Identifying and overcoming barriers to TB/HIV service integration at primary care in Khayelitsha, South Africa Rebecca Welfare1, Gabriela Patten1, Peter Saranchuk1, Virginia de Azevedo2, David Coetzee3, Nompumelelo 4 1-3 1 Mantangana , Gilles van Cutsem , Daniela Garone 1 Médecins
Sans Frontières, 2City of Cape Town Health Department, 3 University of Cape Town, 4 Provincial Government of the Western Cape
Background The global tuberculosis (TB) and HIV epidemics in sub-Saharan Africa are closely intertwined. South Africa has the greatest number of HIV-infected individuals and among the highest TB incidence rates worldwide. Integration of TB and HIV treatment and prevention programs aims to improve the diagnosis, treatment and outcomes for patients affected by both diseases. There has been increasing recognition of the need of promoting this integration, for patients benefits and health system optimization. The National Department of Health in 2011 developed practical guideline for TB and HIV service integration at primary health care (PHC) level that provides a step-by-step guide to implement integration. This study aimed to: 1) describe the current level of TB and HIV service integration in the clinics 2) identify barriers to integration, 3) facilitate the development of practical plans at clinic level in order to ‘move towards better integration of TB and HIV services’.
Figure 2: rooms equipped (%) for providing integration services In this study we considered a room to be equipped to provide integrated care when: clinical algorithms, education material and stationary for both HIV and TB, along with N95 respirators and surgical masks, condoms and rapid HIV test were present during the assessment. 62% of the rooms were having 5 out of 7 items in the room. Education material was present in only 14% of the rooms.
Surgical masks N95 Algorithms Stationary Educational materials HIV rapid tests Condoms 0
5
10 % rooms
15
20
25
30
35
Figure 3: Staff training
Study population
25
35
Training received by nurses
The study was conducted in the 11 primary care clinics in Khayelitsha.
Study design A multi-method cross sectional assessment of TB and HIV services was conducted. One day was spent in each clinic conducting the assessment. This involved the development of simple assessment tools for the collection of routine programmatic data, an observational study of HIV and TB consultation rooms, a folder review, and assessments of the M&E system and TB infection control (IC). HIV and TB clinical staff were approached and asked to participate in a self administered questionnaire on training and clinical practices. An interview to capture knowledge and perceptions of staff' on TB and HIV service integration was also conducted. Data from the quantitative components of the assessment were entered into Epi Data3.1 and analysed using Epi Data analysis and Microsoft Office Excel 2007. For the qualitative component of the assessment (the structured interview) the answers were coded along thematic lines. We defined 3 models of TB/HIV integration: • Collaborative model: TB nurses screen for HIV and HIV nurses for TB and then refer to the other service for investigation, treatment and clinical follow up; • Partially integrated model: A predominately collaborative model exists and some rooms are providing integrated care for HIV/TB co-infected patients; • Integrated model: patients are receiving all the services, in the same room during the same consultation with the same care giver.
Results All 11 primary health care clinics in Khayelitsha participated in the assessment. 38 clinicians, 22 counsellors, 11 facility managers and 7 community-care workers completed the self-administered questionnaire. 45 clinicians, including 7 facility managers and 3 doctors, plus 23 counsellors and community care workers were interviewed. All the clinics were assessed for TB infection control. 62 consultation and 24 counseling rooms were evaluated for integrated practices.
Of the 11 clinics, 3 clinics can be considered to provide integrated services, 4 partially integrated, and 3 collaborative. One clinic had no TB services and refers TB cases to the next door facility. PHCs were more likely to provide an integrated HIV/TB service while community Health centres (CHC), as larger ART/TB sites were more likely to be partially integrated or collaborative The integrated room(s) was most likely to be in the TB department or to be the doctor room
number of counsellors
Khayelitsha sub-district (~500,000 population) is located on the outskirts of Cape Town, South Africa and has one of the highest burdens of both HIV and TB in the country. In 2010 , the antenatal HIV prevalence was 26%; the TB case-notification rate reached 1,500 per 100,000, and the rate of TB/HIV co-infection was 73%. TB program is coordinated by City Health and ART program by the Provincial Department of Health.
Number of nurses
30 25 20 15 10
20
15
10
5
5 0
0 HIV
HCT
TB
DRTB
NIMART
HIV
TB IC
HCT
TB
DR-TB
TB Infection Control
66% (n=23) of nurses were trained in both HIV and TB. 23% (n=7) of the nurses had received training only in HIV and 3% (n=1) only in TB. 11% (n=4) of the nurses had not received training in either HIV or TB. 42% (n=15) of the nurses were trained to initiate clients on ART, i.e. nurse initiation and management of ART (NIMART). Nurses trained in both HIV and TB were more likely to carry out a greater number of clinical practices, suggesting that training acquired in both diseases is essential for the delivery of integrated services. Counsellors were more trained on HIV than on TB and 24% (n=6) received training on drug-resistant TB (DR-TB) or TB infection control.
Figure 4: TB infection control TB risk reduction plan N95 mask worn by all… Public TBIC plans ICC meeting Assessed TB TBIC plan I. Control Committee I. Control responsible TB health talks 0
2
4
6
8
10
12
number of clinics
All 11 clinics had a member of staff dedicated to infection control and an infection control committee (ICC) formed. However, less than 50% (n=4) of the clinics had convened an ICC or performed an Infection Control assessment within the last month.
48% (n=17) of the nurses received basic infection control training and < 20% of the counsellors received basic drug-resistant TB (DR-TB) or TB infection control training.
Conclusions The high burden of TB and HIV in Khayelitsha and South Africa demands a clear operational strategy to optimise service delivery. TB and HIV services are gradually being integrated in Khayelitsha, with 8 of the 11 clinics providing a 'one-stop-service' for co-infected patients. However, different models of TB/HIV integration continue to co-exist, with larger clinics where ART was introduced earlier - struggling to evolve from collaborative to integrated services. Despite progressive policies on TB/HIV integration in South Africa, implementation remains challenging, with insufficient infection control, one third of nurses in need of additional training, and many rooms lacking basic equipment. This study describes the use of simple assessment tools to identify basic gaps in the delivery of integrated HIV/TB care at primary care, which are fundamental in facilitating further strengthening and integration of the existing systems.
Acknowledgements We would like to thank all patients and staff in the clinics in Khayelitsha. We would also like to acknowledge the excellent support and feedback from all staff who have assisted the Khayelitsha HIV&TB services, the University of Cape Town (UCT), the City of Cape Town, the Provincial Government of the Western Cape (PGWC), and the MSF team in Khayelitsha.