The authors have declared that no competing interests exist.
Created study design: JCC AKV PV AP JDK. Wrote study protocol: JCC. Created standardized questionnaire: JCC AKV PV AP JDK. Helped conduct data collection: JCC AKV. Inputed data: JCC. Reviewed and contributed to manuscript: AKV PV AP JDK. Provided inputs in data analysis methods: PV JDK. Conceived and designed the experiments: JCC AKV PV AP JDK. Analyzed the data: JCC. Wrote the paper: JCC.
Public Health Facilities in South Africa.
To assess the current integration of TB and HIV services in South Africa, 2011.
Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type.
Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001).
As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.
Tuberculosis (TB) remains the leading cause of death and morbidity among people living with HIV in developing countries
The profound impact that HIV and TB epidemics have had on health systems worldwide, particularly those in low-resource countries, has prompted the World Health Organization (WHO) to issue strategic guidelines for the integration of TB and HIV
South Africa’s Department of Health subsequently revised their TB management guidelines in 2009
We aimed to assess the current state of TB and HIV integrated services in South Africa.
We surveyed the TB and HIV focal persons of 49 public medical facilities in the high HIV prevalence districts in South Africa’s nine provinces from March 1st to March 31st 2011.
We used a multistage sampling method. Firstly, we systematically selected the single district in each province with the highest HIV prevalence. We chose two districts in Kwazulu-Natal, as it had the highest HIV prevalence and double the number of districts of other provinces
The sample was chosen and we assessed both HIV and TB services. We determined the availability of the HIV services in each facility and stratified this by facility, facility type and province. HIV services we assessed included patient-initiated HIV counseling and testing (HCT), provider-initiated counseling and testing (PICT), WHO clinical staging of HIV, CD4 count, co-trimoxazole preventive therapy (CPT), and antiretroviral therapy (ART). We further investigated ART service delivery to determine whether the service was being provided on-site and who was initiating patients on the therapy: doctors only, nurses only, or both.
We determined the availability of the TB services and stratified them by facility, facility type and province. We investigated the following TB services: routine TB symptom screening, TB clinical diagnosis, TB treatment, and Isoniazid Preventive Therapy (IPT). Routine TB symptom screening was defined as clients being asked if they have any of the following symptoms: persistent cough for more than two weeks, fever for more than two weeks, night sweats, and unexplained weight loss (more than 5 kg in a month). If the answer to any of those questions was yes, the patient was defined as a person with suspected TB. The clinical diagnosis of these patients was followed by the collection and analysis of a minimum of two sputum samples for microbial laboratory confirmation of disease. We also determined whether the availability of IPT and TB services differed for pregnant HIV-infected women, and if TB services differed for patients with STIs.
Lastly, we collected routine TB and HIV monitoring data for the month of February 2011 from registers of sampled sites on newly registered TB patients that included the number of; patients newly diagnosed with HIV-infection; patients on whom CD4 T cell count was conducted; patients eligible AND initiated on ART; newly diagnosed HIV-infected patients screened for TB symptoms; newly diagnosed HIV-infected patients screened negative and positive for any TB symptom; newly diagnosed HIV-infected patients screened positive for TB symptoms and initiated on TB treatment; patients initiated on IPT among facilities providing IPT.
A standardized anonymous survey was created in English, which contained questions on various aspects of TB and HIV service integration, including service availability, location of service provision (whether or not offered on-site), and reporting and recording of routine data. The questionnaire was piloted in a hospital and primary health clinic prior to the assessment, with appropriate changes made.
The Principal Investigator trained ten teams of interviewers in the use of the standardized questionnaire prior to the assessment. Each data collection team assessed 5 sites. Data collection took place from the 1st to the 31st of March 2011.
After obtaining informed consent, the two staff members each responsible for TB and for HIV services in each selected facility was interviewed and administered the questionnaire. All information reported by interviewees was systematically verified by examining and collecting routine TB and HIV data from facility registers.
Questionnaire data were entered into an Epi-Info 3.5.1 database (Centers for Disease Control and Prevention, Atlanta, GA) for analysis. Descriptive statistics were calculated and compared by province and facility type, and differences in proportions calculated using Fisher's exact test.
The Centers for Disease Control and Prevention determined that the collection of routine program data and its analysis for this study was a non-research activity in accordance to United States Federal regulations and waived IRB review. Further, the South African National Department of Health waived the need for local human subjects’ review.
We assessed integration of TB and HIV services in 49 public medical facilities in the highest HIV-burden districts in each of South Africa’s 9 provinces from March 1st to March 31st 2011.
Among the surveyed facilities, 2,512 patients were newly diagnosed with HIV in February 2011, and 1,913 (76%) of those were screened for TB symptoms. Of those screened for TB symptoms, 148 (8%) screened positive for at least one symptom, 1332 (70%) screened negative, and chart data were missing for 433 (23%). Of the 148 individuals who had any potential TB symptom, 125 (85%) were initiated on TB treatment and 23 (16%) were not. Of the 1,332 who screened negative for TB, 616 (46%) were initiated on IPT, whereas 716 (54%) were not.
In February 2011, 1,072 patients were newly registered TB patients among surveyed sites. Of those, 144 (13%) were already on ART prior to TB clinical diagnosis, and 451 (42%) were newly diagnosed as HIV infected. Of those 451 patients, 385 (85%) had CD4 T-cell counts done, 314 (70%) had been initiated on CPT, and 84 (19%) were initiated on ART.
HIV service n (%) | TB service n (%) | |||||||||
Province | HIV Counseling & testing | Provider-initiated Counseling &Testing | CD4 count | WHO Clinical Staging | CPT | ART | Routine TB Symptomscreening | TB diagnosis | TB Treatment | IPT |
|
5 (100%) | 1 (20%) | 5 (100%) | 4 (80%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) |
|
5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 4 (80%) | 5 (100%) | 5 (100%) | 5 (100%) | 4 (80%) |
|
5 (100%) | 4 (80%) | 5 (100%) | 5 (100%) | 5 (100%) | 3 (60%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) |
|
10 (100%) | 1 (10%) | 10 (100%) | 7 (70%) | 8 (80%) | 7 (70%) | 10 (100%) | 9 (90%) | 8 (80%) | 9 (90%) |
|
5 (100%) | 3 (60%) | 5 (100%) | 5 (100%) | 5 (100%) | 3 (60%) | 5 (100%) | 5 (100%) | 5 (100%) | 1 (20%) |
|
5 (100%) | 1 (20%) | 5 (100%) | 5 (100%) | 5 (100%) | 3 (60%) | 5 (100%) | 5 (100%) | 5 (100%) | 3 (60%) |
|
5 (100%) | 3 (60%) | 5 (100%) | 5 (100%) | 5 (100%) | 4 (80%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) |
|
4 (100%) | 4 (100%) | 4 (100%) | 4 (100%) | 4 (100%) | 2 (50%) | 3 (75%) | 3 (75%) | 2 (50%) | 3 (75%) |
|
5 (100%) | 0 (0%) | 5 (100%) | 5 (100%) | 5 (100%) | 4 (80%) | 5 (100%) | 5 (100%) | 5 (100%) | 0 (0%) |
By facility type, antiretroviral therapy was offered in all (100%) district hospitals and community health centers, and absent in 14 (48%) of the 29 primary health clinics assessed. Compared to the other two facility types, primary health clinics were less likely to offer ART (p = 0.0002).
Method | n (%) |
|
10 (29%) |
|
10 (29%) |
|
12 (34%) |
|
3 (9%) |
HIV service | (N = 49) | ||
Offered | Recorded | Reported | |
HCT | 100% (N = 49) | 100% (N = 49) | 96% (N = 47) |
CD4 count | 100% (N = 49) | 94% (N = 46) | 87% (N = 40) |
CPT | 96% (N = 47) | 96% (N = 45) | 89% (N = 40) |
ART | 71% (N = 35) | 97% (N = 34) | 94% (N = 32) |
Only 57% of 35 sites implementing IPT rendered the service to eligible pregnant women. When the client was specified as an STI patient, by facility type, 27 (90%) primary health clinics offered routine symptom screening, 26 (86.7%) TB diagnosis and 23 (76.7%) TB treatment; 9 (90%) of district hospitals offered routine TB symptom screening and TB diagnosis, and 8 (80%) offered TB treatment; and each of these services was offered by 8 (88.9%) community health centers. With the exception of IPT, provision of TB services among pregnant HIV-infected women and STI patients varied little by province.
Province | TB service n (%) | ||||||
Offered to pregnant HIV Women | Offered to STI patients | ||||||
Routine symptom screening | TB clinical diagnosis | TB treatment | IPT | Routine symptom screening | TB clinicaldiagnosis | TB treatment | |
|
5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 4 (80%) |
|
4 (80%) | 4 (80%) | 4 (80%) | 2 (40%) | 4 (80%) | 4 (80%) | 4 (80%) |
|
5 (100%) | 5 (100%) | 5 (100%) | 4 (80%) | 4 (80%) | 4 (80%) | 4 (80%) |
|
10 (100%) | 9 (90%) | 7 (70%) | 7 (70%) | 10 (100%) | 9 (90%) | 7 (70%) |
|
5 (100%) | 5 (100%) | 5 (100%) | 0 (0%) | 5 (100%) | 5 (100%) | 5 (100%) |
|
5 (100%) | 5 (100%) | 5 (100%) | 2 (40%) | 4 (80%) | 4 (80%) | 4 (80%) |
|
5 (100%) | 5 (100%) | 5 (100%) | 5 (100%) | 4 (80%) | 4 (80%) | 4 (80%) |
|
3 (75%) | 4 (100%) | 3 (75%) | 3 (75%) | 3 (75%) | 3 (75%) | 2 (50%) |
|
5 (100%) | 5 (100%) | 5 (100%) | 0 (0%) | 5 (100%) | 5 (100%) | 5 (100%) |
Our study assessed the availability of integrated TB and HIV clinical services in a sample of public medical facilities in South Africa in March 2011. Our data show that integrated HIV and TB services are being provided in the public medical facilities in South Africa. Among the 49 sites we sampled, about three quarters of newly diagnosed HIV-infected patients were screened for TB symptoms. According to South African national data reported to the WHO, 58% of newly diagnosed HIV-infected people were screened for TB symptoms in South Africa in 2010
Several interventions and programs implemented recently might account for those improvements. Firstly, the South African National Department of Health launched several national campaigns, including the Kick TB campaign in partnership with Desmond Tutu TB center and the University of Stellenbosch in December 2009, aimed at increasing TB and HIV awareness among school-aged children, reaching almost 39,000 learners to date
Not all TB and HIV services, however, are improving. In our study, the proportion of newly diagnosed TB patients living with HIV initiated on co-trimoxazole in February 2011 was lower than national estimates in South Africa of 74% in 2010
South Africa is shifting from a vertical programmatic approach with separate staff and service model in the early 2000s
Recommendations on ART initiation among TB patients have been a moving target: until recently, South African ART guidelines followed the 2003 WHO guidelines recommending the delay of ART initiation among co-infected patients with CD4 T-cell counts of 200 cells/mm3 or above until completion of TB therapy
Another barrier to the implementation of integrated services is under-staffing
We conducted the rapid assessment only in districts with the highest antenatal HIV prevalence, and our results might therefore not be representative of areas with lower HIV prevalence. Our assessment only included a few facilities in each province, thus limiting the generalizability of our results. Our small sample size reduced the power of the survey, and may have concealed statistically significant differences in our study population. A larger sample size could have shown an association between factors such as facility type and location of ART provision, and facility type and method of initiation and management of ART. We sought to maximize external validity through random sampling and by selecting sites based on the approximated national distribution of facility types. We randomly selected double the number of sites in Kwazulu-Natal to account for the fact that the province had double the number of districts compared to most other provinces and the highest overall HIV prevalence in 2008
Our study demonstrated important progress is being made towards integration of TB and HIV services in South Africa, where nearly all facilities offered routine TB screening to people living with HIV infection, and routine HIV Counseling and Testing to TB patients. However, uptake of other essential services, such as ART and IPT, needs to be improved, as less than half of eligible people living with HIV were initiated on IPT, and only a small proportion of newly registered TB patients newly diagnosed as HIV-infected in February 2011 were initiated on ART. Addressing those gaps is a priority and future interventions should build on existing efforts to support current national policies of routine TB screening of all HIV patients, initiation of all eligible HIV-infected patients on IPT and early ART initiation of eligible TB patients irrespective of CD4 T-cell count
Kgomotso Vilakazi-Nhlapo, Ntombi Mhlongo and Lorna Nshuti of the South African National Department of Health were essential in obtaining the support from Provincial Departments and liaising with medical facilities. We would like all PEPFAR implementation partners involved in the data collection for their invaluable support. We would also like to thank all the selected facilities and their staff for their time and participation that have made this survey possible. The findings and conclusions of this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.