external resources Provide technical and business management expertise, funding, equipment and resources, policy and programs, advocacy, joint programs, shared materials Provide support, labour, community knowledge Provide support Provide equipment and support, supply technical knowledge (especially health service contractors) Provide policy input and program support, as well as assisting with educating member employees Provide information resources and case study libraries, provide a business partner network, serve as a focal point to get access to external funding Form linkages to serve as an effective mechanism for diffusion of information on business responses, sharing of market-orientated knowledge and experience, and combining of advocacy efforts
Provide community-based programs, networks, community knowledge, technical specialist knowledge, access to funding, advice and guidance
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Box A1 Examples of International NGOs and Funding Partners
Box A2 ExxonMobil: Malaria Prevention Clause for Contractors
Where ExxonMobil has determined malaria to be a significant health risk for operations, the Contractor shall develop and implement a site-specific plan for the control of malaria for its employees and subcontractor, both non-immune and partially immune. Such a plan should include: awareness and education; bite prevention; chemoprophylaxis (where applicable); and early diagnosis and early treatment. It is the Contractors responsibility to notify its employees and subcontractors who are resident in a malaria area or planning to travel to such an area (in advance of travel), in order to take necessary actions including any required chemoprophylaxis provision. Source: World Economic Forum: Guidelines for Employer-Based Malaria Control Programs http://www.weforum.org/pdf/Malaria.pdf
World Bank International Finance Corporation World Health Organization International Red Cross The Malaria Consortium Roll Back Malaria Global Health Initiative World Economic Forum Global Health Initiative Oxfam Presidents Malaria Initiative CARE The Hope Foundation Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria Medecins Sans Frontieres United Nations Childrens Fund (UNICEF) NetMark (partner with USAID) African Medical and Research Foundation Population Services International Australian Agency for International Development United States Agency for International Development (USAID) The South African Medical Research Council Medicines for Malaria Venture Global Fund to Fight AIDS, Tuberculosis and Malaria Department for International Development (UK)
Box A3 Models of HIV/AIDS Care and Treatment in South Africa
Model 1: Employer Provider. The employer internally finances and delivers treatment and care for HIV-positive employees. The company may use a closed medical scheme, company clinic facilities, or a combination of the two. (Source: Connelly and Rosen 2006; Bureau for Economic Research, 2004)
Model 2: Medical Aid Scheme. Employers subsidize medical aid health insurance scheme premiums for employees who choose to make the co-payment. Most medical schemes contract with a disease management program to handle the treatment and care of HIV-positive members.
Model 3: Independent Disease Management Program. A specialized HIV/AIDS disease management company is contracted by an employer to manage the costs and treatment of HIV-positive employees, independent of the medical aid scheme.
Model 4: Clinic Provider. An external treatment and care provider or clinic is contracted by the employer to provide HIV-related services either at the workplace or at an outside clinic.
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Table B1
Annex B: Roles and Responsibilities

Key Tasks Step 1: Screening Undertake legislative review Determine whether the company has adopted any best practice arrangements Refer to international, national and regional/local data sets and health reports Feed results of screening into company risk assessment matrix Complete terms of reference for the baseline survey/s Refer to UNAIDS report to assess prevalence of disease in project area Consider HIV/AIDS rates among labour source areas Step 2: Scoping Undertake desktop literature review Undertake preliminary site visit Review existing reports and relevant information Review potential resources (internal and external) available to undertake baseline studies Hold preliminary consultation with key stakeholders in order to gain further insight into disease/s and associated risks Undertake gap analysis to determine what data are already available and what data gaps need to be filled in Develop TOR for baseline studies Appoint external consultant / specialist, if required Carry out actuarial modelling to estimate impact on production, group benefits and health resources (technical expertise may be needed) Review personnel data (e.g., absenteeism, staff turn-over, disability insurance claims, STI incidence) Assess list of mine activities and associated impact on transmission of HIV/AIDS Step 3: Situation Analysis (Health baseline) Undertake detailed literature review of existing reports and data Undertake household surveys Undertake focus group discussions Undertake health facility surveys Undertake workforce KAP surveys Undertake workforce screening program Identify high risk groups (within workforce and community) Consult with key stakeholders HIV/AIDS Key HIV/AIDS Program Elements Person Responsible
Completed (Y/N)
Define community action plan Undertake anonymous HIV sero-prevalence survey Beware not to enforce workforce screening program Step 4: Stakeholder Analysis Identify and analyse stakeholders: those affected by the disease/s (employees, community residents) and those who influence management of the disease/s, including implementation of health programs (NGOs, national and/or local authorities, community leaders, health staff, funding agencies, etc.) Define and understand potential partners Develop stakeholder engagement plan Carry out stakeholder engagement Feed results of stakeholder engagement into Steps 2, 3, and 59 Define community action plan Step 5: Policy, Priority, Goal and Objective Setting Develop company policy on management of the three diseases (if it does not exist); policy to include contractors and be in line with company social and community development plans and goals Identify program priorities, goals and objectives: to be linked to broader, external objectives and targets (e.g., National HIV, TB and malaria programs) and to reflect findings of Steps 1-4 Step 6: Option Appraisal Assess options against key considerations: a) Feasibility (technical, financial, political) b) Impact of options on the three diseases c) Cost-effectiveness, equity, efficiency and sustainability d) In-house capacity e) Necessity to outsource f) Availability of funding for options under consideration g) Prevalence of disease/s h) Size and life of operation i) Quality of local health services Appoint experienced service providers to limit margin of error in HIV/AIDS programs Run pilot program of selected option before full roll-out Refer to outcome of actuarial review when selecting options Consider Model 1, 2, 3 or 4 (as defined in Annex A) Step 7: Program Design, Budgeting and Reporting Identify and ensure compliance with legal requirements Develop comprehensive and accurate budgeting Identify and link up with external funders, where appropriate
Key Tasks
Person Responsible
Completed (Y/N)
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Key Tasks
Define clear timelines Allocate sufficient staff (numbers and skills), and provide training (or outsource where necessary) Ensure senior management buy-in and support Define program roles and responsibilities and organizational chart Establish procurement procedures for equipment, drugs ans consumables Establish partnerships, where appropriate Set up clear, quality monitoring and evaluation system Ensure that appropriate infrastructure and equipment are established, where required Define education and awareness activities for the workforce and community Develop/provide list of HIV testing and ARV treatment centers Provide onsite HIV diagnostics Specifically train healthcare workers in HIV management Develop/provide list of safe blood banks for emergency blood Step 8: Program Implementation Do on-going monitoring against goals, objectives and targets Establish a coordinating committee and allocation of dedicated funds for all three diseases Establish a joint TB/HIV/malaria plan (to include resource mobilization, capacity building and training, communication, community involvement and research) Provide joint TB/HIV/malaria training for health care providers Strengthen laboratory services to ensure quality diagnosis and management of all three diseases Establish referral networks Establish system for joint reporting for all three diseases Provide surveillance of HIV prevalence among TB patients Provide regular screening for TB among employees known to be HIV-positive; offer TB preventive therapy for those who do not have active TB Implement TB infection control in health care facilities and congregate settings in order to reduce the risk of exposure Offer HIV testing and counselling (with an opt-out option) to all people diagnosed with TB PREVENTION: Provide awareness programs Offer peer education Review occupational health and safety procedures
Person Responsible
Completed (Y/N)
Key Tasks
Distribute condoms Provide voluntary counselling and testing Provide information on male circumcision Prevent and treat STIs TREATMENT AND CARE: Provide ARV program for employees and family members Promote adherence to treatment Prepare for treatment Dispense medication Promote on-going adherence monitoring Provide PEP for occupational exposures Treat opportunistic infections Provide immune support and nutritional program Provide MTCT program for pregnant employees Train line managers and supervisors Provide terminal care Use an employee assistance program Step 9: Monitoring and Evaluation Develop indicators Monitor Report Evaluate
Person Responsible
Completed (Y/N)
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Table B2
Key Tasks
Step 1: Screening Undertake legislative review Determine whether the company has adopted any best practice arrangements Refer to international, national and regional/local data sets and health reports Feed results of screening into company risk assessment matrix Complete terms of reference for the baseline survey/s Refer to key Web sites with updated epidemiological information, in particular: WHO Tuberculosis site, WHO Stop TB Partnership program and International Union Tuberculosis and Lung Disease Consider TB rates among labour source areas Assess TB incidence rate, with help of health specialist: in particular, assess number of employees with untreated TB at take-on or start-up and number of employees who develop TB during employment Consider prevalence of factors contributing to TB on site: HIV prevalence, exposure to silica, standard of hostel or camp accommodation, TB incidence among labour source areas, tobacco and heavy alcohol use Consider prevalence of factors contributing to TB in adjacent communities: poor standards of living in project area, tobacco and heavy alcohol use, HIV prevalence Consider rates of local MDR and XDR TB to assess potential for spread of drug-resistant TB (high risk) Step 2: Scoping Undertake desktop literature review Undertake preliminary site visit Review existing reports and relevant information Review potential resources (internal and external) available to undertake baseline studies Hold preliminary consultation with key stakeholders in order to gain further insight into disease/s and associated risks Undertake gap analysis to determine what data are already available and what data gaps need to be filled in Develop TOR for baseline studies Appoint external consultant / specialist, if required Further refine TB epidemiology Step 3: Situation Analysis (Health baseline) Undertake detailed literature review of existing reports and data
TUBERCULOSIS
Key Tuberculosis Program Elements
Person Responsible
Completed (Y/N)
Key Tasks
Undertake household surveys Undertake focus group discussions Undertake health facility surveys Undertake workforce KAP surveys Undertake workforce screening program Identify high risk groups (within workforce and community) Consult with key stakeholders Define community action plan Undertake occupational hygiene assessment of silica exposures Estimate HIV prevalence in the workforce (and labour sending areas) Assess quality of housing and accommodation, particularly with regards to overcrowding Assess extent of new versus re-treatment TB cases (influencing length of treatment and time off work), and whether they are complicated by other diseases or permanent health damage (influencing return to full work capacity) Step 4: Stakeholder Analysis Identify and analyse stakeholders: those affected by the disease/s (employees, community residents) and those who influence management of the disease/s, including implementation of health programmes (NGOs, national and/or local authorities, community leaders, health staff, funding agencies etc.) Define and understand potential partners Develop stakeholder engagement plan Carry out stakeholder engagement Feed results of stakeholder engagement into Steps 2, 3, and 59 Define community action plan Step 5: Policy, Priority, Goal and Objective Setting Develop company policy on management of the three diseases (if it does not exist); policy to include contractors and be in line with company social and community development plans and goals Identify program priorities, goals and objectives: to be linked to broader, external objectives and targets (e.g., National HIV, TB and malaria programmes), and to reflect findings of Steps 14. Step 6: Option Appraisal Assess options against key considerations: a) Feasibility (technical, financial, political) b) Impact of options on the three diseases c) Cost-effectiveness, equity, efficiency and sustainability d) In-house capacity e) Necessity to outsource
Person Responsible
Completed (Y/N)
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f) Availability of funding for options under consideration g) Prevalence of disease/s h) Size and life of operation i) Quality of local health services Appoint experienced service providers to limit margin of error in TB programs Run pilot program of selected option before full roll-out Select preferred option: minimum, intermediate or advanced (as defined in Table 5.2) Step 7: Program Design, Budgeting and Reporting Identify and ensure compliance with legal requirements Develop comprehensive and accurate budgeting Identify and link up with external funders, where appropriate Define clear timelines Allocate sufficient staff (numbers and skills) and provide training (or outsource where necessary) Ensure senior management buy-in and support Define program roles and responsibilities and organizational chart Establish procurement procedures for equipment, drugs and consumables Establish partnerships, where appropriate Set up clear, quality monitoring and evaluation system Ensure that appropriate infrastructure and equipment are established, where required Define education and awareness activities for the workforce and community Develop/provide list of TB diagnostic and treatment centres (local) Develop/provide onsite TB laboratory diagnostics Develop/provide onsite radiological capability Specifically train health care workers in DOTS and TB recognition Define reporting of TB to national TB control program Step 8: Program Implementation Do on-going monitoring against goals, objectives and targets Establish a coordinating committee and allocation of dedicated funds for all three diseases Establish a joint TB/HIV/malaria plan (to include resource mobilization, capacity building and training, communication, community involvement and research) Provide joint TB/HIV/malaria training for health care providers
Key Tasks
Person Responsible
Completed (Y/N)
Key Tasks
Strengthen laboratory services to ensure quality diagnosis and management of all three diseases Establish referral networks Establish system for joint reporting for all three diseases Provide surveillance of HIV prevalence among TB patients Provide regular screening for TB among employees known to be HIV-positive; offer TB preventive therapy for those who do not have active TB Implement TB infection control in health care facilities and congregate settings in order to reduce the risk of exposure Offer HIV testing and counselling (with an opt-out option) to all people diagnosed with TB PREVENTION: Provide education Introduce passive case finding Use active case detection Institute silicosis control TREATMENT AND CARE: Establish a return to work process Provide DOTS program Monitor drug resistance Step 9: Monitoring and Evaluation Develop indicators Monitor Report Evaluate
Person Responsible
Completed (Y/N)
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Table B3
Key Tasks
Step 1: Screening Undertake legislative review Determine whether the company has adopted any best practice arrangements Refer to international, national and regional/local data sets and health reports Feed results of screening into company risk assessment matrix Complete terms of reference for the baseline survey/s If in Africa, refer to Mapping Risk in Africa project Web site Consider malaria rates among labour source areas Refer to UNDP Web site for world-wide prevalence of malaria Consider key mining activities that are likely to encourage transmission of malaria (e.g., construction of roads, clearing of vegetation, construction of environmental containment dams and water storage facilities, drilling operations) Step 2: Scoping Undertake desktop literature review Undertake preliminary site visit Review existing reports and relevant information Review potential resources (internal and external) available to undertake baseline studies Hold preliminary consultation with key stakeholders in order to gain further insight into disease/s and associated risks Undertake gap analysis to determine what data are already available and what data gaps need to be filled in Develop TOR for baseline studies Appoint external consultant / specialist, if required Consult key information sources on the incidence and prevalence of malaria in project area (e.g., MARA maps, MICS data, MIS data, DHS data, local and regional health reports) Step 3: Situation Analysis (Health baseline) Undertake detailed literature review of existing reports and data Undertake household surveys Undertake focus group discussions Undertake health facility surveys Undertake workforce KAP surveys Undertake workforce screening program Identify high risk groups (within workforce and community)
MALARIA
Key Malaria Program Elements
Person Responsible
Completed (Y/N)
Consult with key stakeholders Define community action plan Undertake geospatial mapping Undertake vector mosquito surveys Undertake malaria prevalence surveys Undertake insecticide sensitivity survey Ensure that project accommodation geo-positioning and engineering designs have taken malaria control into account Make sure community sensitization and support in place Step 4: Stakeholder Analysis Identify and analyse stakeholders: those affected by the disease/s (employees, community residents) and those who influence management of the disease/s, including implementation of health programs (NGOs, national and/or local authorities, community leaders, health staff, funding agencies, etc.) Define and understand potential partners Develop stakeholder engagement plan Carry out stakeholder engagement Feed results of stakeholder engagement into Steps 2, 3, and 59 Define community action plan Step 5: Policy, Priority, Goal and Objective Setting Develop company policy on management of the three diseases (if it does not exist); policy to include contractors and be in line with company social and community development plans and goals Identify program priorities, goals and objectives: to be linked to broader, external objectives and targets (e.g., National HIV, TB and malaria programs) and to reflect findings of Steps 14 Step 6: Option Appraisal Assess options against key considerations: a) Feasibility (technical, financial, political) b) Impact of options on the three diseases c) Cost-effectiveness, equity, efficiency and sustainability d) In-house capacity e) Necessity to outsource f) Availability of funding for options under consideration g) Prevalence of disease/s h) Size and life of operation i) Quality of local health services Appoint experienced service providers to limit margin of error in malaria programs Run pilot program of selected option before full roll-out
Key Tasks
Person Responsible
Completed (Y/N)
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Key Tasks
Determine the size of the primary malaria control zone, including buffer zone Define control activities for particular zones Define education and awareness activities per zone Define malaria medical management activities Define secondary and tertiary prevention interventions Step 7: Program Design, Budgeting and Reporting Identify and ensure compliance with legal requirements Develop comprehensive and accurate budgeting Identify and link up with external funders, where appropriate Define clear timelines Allocate sufficient staff (numbers and skills), and provide training (or outsource where necessary) Ensure senior management buy-in and support Define program roles and responsibilities and organizational chart Establish procurement procedures for equipment, drugs and consumables Establish partnerships, where appropriate Set up clear quality monitoring and evaluation system Ensure that appropriate infrastructure and equipment is established, where required Define education and awareness activities for the workforce and community Develop/provide list of malaria diagnostic centres and ICU capable facilities Develop medical emergency response plan and evacuation procedure Provide onsite infrastructure for pesticides storage and malaria control Train spraymen for chemical control Train health care and lab workers in malaria management Step 8: Program Implementation Do on-going monitoring against goals, objectives and targets Establish a coordinating committee and allocation of dedicated funds for all three diseases Establish a joint TB/HIV/malaria plan (to include resource mobilization, capacity building and training, communication, community involvement and research) Provide joint TB/HIV/malaria training for health care providers Strengthen laboratory services to ensure quality diagnosis and management of all 3 diseases Establish referral networks
Person Responsible
Completed (Y/N)
Key Tasks
Establish system for joint reporting for all three diseases PREVENTION: Screen all site accommodation, working and mess areas Install LLITNs in all site accommodations Screen outdoor entertainment areas as appropriate Make mosquito repellent (DEET and Picaridin) widely available Ensure workforce education activities in place Issue EST to all non-immune and high-risk groups as appropriate Issue LLITNs Conduct pesticide spray training Put cholinesterase bio-monitoring program in place for pesticide workers Put chemoprophylaxis program in place for nonimmune and high-risk groups Set up malaria 24/7 telephone hotline Establish employee online learning module Ensure malaria medical management protocols in place Provide environmental control Provide larval control Establish Indoor residual spraying Set up space spraying Establish passive case detection Set up active case detection TREATMENT: Provide prompt diagnosis and treatment Establish community ACT roll-out if needed, consistent with the community action plan Provide emergency standby treatment Step 9: Monitoring and Evaluation Develop indicators Monitor Report Evaluate
Person Responsible
Completed (Y/N)
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Project Life Cycle and Associated Program Tasks

Exploration Feasibility Construction Operation Closure
This table provides a summary of the key tasks that should be carried out as part of the management of HIV/AIDS, tuberculosis and malaria. These tasks are divided according to the nine steps outlined in Section 2. The table provides guidance on the phase of mine during which each task should be initiated and implemented, in accordance with good practice.
STEPS AND ASSOCIATED TASKS
STEP 1: SCREENING
Generic across the three diseases
Undertake legislative review
Determine whether the company has adopted any best practice arrangements
Refer to international, national and regional/local data sets and health reports
Consider prevalence of factors contributing to TB on site: HIV prevalence, exposure to silica, standard of hostel or camp accommodation, TB incidence among labour source areas, tobacco and heavy alcohol use
Feed results of screening into company risk assessment matrix
Complete terms of reference for the baseline survey/s
HIV/AIDS
Refer to UNAIDS report to assess prevalence of disease in project area
Consider HIV/AIDS rates among labour source areas
TB
Refer to key Web sites with updated epidemiological information, in particular: WHO Tuberculosis site, WHO Stop TB Partnership program, and International Union Tuberculosis and Lung Disease
Annex C: Project Phases and Associated Program Tasks
Consider TB rates among labour source areas
Assess TB incidence rate, with help of health specialist: in particular, assess number of employees with untreated TB at take-on or start-up and number of employees who develop TB during employment
Consider prevalence of factors contributing to TB in adjacent communities: poor standards of living in project area, tobacco and heavy alcohol use, HIV prevalence
Consider rates of local MDR and XDR TB to assess potential for spread of drug-resistant TB (high risk)
Malaria
If in Africa, refer to Mapping Risk in Africa project Web site
Consider malaria rates among labour source areas
Refer to UNDP Web site for world-wide prevalence of malaria
Consider key mining activities that are likely to encourage transmission of malaria (e.g., construction of roads, clearing of vegetation, construction of environmental containment dams and water storage facilities, drilling operations)
STEP 2: SCOPING
Undertake desktop literature review
Undertake preliminary site visit
Review existing reports and relevant information
Review potential resources (internal and external) available to undertake baseline studies
Hold preliminary consultation with key stakeholders in order to gain further insight into disease/s and associated risks
Undertake gap analysis to determine what data are already available and what data gaps need to be filled in
Exploration
Feasibility
Construction
Operation
Closure
Develop TOR for baseline studies
Appoint external consultant / specialist, if required
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HIV/AIDS
Carry out actuarial modelling to estimate impact on production, group benefits and health resources (technical expertise may be needed)
Review personnel data (e.g., absenteeism, staff turn-over, disability insurance claims, STI incidence)
Assess list of mine activities and associated impact on transmission of HIV/AIDS
TB
Further refine TB epidemiology
Malaria
Consult key information sources on the incidence/prevalence of malaria in the project area (e.g., MARA maps, MICS data, MIS data, DHS data, local and regional health reports)
STEP 3: SITUATION ANALYSIS (HEALTH BASELINE)
Undertake detailed literature review of existing reports and data
Undertake household surveys
Undertake focus group discussions
Undertake health facility surveys
Undertake workforce KAP surveys
Undertake workforce screening program
Exploration
Feasibility
Construction
Operation
Closure
Identify high risk groups (within workforce and community)
Consult with key stakeholders
Define community action plan
HIV/AIDS
Undertake anonymous HIV sero-prevalence survey
Beware not to enforce workforce screening program
TB
Undertake occupational hygiene assessment of silica exposures
Estimate HIV prevalence in the workforce (and labour sending areas)
Assess quality of housing and accommodation, particularly with regards to overcrowding
Assess extent of new versus re-treatment TB cases (influencing length of treatment and time off work), and whether they are complicated by other diseases or permanent health damage (influencing return to full work capacity)
Malaria
Undertake geospatial mapping
Undertake vector mosquito surveys
Undertake malaria prevalence surveys
Undertake insecticide sensitivity survey
Ensure that project accommodation geo-positioning and engineering designs have taken malaria control into account
Make sure community sensitization and support in place
STEP 4: STAKEHOLDER ANALYSIS
Exploration
Feasibility
Construction
Operation
Closure
Identify and analyse stakeholders: those affected by the disease/s (employees, community residents) and those who influence management of the disease/s, including implementation of health programmes (NGOs, national and/or local authorities, community leaders, health staff, funding agencies, etc.)
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Define and understand potential partners
Develop stakeholder engagement plan
Carry out stakeholder engagement
Feed results of stakeholder engagement into Steps 2, 3, and 5 - 9
Define community action plan
STEP 5: PRIORITY, GOAL AND OBJECTIVE SETTING
Develop company policy exists on management of the three diseases (if it does not exist); policy to include contractors and be in line with company social and community development plans and goals
Identify program priorities, goals and objectives: to be linked to broader, external objectives and targets (e.g., National HIV, TB and malaria programs) and to reflect findings of Steps 14
STEP 6: OPTION APPRAISAL
Assess options against key considerations:
a) Feasibility (technical, financial, political)
b) Impact of options on the three diseases
c) Cost-effectiveness, equity, efficiency and sustainability
d) In-house capacity
Exploration
Feasibility
Construction
Operation
Closure
e) Necessity to outsource
f) Availability of funding for options under consideration
g) Prevalence of disease/s
h) Size and life of operation
Appoint experienced service providers to limit margin of error in HIV/AIDS programmes
Run pilot program of selected option before full roll-out
HIV/AIDS
Refer to outcome of actuarial review when selecting options
Consider Model 1, 2, 3 or 4 (as defined in Annex A)
TB
Select preferred option: minimum, intermediate or advanced (as defined in Table 5.2)
Malaria
Determine the size of the primary malaria control zone, including buffer zone
Define control activities for particular zones
Define education and awareness activities per zone
Define malaria medical management activities
Define secondary and tertiary prevention interventions
STEP 7: PROGRAM DESIGN, BUDGETING AND RESOURCING
Identify and ensure compliance with legal requirements
Develop comprehensive and accurate budgeting
Identify and link up with external funders, where appropriate
Define clear timelines
i) Quality of local health services
Exploration
Feasibility
Construction
Operation
Closure
Allocate sufficient staff (numbers and skills) and provide training (or outsource where necessary)
Ensure senior management buy-in and support
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Define program roles and responsibilities and organizational chart
Establish procurement procedures for equipment, drugs and consumables
Establish partnerships, where appropriate
Set up clear quality monitoring and evaluation system
Ensure that appropriate infrastructure and equipment is established, where required
Define education and awareness activities for the workforce and community
HIV/AIDS
Develop/provide list of HIV testing and ARV treatment centers
Provide onsite HIV diagnostics
Specifically train healthcare workers in HIV management
Develop/provide list of safe blood banks for emergency blood
TB
Develop/provide list of TB diagnostic and treatment centres (local)
Develop/provide onsite TB laboratory diagnostics
Develop/provide onsite radiological capability
Specifically train health care workers in DOTS and TB recognition
Define reporting of TB to national TB control program
Malaria
Develop/provide list of malaria diagnostic centres and ICU capable facilities
Exploration
Feasibility
Construction
Operation
Closure
Develop medical emergency response plan and evacuation procedure
Provide onsite infrastructure for pesticides storage and malaria control
Train spraymen for chemical control
Train health care and lab workers in malaria management
Establish a coordinating committee and allocation of dedicated funds for all three diseases
Establish a joint TB/HIV/malaria plan (to include resource mobilization, capacity building and training, communication, community involvement and research)
Strengthen laboratory services to ensure quality diagnosis and management of all three diseases
Provide regular screening for TB among employees known to be HIV positive; offer TB preventive therapy for those who do not have active TB
Implement TB infection control in health care facilities and congregate settings in order to reduce the risk of exposure
Do on-going monitoring against goals, objectives and targets
Provide joint TB/HIV/malaria training for health care providers
Establish referral networks
Establish system for joint reporting for all three diseases
HIV/TB
Provide surveillance of HIV prevalence among TB patients
Offer HIV testing and counselling (with an opt-out option) to all people diagnosed with TB
HIV/AIDS
Exploration
Feasibility
Construction
Operation
Closure
Prevention:
Provide awareness programs
Offer peer education
Review occupational health and safety procedures
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Distribute condoms
Provide voluntary counselling and testing
Provide information on male circumcision
Prevent and treat STIs
Treatment and Care:
Provide ARV program for employees and family members
Promote adherence to treatment
Prepare for treatment
Dispense medication
Promote on-going adherence monitoring
Provide PEP for occupational exposures
Treat opportunistic infections
Provide immune support and nutritional program
Provide MTCT program for pregnant employees
Train line managers and supervisors
Provide terminal care
Use an employee assistance program
TB
Prevention:
Exploration
Feasibility
Construction
Operation
Closure
Provide education
Introduce passive case finding
Use active case detection
Introduce silicosis control
Treatment and Care:
Establish a return to work process
Provide DOTS program
Monitor drug resistance
Malaria
Prevention:
Screen all site accommodation, working and mess areas
Install LLITNs in all site accommodations
Screen outdoor entertainment areas as appropriate
Make mosquito repellent (DEET and Picaridin) widely available
Ensure workforce education activities in place
Issue EST to all non-immune and high-risk groups as appropriate
Issue LLITNs
Conduct pesticide spray training
Put cholinesterase bio-monitoring program in place for pesticide workers
Put chemoprophylaxis program for non-immune and high risk groups
Set up malaria 24/7 telephone hotline
Establish employee online learning module
Ensure malaria medical management protocols in place
Exploration
Feasibility
Construction
Operation
Closure
Provide environmental control
Provide larval control
Establish indoor residual spraying
Set up space spraying
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Establish passive case detection
Set up active case detection
Treatment:
Provide prompt diagnosis and treatment
Establish community ACT roll-out if needed, consistent with the community action plan
Provide emergency standby treatment
STEP 9: MONITORING AND EVALUATION
Develop indicators
Monitor
Report
Evaluate
Exploration
Feasibility
Construction
Operation
Closure
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Annex D Acronyms/Abbreviations and Glossary

ACRONYMS AND ABBREVIATIONS ACT AIDS ART ARV BCG BSR CBO COSATU CSW CTX DFID DHS DMP DOTS EAP EIR ESIA EST FHI GBC GFATM GHI GRI HAART HIA HIV HR ICMM IFC IGRA ILO IPT IPTp IRS ISO ITN KPI LLITN LRA M&E MARA MDG MDR-TB MICS MIS MMV MTCT NGO NIH NTP
artemisinin combination therapy acquired immune deficiency syndrome anti-retroviral therapy anti-retroviral bacillus Calmette-Guerin Business for Social Responsibility community-based organization Congress of South Africa Trade Unions commercial sex worker Cotrimoxazole (drug used for HIV and Malaria) Department for International Development (United Kingdom) demographic and health survey disease management program directly observed therapy, short course Employee Assistance Program entomological inoculation rate environmental and social impact assessment emergency standby treatment Family Heath International Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria Global Fund to Fight AIDS, Tuberculosis and Malaria Global Health Initiative Global Reporting Initiative highly active anti-retroviral therapy health impact assessment human immunodeficiency virus Human Resources International Council on Mining and Metals International Finance Corporation interferon-gamma release assay International Labour Organization intermittent preventive treatment (or therapy) intermittent preventive treatment (or therapy) in pregnancy indoor residual spraying International Organization for Standardization insecticide-treated bed net key performance indicator long-lasting insecticide-treated bed net Labour Relations Act No. 66 of 1999 (Republic of South Africa) monitoring and evaluation Malaria Risk in Africa Millennium Development Goal multi drug-resistant tuberculosis multiple indicator cluster surveys malaria indicator surveys Medicines for Malaria Venture mother-to-child transmission non-governmental organization National Institutes of Health (United States) national TB control program
OHS Act
OI OPEC PE PEP PEPFAR PLWHA PPD PPP PPV PS PTB RBM RDT SIR STD STI TB TOR TST ULV UNAIDS UNDP UNICEF USAID VCT WEF WHO XDR-TB
Occupational Health and Safety Act, No. 85 of 1993 (Republic of South Africa) opportunistic infections Organization of the Petroleum Exporting Countries peer educators post-exposure prophylaxis Presidents Emergency Fund for AIDS (United States) people living with HIV/AIDS purified protein derivative public-private partnership positive predictive value performance dtandards pulmonary tuberculosis Roll Back Malaria rapid diagnostic test sporozoite infectivity rate sexually transmitted disease sexually transmitted infection tuberculosis terms of reference tuberculin skin test ultra-low volume Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Childrens Fund United States Agency for International Development voluntary counseling and testing World Economic Forum World Health Organization extensively drug-resistant tuberculosis
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Cofactors: Factors that increase the probability of development of a disease. For example, sexually transmitted infections such as gonorrhoea and chlamydia are cofactors for HIV transmission. Defaulting: A patient stopping treatment before completion. Directly observed therapy, short course: An internationally standardized recommended program for TB treatment and management. Discordant couple: A couple in which one partner is HIV-positive and the other is HIV-negative. Endemic: Normal expected background of disease occurrence in an area. Epidemic: A sudden, unusual increase in a disease that exceeds the number expected on the basis of experience. Epidemiology: the science of determining the patterns and control of disease in a population.
Demographic and health survey: Nationally representative stratified cluster surveys conducted every five years in many developing countries. Discrimination: Denial of opportunities or benefits (otherwise available to everyone) to a person or group because of real or assumed features or conditions of that person or group.
Circumcision: In males, removal of the foreskin, or prepuce, of the penis.
ELISA: A blood test that detects the presence of antibodies to HIV, used to determine whether a patient is HIV-positive. The term stands for enzyme-linked immunosorbent assay.
Asymptomatic: Without signs or symptoms of disease or illness (i.e., the patient does not complain of any symptoms). Most people who are HIV-positive are asymptomatic for 510 years or more.
Bacillus Calmette-Guerin: A vaccine against TB, usually given at birth, which offers partial protection.
Acquired immune deficiency syndrome (AIDS): The late stage of HIV disease. AIDS involves the loss of function of the immune system as CD4 cells are infected and destroyed, allowing the body to succumb to opportunistic infections or unusual cancers that are generally not pathogenic in people with intact immune systems. Common symptoms of AIDS include malignancies and wasting syndrome. Adherence to treatment: A patient taking medicines as prescribed. Antenatal: Prenatal; the period between conception and birth. Adolescents: Youth, ages 10 to 19. Young women in this age group are often at high risk of HIV and other STIs for biological and social reasons. Anti-retroviral therapy: Drugs that kill or suppress a retrovirus such as HIV. All of the anti-HIV drugs AZT, protease inhibitors, etc. are anti-retroviral drugs.
GLOSSARY
Abstinence: Refraining from sexual intercourse.
Active TB case finding: Screening high-risk groups for TB, irrespective of whether they have symptoms.
Pandemic: An epidemic occurring in many regions and countries.
Passive case-finding: Testing of sputum in all people presenting themselves with symptoms suspicious of TB.
Opportunistic infection: An illness that afflicts people with weak immune systems, as occurs with HIV. Common opportunistic infections in people with HIV/AIDS include TB, certain kinds of pneumonia, fungal infections and viral infections. Cancers such as lymphoma may also occur.
Non-governmental organization: A group that functions outside of formal government structures, usually on a non-profit basis. Some NGOs provide a variety of program services and advocacy around HIV/AIDS.
Multiple indicator cluster surveys: Nationally representative cluster surveys of between 4,000 and 12,000 women conducted every five years. The malaria component is conducted during the dry season.
Malaria indicator surveys: Smaller surveys, when compared to the DHS and MICS surveys, conducted at sub-national level and may include wet season data during peak transmission periods.
Incubation period: The time period between initial infection with a disease-causing agent and clinical manifestation of the disease. With HIV, the incubation period may be 510 years or more. Inter-current diseases/ infection: An infection occurring at the same time as and possibly altering the course of another disease. Indicator: Quantifiable measures of program performance and impact. Latent TB: presence of mycobacterium tuberculosis in the tissues without causing disease.
Front-line drugs: Drugs that are used as the first line or initial preferred regimen in treating a disease. Long-lasting insecticide treated net: A bed net that has been impregnated with insecticide using technology that ensures the repellency effect lasts for three to five years.
Incidence: The number of new cases of a disease recorded in a specific time period, typically one year.
Extrapulmonary TB: Tuberculosis in organs other than the lungs.
Extremely drug-resistant TB: Tuberculosis resistant to first- and second-line drugs. Intermittent preventative treatment in pregnancy for malaria: All pregnant women should receive two doses of chemoprophylaxis against malaria during their pregnancy, as it has been shown to increase birth weight and decrease malaria mortality.
Human immunodeficiency virus (HIV): The virus that causes AIDS. The virus is acquired through sexual activity, sharing of infected needles or cutting instruments, contaminated blood supplies and/or mother-to-foetus/infant transmission. The virus remains in the body for 510 years or more before full symptoms of opportunistic infections or AIDS appear. The virus is detected in the bloodstream through the ELISA test.
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Sputum: secretion brought up from lung or bronchi (not to be confused with saliva). Stable transmission area: An area where malaria transmission potentially occurs throughout the year, although transmission levels may fluctuate.
Seroconversion: Development of detectable antibodies to HIV in the blood. Seroconversion may take several months or more after initial HIV transmission. After antibodies to HIV appear in the blood, a person will test positive for the infection on the standard ELISA test. Sexual coercion: Forcing someone to engage in sexual behaviour against her/his will, through threatened or actual violence, severe social consequences or financial or material inducements. Sexual harassment is a form of sexual coercion.
Sexually transmitted infection and sexually transmitted disease: A virus or bacteria transmitted between sexual partners. Common STIs include chancroid (often causing painful sores on the penis, vagina or anus and swollen lymph nodes), chlamydia (often causing irregular bleeding and pain during intercourse in women, burning during urination in men and discharge in both men and women) and gonorrhoea (symptoms include urethral or vaginal discharge).
Regimen: A drug, or several drugs, given in certain doses for a stated duration. Rapid diagnostic test: A rapid test for malaria similar in concept to a home pregnancy test.
Second-line drugs: Drugs that are used to treat a disease in the event that first-line drugs cannot be used or prove ineffective.
Roll Back Malaria: A program promoted by WHO with specific targets agreed upon through the Abuja Declaration.
Policy: A framework for expected actions by members of an organization.
Prevalence: The number of persons with a particular condition in a given population. Prevalence is determined by dividing the number of people with the condition by the total population. Primary care: Basic medical care; the first line of medical management of a condition. Project life-cycle: The full life-cycle of a project from exploration through to closure. Protease inhibitor: A class of anti-HIV drugs that prevent the creation of an HIVspecific protease enzyme.
Perinatal transmission (vertical transmission; mother-to-child transmission): The transmission of HIV from a woman with HIV infection to her foetus/infant before or during birth or through breastfeeding.
Peer education: Sharing of information by people of similar backgrounds and experiences (e.g., similar ages, occupations or life experiences).
Peer pressure: Emotional or mental coercion by people belonging to a given individuals social group (e.g., same age, grade or status) to act or behave in a manner similar to themselves. Peer pressure has a great influence on adolescent behaviour, reflecting young peoples desire to fit in and be accepted by others.
Vector: In terms of malaria, the vector of malaria is the female Anopheles mosquito. Virus: A large group of sub-microscopic agents capable of infecting plants, animals and bacteria. Viruses are characterized by total dependence on living cells for reproduction and a lack of independent metabolism. Western blot: A blood test to confirm the results of an ELISA test for HIV antibodies, used because it is much more specific.
Unstable transmission area: An area where there is normally an interruption to malaria transmission for part of the year, and potentially no transmission for more than one year, with epidemics occurring when environmental conditions and human factors are suitable.
Syndrome: A set of symptoms that occur together.
Universal precautions: Infection control measures that prevent the transmission of blood-borne pathogens (e.g., HIV) between patients and health workers, without specifically knowing the HIV status of any patient. They include washing hands; using gloves and protective clothing; handling sharp objects safely; disposing of waste materials; cleaning, disinfecting and sterilizing medical instruments; handling corpses properly; and treating injuries at work.
TB skin test: A test for TB infection (not disease) with tuberculin protein extracted from TB bacilli, also known as purified protein derivative or Mantoux tests.
Stigma: Negatively perceived characteristic(s) of a person or group. Stigmatization is the labelling of persons with such feature(s) for example, of persons who are (or are considered to be) HIV-positive.
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Annex E References and Useful Resources

REFERENCES HIV/AIDS
INTEGRATED MANAGEMENT OF HIV/AIDS, TB AND MALARIA
Abu-Raddad, LJ, Patnaik, P, and Kublin, JG, 2006. Dual infection with HIV and malaria fuels the spread of both diseases in sub-Saharan Africa, Science 314, pp 1603-1606. Corbett, E, Marson, B, Churchyard, C and De Cock, K, 2006. Tuberculosis in subSaharan Africa: opportunities, challenges, and change in the era of antiretroviral treatment, Lancet, 367, pp 926-937. Business for Social Responsibility, 2007. Issue Brief: HIV/AIDS in the workplace. Business for Social Responsibility, 2003, Issue Brief: HIV/AIDS in the workplace. http://www.bsr.org/CSRResources/IssueBriefDetail.cfm?DocumentID=49032. International Finance Corporation, 2002. Good Practice Note: HIV/AIDS in the workplace.
Corbett, E, Watt, C, Walker, N, Maher, D, Williams, B, Raviglione, M, and Dye, C, 2003. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic, Arch Intern Med, 163, pp 1009-1021. Connelly, P, and Rosen, S, 2006. Treatment for HIV/AIDS at South Africas largest employers: myth and reality, South African Medical Journal 96(2), pp. 128-133.
Ainsworth, M, and Teokul, W, 2002. Breaking the silence: setting realistic priorities for AIDS control in developing countries, Lancet, 356, pp 55-60. Barnett, T, and Whiteside, A, 2002. AIDS in the Twenty-First Century: Disease and Globalisation. Palgrave MacMillan, UK. ISBN 1-4039-0006-X. Dorrington, RE, Johnson, LF, Bradshaw D, and Daniel ,T, 2006. The Demographic Impact of HIV/AIDS in South Africa. National and Provincial Indicators. Cape Town: Centre for Actuarial Research, South Africa Medical Research Council, Actuarial Society of South Africa. Leighton, C, 1993. Economic Impacts of Malaria in Kenya and Nigeria, Ph.D. With Rebecca Foster, About Associates Inc. In collaboration with Vector Biology Control Project, Medical Services Corporation International.
Bureau for Economic Research, 2004. The Economic Impact of HIV/AIDS on Business in South Africa 2003. Stellenbosch. International Labour Organization, 2005. Legal Initiatives to Address HIV/AIDS in the World of Work; The ILO Programme on HIV/AIDS and the World of Work.
International Finance Corporation, undated. HIV/AIDS guide for the mining sector. http://www.ifc.org/ifcext/aids.nsf/AttachmentsByTitle/HIV_AIDS_Mining_Guide/$FILE /AIDS_Mining_Guide.pdf.
Mathers, CD, and Loncar, D, 2006. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 3(11): e442. doi:10. 1371/journal.pmed.0030442. World Health Organization, undated. Male circumcision in HIV prevention. http://www.who.int/hiv/topics/malecircumcision/en/index.html. TUBERCULOSIS MALARIA
Minister of Manpower and Transmigration of Republic of Indonesia, 2004. Indonesia HIV / AIDS Prevention and Control in the Workplace; Decree; KEP68/MEN. Russell, S, 2004. The economic burden of illness for households in developing countries: a review of studies focusing on malaria, tuberculosis and human immunodeficiency virus/acquired immunodeficiency syndromes. Am. J. Trop. Med. Hyg., 71(Suppl 2), pp. 147-155. World Health Organization, 2003. WHO HIV/AIDS Treatment and Care Protocols for Countries of the Commonwealth of Independent States, Geneva. World Health Organization, 2001. Basic Principles for Effective Prevention of HIV Infection among Injecting Drug Users: As a Public Health Priority in Countries of Central and Eastern Europe and Central Asia, Geneva. World Health Organization. WHO Stop TB Program Global MDR-TB, XDR-TB Response Plan 2007-2008. World Health Organization, 2006. Instructions for Applying to the Green Light Committee for Access to Second Line Anti-Tuberculosis Drugs. Geneva, WHO/HTM/TB 2006.369. http://www.who.int/tb/dots/dotsplus/management/en/index.html. USAID, 2004. Workplace HIV/AIDS Programs: An Action Guide for Managers, USAID funded publication. Department of Minerals and Energy, Republic of South Africa, 2003. Guidance note for occupational medical practitioners: TB control programmes. Pretoria. www.dme.gov.za. Barnes, KI, Durrheim, DN, Little, F, Jackson, A, and Mehta, U, 2005. Effect of artemether-lumefantrine policy and improved vector control on malaria burden in KwaZuluNatal, South Africa. PLoS Med 2(11): e330.
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International Union Against Tuberculosis and Lung Disease. Various resources on TB for health professionals. http://www.tbrieder.org. Ault, SK, 1989. Effect of demographic patterns, social structure, and human behaviour on malaria. pp. 283-301. In: Curtis, CF (ed.), 1990, Appropriate Technology in Vector Control, CRC Press, Boca Raton, Florida.
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Breman, JG, Alilio, S, and Mills, A, 2004. Conquering the intolerable burden of malaria: whats new, whats needed: a summary. Am. J. Trop. Med. Hyg., 71(Supplement 2), pp. 1-15. Keiser J, Singer BH, and Utzinger, J. 2005. Reducing the burden of malaria in different eco-epidemiological settings with environmental management: a systematic review. Vol. 5: 695-708. http://infection.thelancet.com.
Curtis, CF, Lines, JD, Carnevale, P, and Robert, V, 1989. Impregnated bed nets and curtains against malaria mosquitoes. pp 5-46. In: Curtis CF (ed.), 1990. Appropriate Technology in Vector Control, CRC Press, Boca Raton, Florida. Curtis, CF and Mnzava, AEP, 2000. Comparison of house spraying and insecticidetreated nets for malaria control. Bull. Wld. Hlth. Organ. 78, pp 1389-1400. Gillett, JD, 1989. The behaviour of Homo sapiens, the forgotten factor in the transmission of tropical diseases. Trans. Roy. Soc. Trop. Med. Hyg. 79, pp 12-20. Goodman, CA, Coleman PG, and Mills AJ, 1999. Cost- effectiveness of malaria control in sub Saharan Africa. Lancet 354, pp 378-385. Lengeler, C, Cattani, J, and de Savigny, D, 1996. Net Gain: A New Method for Preventing Malaria Deaths. World Health Organization, International Development Research Centre, Geneva. Nahlen, BR, Clark, JP, and Alnwick, D, 2003. Insecticide-treated bed nets. Am. J. Trop. Med. Int. Hlth. 68 (Supplement 4), pp 1-2. Institute of Medicine, 1991. Committee for the Study on Malaria Prevention and Control: Status Review and Alternative Strategies. Division of International Health, Institute of Medicine, National Academy of Sciences, Washington, DC. http://www.iom.edu/. Lengeler, C, and Sharp, B, 2003. Indoor Residual Spraying and Insecticide-Treated Nets: Reducing Malarias Burden, Evidence of Effectiveness for Decision Makers. Global Health Council, Washington, DC. pp. 17-24.
Hess, AD, 1984. Ecological management of malaria vectors. Bull. Soc. Vector Ecol. 9, pp 23-26. Kiszewski, AA, Mellinger, A, Spielman, A, Malaney, P, Sachs, SE, and Sachs, J, 2004. A global index representing the stability of malaria transmission. Am. J. Trop. Med. Int. Hlth. 70, pp 486-498. Rafatjah HA, 1988. Malaria vector control: environmental management. pp. 11351172. In: Wernsdorfer, WH, and McGregor, I (eds.), Malaria: Principles and Practice of Malariology. Vol. 2. Churchill Livingstone, London.
Mabaso, MLH, Sharp, B, and Lengeler, C, 2004. Historical review of malaria control in southern Africa with emphasis on the use of indoor residual house-spraying, Trop. Med. Int. Hlth. 9(8), pp 846-856.
Utzinger, J, Tozan, Y, and Singer, BH, 2001. Efficacy and cost effectiveness of environmental management for malaria control. Trop. Med. Int. Hlth. 6 pp 677-687. Wiseman, V, Hawley, W, Ter Kuile, F, Phillips-Howard, P, Vulule, J, Nahlen, B, and Mills, A, 2003, The cost-effectiveness of permethrin-treated bed nets in an area of intense malaria transmission in Western. Am. J. Trop. Med. Hyg. 68 (Suppl 4), pp 161-167. World Health Organization, 1982. Manual on Environmental Management for Mosquito Control. WHO Offset Publication No. 66, Geneva. pp 1-283. CLIMATE CHANGE AND MALARIA World Health Organization, 1989. The Use of Impregnated Bednets and Other Materials for Vector-borne Disease Control. A report of the WHO/VBC informal consultation, Geneva. WHO/VBC/89.981 (unpublished), pp 1-45. Jetten, TH, Martens, WJ, and Takken, W, 1996. Model simulations to estimate malaria risk under climate change. J. Med. Entomol. 33, pp 361-371. World Health Organization, 1993. Implementation of the Global Malaria Control Strategy. WHO Tech. Rep. Ser. No. 839. Geneva, pp 1-57. World Health Organization, 1995. Vector Control for Malaria and Other Mosquitoborne Diseases. WHO Tech. Rpt. Ser. 857. WHO, Geneva, pp 1-9. Bangs, MJ, and Subianto, DB, 2000. El Nio and associated outbreaks of severe malaria among highland populations in Irian Jaya, Indonesia: A review and epidemiological perspective. Southeast Asian J. Trop. Med. Pub. Hlth. 30, pp 608619.
Utzinger, J, Tozan, Y, Doumani, F and Singer, BH, 2002. The economic payoffs of integrated malaria control in the Zambian copperbelt between 1930 and 1950, Trop. Med. Int. Hlth. 7(8) pp 657677.
Utzinger, J, Tanner, M, Kammen, DM, Killeen, GF, and Singer, BH. 2002b, Integrated programme is key to malaria control. Nature 419, p 431.
World Health Organization, 1974. Manual on Personal and Community Protection against Malaria in Development Areas and New Settlements. WHO Offset Publication No.10, Geneva; pp 1-49. Lindblade, KA, Walker, ED, Onapa, AW, Katungu, J, and Wilson, ML, 1999, Highland malaria in Uganda: prospective analysis of an epidemic associated with El Nino. Trans. Roy. Soc. Trop. Med. Hyg. 93 pp 22-23. Mouchet, J, Manguin, S, Sircoulon, J, Laventure, S, Faye, O, Onapa, AW, Carnevale, P, Julvez, J, and Fontenille, D, 1998. Evolution of malaria in Africa for the past 40 years: impact of climatic and human factors. J Am. Mosquito Control Assoc. 14, pp 121-130. Van Lieshout, M, Kovats, RS, Livermore, MTJ, and Martens, P, 2003. Climate change and malaria: Analysis of the SRES climate and socio-economic scenarios. Global Environmental Change 14(1): pp 87-99.
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USEFUL RESOURCES
The resources listed here serve as useful sources of good information on some of the topics covered in the guideline. It is important to note that information does evolve and that as new evidence becomes available some of these Web links may change and/or documentation may be updated. WEB SITES (GENERAL) World Business Council for Sustainable Development (WBCSD). http://www.wbcsd.org/web/devguide.htm. Organizations that fund projects in the UK and overseas. http://www.cafonline.org/Default.aspx?page=12481. The Foundation Center. http://www.fdncenter.org. HIV/AIDS Online available at: http://www.thebody.com.
International Finance Corporation (IFC) and part of the World Bank, Environmental Health and Safety Guidelines includes updated Occupational Health & Safety and Community Health & Safety guidelines and reporting criteria. http://www.ifc.org/ifcext/enviro.nsf/Content/EnvironmentalGuidelines. Global Reporting Initiative (GRI) corporate social responsibility and sustainability reporting guidelines; ICMM members have agreed to report against GRI indicators (including community and occupational health indicators), which can be found at http://www.globalreporting.org. Joint United Nations Programme on HIV/AIDS. www.unaids.org. Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC). http://www.businessfightsaids.com. World Economic Forum (WEF) Global Health Initiative (GHI) promotes publicprivate partnerships to tackle HIV/AIDS, tuberculosis, malaria and health systems. http://www.weforum.org/en/initiatives/globalhealth/index.htm. Business Responds to AIDS and Labour Responds to AIDS (BRTA/LRTA). http://www.brta-lrta.org.
Brehaut, H. 2001. The Community Health Dimension of Sustainable Development in Developing Countries. Report commissioned by the MMSD project of IIED. http://www.iied.org./mmsd/mmsd_pdf/community_health_in_developing_countries. pdf. Department of Minerals and Energy Republic of South Africa, 2003 contains an occupational medicine section with information on HIV and guidelines on TB control in mines: http://www.dme.gov.za/mhs/documents.stm. Centers for Disease Control and Prevention, Atlanta, Georgia, USA - HIV Web site at http://www.cdc.gov/hiv.
South African Business Council on HIV/AIDS (SABCOHA). http://www.sabcoha4business.co.za. HIV BUSINESS CASE HIV WORKPLACE PROGRAMS TUBERCULOSIS
IPIECA HIV/AIDS management guideline (2005). http://www.ipieca.org/activities/health/health_publications.php. HIV POST-EXPOSURE PROPHYLAXIS World Health Organization PEP site. http://www.who.int/hiv/topics/arv/pep/en/index.html. Global Stop TB Partnership. http://www.stoptb.org. International Labour Organization (ILO). www.ilo.org.
South African AIDS Management System (AMS 16001) [[this needs more info if kept; no url provided]] Business for Social Responsibility Issue brief on HIV in the workplace. http://www.bsr.org/insight/issue-brief-details.cfm?DocumentID=49032. The ILO Code of Practice on HIV/AIDS and the World of Work. http://www.ilo.org/public/english/protection/trav/aids/publ/code.htm; http://www.ilo.org/public/english/protection/trav/aids/publ/employerguideline_eng.pdf. Centers for Disease Control and Prevention PEP site: http://www.cdc.gov/hiv/resources/factsheets/hcwprev.htm Cost effectiveness analysis toolkits provided by the Centers for Disease Control and Prevention. http://www.cdc.gov/hiv/topics/prev_prog/ce/resources.htm. Various international agencies provide support to countries for their NTP activities, including WHO, the International Union Against Tuberculosis and Lung Disease, other NGOs with international activities (e.g., the Royal Netherlands Tuberculosis Association) and bilateral development assistance agencies.
The Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC) provides a good resource section outlining the economic impact of HIV/AIDS on business. http://www.businessfightsaids.org/live/resources/economic.php.
Opportunities for business in the fight against AIDS from the GBC. http://www.businessfightsaids.org/documents/resources/economic%20impact/Execu tive%20Summary.pdf. International Union Against Tuberculosis and Lung Disease. http://www.tbrieder.org.
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TB WORKPLACE PROGRAMS TB EPIDEMIOLOGY
Maher, D, Boldini, F, Pathania, V, Alli, B, Gabriel, P, Kisting, S, and Norval, P-Y, 2003. Guidelines for Workplace Control TB Activities: The Contribution of Workplace TB Control Activities to TB Control in the Community. World Health Organization. http://whqlibdoc.who.int/publications/2003/9241546042.pdf. Churchyard, G, and Corbett,E, 2001, Tuberculosis and associated diseases. Section 6 in: Guild, R, Johnston, J, and Ross, M (eds), 2001. Handbook of Occupational Health Practice in the South African Mining Industry. Johannesburg: Safety in Mines Research Advisory Committee. Safety in Mines Research Advisory Committee, Guidelines for TB Management in Mines in South Africa. http://www.weforum.org/pdf/Initiatives/GHI_Olyset_BHP%20Billiton.pdf. WHO Tuberculosis Web site. http://www.who.int/tb/en. COMPREHENSIVE MANAGEMENT OF TB Global Stop TB Partnership program. http://www.stoptb.org. National TB Program data for the country of operation. Demographic and Health Survey data. http://www.measuredhs.com. World Health Organization. Tuberculosis. Data and Country Profiles. http://www.who.int/tb/country/en. World Health Organization, 2000. Global Plan to Stop TB. Geneva. WHO/CDS/STB/2000.16. http://www.stoptb.org/GPSTB. World Health Organization, 2007. Global Tuberculosis Control: Surveillance, Planning, and Financing. Geneva. http://www.who.int/tb/publications/global_report/2007/pdf/full.pdf. World Health Organization, 1999. Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-limited Settings. WHO/TB/99.269. Geneva. International Union Against Tuberculosis and Lung Disease. http://www.tbrieder.org. Maher, D, and Mikulencak, M, 1999. What is DOTS? A Guide to Understanding the WHO-recommended TB Control Strategy Known as DOTS. World Health Organization, Geneva. WHO/CDS/CPC/TB/99.270. http://whqlibdoc.who.int/hq/1999/WHO_CDS_CPC_TB_99.270.pdf. World Health Organization, 2003. Treatment of Tuberculosis: Guidelines for National Programmes, 3rd ed. Geneva. WHO/CDS/TB/2003, 313. http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.313.pdf.
TB WORKPLACE CASE STUDIES MALARIA
Anglogold, 2002. Detecting active tuberculosis (TB) cases, with 88% of cases being cured or completing treatment, for less than US$ 85 per employee per year. South Africa. http://whqlibdoc.who.int/publications/2003/9241546042.pdf. Chevron Texaco, 2002. Partnering with the community, the local government and Stop TB to establish DOTS treatment in the Cabinda province. Angola. www.weforum.org/pdf/Initiatives/GHI_TB_CaseStudy_ChevronTexaco.pdf. Global Drug Facility, 2007. A new perspective on TB drug procurement. www.stoptb.org/gdf/assets/documents/FS%20GDF%20An%20Introduction.pdf. GENERAL WHO Global Malaria Program Web site, source of technical information and management guidelines. http://www.who.int/malaria. WHO Roll Back Malaria Web site, more devoted to partnership development and advocacy. http://www.rbm.who.int. IPIECA A Guide to Malaria Management Programs in the Oil and Gas Industry. 2006. http://www.ipieca.org/activities/health/health_publications.php. MALARIA AND HIV WHO flyer on HIV and Malaria from 2004 (check for updated version post 2007. http://www.who.int/malaria/malaria_HIV/malaria_hiv_flyer.pdf. De Beers, 2002. Global health initiative: Private sector intervention case example. Developing an enhanced tuberculosis (TB) programme before TB becomes a significant business risk. South Africa. http://www.weforum.org/pdf/Initiatives/GHI_TB_CaseStudy_DeBeers.pdf.
Gold Fields, 2002. Renewing focus on tuberculosis (TB) detection and treatment given a 21% annual increase in case rates in the last decade. South Africa. http://www.weforum.org/en/initiatives/globalhealth/Case%20Study%20Library/GoldF ieldsTB. Malaria Journal open access journal for scientific information on malaria (expert resource). http://www.malariajournal.com/home. MALARIA BUSINESS CASE Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (coalition of private companies committed to fighting the three diseases, with a good library of case studies). http://www.businessfightsaids.org/live/home/home.php. AngloGold Ashanti Report to Society, 2006. Obuasi Mine case study. Kokola Copper Mine, Zambia: World Economic Forum KCM case study. Online available at: http://www.weforum.org/pdf/Initiatives/GHI_Malaria_Konkola_AppendixB.pdf.
World Economic Forum, 2002. http://www.weforum.org/en/initiatives/globalhealth/Case%20Study%20Library/index. htm.
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Guidelines for Employer-Based Malaria Control Programmes. http://www.malaria.org.za/lsdi/home.html. MALARIA INSECTICIDE-TREATED NETS WHO position statement at http://www.who.int/malaria/docs/itn/ITNspospaperfinal.pdf. MALARIA RISK ASSESSMENT Mapping Malaria Risk in Africa. http://www.mara.org.za. National Malaria Control Program data (if available).
Lubombo Spatial Development Initiative, good example of a public-private partnership. http://www.malaria.org.za/MRP/mrp.html. MALARIA RAPID DIAGNOSTIC TESTS WHO site on RDTs, includes a list of commercially available RDTs from manufacturers with evidence of good manufacturing. http://www.wpro.who.int/sites/rdt. Demographic and Health Survey data. http://www.measuredhs.com.
World Economic Forum, 2006. Business and Malaria: A Neglected Threat? Geneva. http://www.weforum.org/pdf/MalariaReport.pdf. World Economic Forum, 2006. Guidelines for Employer-Based Malaria Control Programmes. http://www.weforum.org/pdf/Malaria.pdf. WHO Burden of Disease data (see relevant report from the Burden of Disease project). http://www.who.int/topics/global_burden_of_disease/en. Multiple Indicator Cluster Surveys data and Malaria Indicator Survey data from the WHO RBM Web site. http://www.rbm.who.int. A library of case studies to support this guidance document is available on-line at www.icmm.com
World Economic Forum, (no date). Lubombo Spatial Development Initiative: creating a public private partnership to build malaria intervention capacity in Mozambique, Swaziland and South Africa. http://www.weforum.org/pdf/Initiatives/GHI_Olyset_BHP%20Billiton.pdf.
List of contributors
ICMM Working Group Dr David Barnes, AngloGold Ashanti Health Services Dr Mel Mentz, Lonmin Platinum Mr Andre van der Bergh, BHP Billiton Mr Fazel Randera, South African Chamber of Mines Dr Frank Fox, Anglo American Mr Paul Jones, Xstrata Dr Richard Gaunt, Rio Tinto (Chair) Mr Stan Batey, Freeport McMoran Inc
Specialists Dr David Knight, International SOS and University of Cape Town (Malaria) Dr Michael Bangs, International SOS (Malaria) Dr Gavin Churchyard, Aurum Institute for Health Research (HIV/AIDS & TB) Mr Gavin George, HEARD, University of KwaZulu Natal (HIV/AIDS) Dr Tony Davidson, Organizational Health Consultant, Cape Town (HIV/AIDS) Professor Rodney Erhlich, University of Cape Town (TB) Project Team Ms Christine Copley, International Council on Mining and Metals (ICMM) Dr Andrew Parsons, ICMM Ms Sue Posnik, Environmental Resources Management (ERM) Ms Alison McCallum, ERM Dr David Knight, International SOS and University of Cape Town Additional Contributors Special thanks to those who shared their knowledge and experience in the compilation of these guidelines: Dr Alistair Calver, AngloGold Ashanti Health Services Professor Jill Murray, National Institute of Occupational Health, Johannesburg Dr Liesl Page-Shipp, Independent TB Specialist Dr Jan Pienaar, Anglo Coal South Africa Dr Pasi Petinnen, International SOS Professor May Hermanus, University of Witwatersrand Dr Alasdair Reid, UNAIDS Mr Rob Cox, International Petroleum Industry Environmental Conservation Association.
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Front cover photo credits
Top, L-R 1. Photo courtesy Anglo American/Vismedia 2. Photo courtesy Science Museum of Minnesota 3. Photo courtesy BHP Billiton
Bottom, L-R 1. Photo courtesy Anglo American/Vismedia 2. Photo courtesy Anglo American/Vismedia 3. Photo courtesy Lung Health Image Library/Pierre Virot
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The International Council on Mining and Metals (ICMM) is a CEO-led industry group that addresses key priorities and emerging issues within the industry. It seeks to play a leading role within the industry in seeking to promote good practice and improved performance and encourages greater consistency of approach nationally and across different commodities through its association members and member companies. ICMMs vision is for a respected mining and metals industry that is widely recognized as essential for society and as a key contributor to sustainable development. Our library at www.goodpracticemining.com has case studies and other examples of leading practices.
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ICMM Good Practice On HIV-TB-Malaria

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ICMM Good Practice On HIV-TB-Malaria

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Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

6 6.1 6.2 6.3 6.4

ANNEX B: Roles and Responsibilities

108 112 124 136 142

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

1.2 HOW TO USE THE GUIDANCE

1.3 OVERVIEW OF THE DISEASES HIV/AIDS Tuberculosis Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Table 1.1: Stage 3 1 4 2

Name of Stage Clinically asymptomatic infection Symptomatic HIV infection AIDS

Four Stages of HIV Infection

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

The management plan process

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Section 2. The management plan process

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Photo courtesy Xstrata

RISK ASSESSMENT (Exposure): Do we need the program?

STEP 8: PROGRAM IMPLEMENTATION

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Figure 2.2: The Management Plan Process - Summary of Key Considerations

Key or strategic issues

diseases with medium to high risk

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

STEP 8: PROGRAM IMPLEMENTATION

STEP 6: OPTION APPRAISAL

STEP 9: MONITORING & EVALUATION

STEP 7: PROGRAM DESIGN, BUDGETING & REPORTING

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Photo courtesy Anglo American/Vismedia

Data Gathering Techniques

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Obtaining External Funding

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Box 2.8. Minimum Practical Standards

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria

Good Practice Guidance on HIV/AIDS, Tuberculosis and Malaria