2.5.1 In conjunction with health workers’ representatives, develop and implement programmes for regular, free, voluntary, and confidential counselling and testing for HIV and TB, including addressing sexual and reproductive health issues, as well as intensified case finding in the families of health workers with TB.

This statement has several components. The focus of the discussion below will begin with the issue of involving health workers' representatives. The issues of addressing reproductive health issues and intensified case findings in the families of health workers with TB will be addressed afterwards. It should be noted, however, that both phrases in this statement are supported by existing guidelines, as well as evidence from the literature.

Vaas (2008) used a qualitative study model to examine the role of HIV committees in effective workplace governance of HIV in small and medium sized companies in South Africa. In-depth qualitative case studies were conducted in five South African small and medium-sized enterprises that were actively implementing HIV policies and programmes. Companies commonly implemented HIV policies and programmes through a workplace committee dedicated to HIV or a generic committee dealing with issues beyond HIV. Vaas found that management, through the human resources department and the occupational health practitioner, often drove initial policy formulation, and had virtually sole control of the AIDS budget. These non-statutory committees appeared to co-exist with other statutory committees, facilitating sharing of information and feedback on HIV activities. Vaas noted that committees were seen to be valuable in determining the needs of a workplace VCT programme and can play an essential role in bridging communication between front-line staff and management. Advancing strong conclusions regarding committees, Vaas stated: "The single most effective intervention for meaningful HIV governance would be the support and empowerment of employee representatives and shop stewards at the workplace."

As noted in the discussion of Statement #3, Morris and Cheevers (2001) found that the issues that were important in the formation of a workplace committee to oversee an occupational-based HIV package, included confidentiality, trust, and the traditional roles of the stakeholder relationships. When these points were addressed through the focus on a common goal, the committee was able to fulfill its role as a coordinating body. The authors concluded that central to success was the inclusion of all stakeholders in the process, including those with traditionally opposing interests. The experience they describe in this sugar mill demonstrated the benefit of a workplace committee dedicated to addressing HIV issues.

Yassi et al. (2009b) recently published the results of a baseline study conducted at Pelonomi Hospital in Free State, and also noted the importance of health and safety committees in addressing occupational health and infection control generally, as well as prevention, treatment and case for HIV and TB specifically. This study built on earlier work evaluating the value of labour- management health and safety committees in healthcare (Yassi et al. 2005) and highlighted the importance of committee member training.

In an international workshop of the International Commission of Occupational Health, attended by approximately 50 participants from 12 countries (Rebman 2008), it was concluded that health and safety committees have an important role to play worldwide, and where occupational health services are not well-developed or fully-resourced, occupational health committees provide a way to draw attention to workplace health and safety issues and support workplace exposure prevention activities. In many parts of the world, these committees have facilitated workers' active participation in detecting workforce health concerns, raising awareness of problems to management, finding solutions, and making decisions about programmes and services. These committees should include representatives elected by the workforce, rather than appointed by management, and management representatives.

As noted, for example, by PAHO (2006), in collaboration with occupational health professionals, health and safety committees can coordinate four important spheres of activities: monitoring the work environment; employee health surveillance; education and training; and occupational health services (e.g. first aid, vaccinations) (Rebman et al., 2008). Examples were provided from various low and middle-income countries in which health and safety committees were responsible for the implementation of hospital-based micro projects and delivered training sessions on occupational health and infection control to health care workers, including training on the prevention of needlestick injuries as well as on universal precaution principles. Committees also advocated on behalf of the workforce to hospital managers for the accessibility and availability of equipment and training to improve the safety of the hospital environment. (Lavoie et al., 2010)

The study by Kiragu and colleagues conducted in Zambia in 2008 (profiled in Table 2) is also particularly relevant to this statement. The objective of the study was to develop and test an HIV risk reduction workplace programme for hospital staff. This intervention included a peer education programme. Two hospitals were selected where the intervention would be implemented, and three other hospitals served as comparison sites. The workplace based programmes in the intervention hospitals reported higher HIV knowledge, lower stigma, and greater awareness of PEP. It was also noted that not all hospital staff are heterogeneous, with both clinical and non-clinical staff having varying levels of understanding regarding HIV and TB transmission, and that these different needs must be considered when designing and implementing a programme. Yassi et al (2009b) also found that knowledge, and more importantly, health workers' confidence in their own knowledge, differed by occupation, and concluded as well that the different levels of knowledge and confidence amongst members of health and safety committees, must be addressed in building capacity of health and safety committees to address occupational health and infection control issues generally.

The systematic review and key informant interview study conducted by Mahajan and colleagues (2007), while not addressing the issue of health worker committees, did indeed find that trade union involvement was important for success. However they noted that in a study of 302 union shop stewards from firms representing 10 different sectors, only 15% reported that their union discussed HIV issues with the employer, 52% reported an existing HIV workplace policy and only 15% reported that they had received a copy of the policy. As noted by Vaas (2008), union officials have many issues to address, and may not have the capacity needed within their existing resources to fully address this issue; health and safety committees would therefore take on particular importance in this regard.

A study conducted by the Industrial Health Research Group and the South African Municipal Workers Union (2005) to explore attitudes, experience, culture and practices of occupational health and safety for health care workers characterized the situation they found at that time as a culture of reactivity and minimal compliance, in which management did not actively engage with workers and ask for their input in developing health and safety practices in clinics. Corbett's 5-country study lent support to involving health and safety representatives in noting that there is currently poor communication to staff.

Tarwireyi et al. published a study in 2003 that aimed to determine the proportion of health workers who had undergone VCT for HIV in three rural districts in Zambia while also exploring reasons for non-participation in those who had not been tested. The authors concluded that programmes should have a strong counselling component and should focus on self-efficacy so that health workers will be able to cope with HIV results and have the courage to participate in VCT. The authors also state the counselling, testing, and treatment programmes to date have been directed at the general population and have neglected the high-risk health workforce. Therefore, effective programmes should be created with direct input from unions, front-line workers, and management to ensure that the specific needs of this population are being met.

The Systematic Review conducted to support the Guideline development process identified few intervention studies in which model programmes were properly evaluated, and none specifically evaluated the importance of health and safety committees. In the realist review, the support of unions, and involvement of front-line health workers, especially those living with HIV, were highlighted by investigators in determinants of successful programmes.

To turn now to the issue of case finding within families of health workers with TB, it should be noted that WHO guidelines address this issue - -and there seems to be little controversy that this should indeed be implemented. All ten countries surveyed in the WHO led study of country policies reported free treatment of TB for family members of health workers.

The 5-country study conducted by Corbett did indeed note that provisions for families was important and that considerable strengthening is needed around access to HIV testing and care for family members of healthcare workers. Corbett found that only one of the five countries studied (Zimbabwe) had a budget or training schedule to provide ART for families of health workers. Treatment of TB in family members of health workers is currently provided only in two of the five countries (Mozambique and Zimbabwe). Thirteen percent of randomly selected facilities surveyed and fifty percent of best practice facilities had written guidelines accessible for priority access to ART for family members of staff. The WHO Multi-Country Survey found that family members of healthcare workers accessed ART services through general services as did the rest of the population or at special service at the employee's 'own' facility if available.

In a qualitative study, reported by Galvin and De Vries (2008) based at the Swaziland HIV centers for health workers, about half the respondents supported including family members for priority access to ART, while half felt that including family members would anger patients on waiting lists. It is thus noteworthy that the statement above focuses on TB case finding, NOT including families for priority access to ARV.

Our search of website sources revealed that not only have there been few solid intervention evaluations, there are few model programmes available for the implementation of free VCT services for health workers. The Treatment Action Campaign (TAC) states that there needs to be better access for health workers to HIV treatment for themselves and their families before they can continue to roll out ARV initiatives to the general public. However, this website offers little information about HOW this should be done.

A brief report was found on a website linked to UNAIDS entitled; "Botswana Trade Unions Put HIV High on the Agenda."(http://www.ilo.org/public/english/protection/trav/aids/events/wad08/stories/botswana.pdf) This document reports that with support from the ILO's Strategic HIV Responses in Enterprises (SHARE) programme, the trade unions have developed a five-year HIV strategy, which focuses on improving access to prevention, voluntary counselling and testing, treatment and support services for its members and their families. These are rolled out at workplace level by a team of peer educators. This programme has been extended and recently carried out a survey to measure the impact of the project. The results indicated that implementation of workplace services and policies coupled with awareness-raising work had resulted in a significant reduction in workers' fears that they could be dismissed or be denied promotion because of their HIV status.

In reviewing the evidence, the GG concluded that involvement of front-line health workers and those they elect to represent them, including the unions representing the healthcare workforce, and people living with HIV and/or TB, can play a major positive role, along with promoting self-efficacy and peer-education. The involvement of health and safety committees or worker representatives is vital to the successful uptake of newly developed HIV and TB workplace programmes. Policies should be in place to ensure appropriate management, union and worker representation. Issues of confidentiality and stigma should be carefully considered, and champions to advocate for testing should be identified and empowered.

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