Addressing challenges in scaling up TB and HIV treatment integration in public health settings in South Africa

Tuberculosis is the most common cause of death in people who are HIV-infected. Research has shown that when TB and HIV treatment and services are offered together there is a decrease in deaths for patients who have both these diseases. However, health care facilities in poor and developing countries struggle to efficiently provide both TB and HIV services to patients. We are testing whether an intervention for clinic staff, called ‘Quality Improvement’, will assist the staff to work in a more planned and structured manner to incorporate both TB and HIV services in their clinic and provide excellent quality of services. Our study will select 40 clinics from 2 rural districts in KwaZulu, South Africa and at random assign 20 clinics to receive the Quality Improvement intervention and 20 clinics to receive the standard support for delivering both TB and HIV services. We anticipate that clinics receiving the Quality Improvement intervention will have lower numbers of patient deaths from TB and HIV than those clinics receiving the standard support. Our study will inform how we can make combined TB and HIV services more manageable for clinics in poor and developing countries and so reduce deaths in TB and HIV patients.

Tuberculosis (TB) and HIV prevalence is highest in sub-Saharan Africa, a region with limited health budgets, infrastructure, human resources, and suboptimal TB infection control practices. Persistently high rates of mortality and morbidity associated with HIV and TB continues to devastate families and overwhelm heath systems in South Africa. A large and compelling clinical evidence base suggests that integrating HIV and TB services improves survival in co-infected patients and presents a more effective & efficient use of limited health resources. Global policy makers have been responsive in translating research findings into TB HIV integration policy and recommendations, however there is a growing concern that the gains made in the field of TB HIV research will not be realized if not effectively translated into practice at the point-of-care. Implementing the full integrated TB HIV service ‘package’ at a health care facility level is not simple as very little is known about the best ‘scale up’ model for integrated TB HIV service delivery. This study is a cluster randomized controlled trial, which evaluates the effectiveness of implementing a quality improvement model to integrate TB HIV service delivery in primary health care clinics. The study will be conducted in 2 rural districts in KwaZulu-Natal, South Africa, namely the Ugu & uThungulu districts. Our hypothesis is that survival rates in TB and HIV infected patients accessing services in clinics using Quality Improvement methods to deliver comprehensive and reliable processes in implementing integrated TB HIV care, will be better than in patients accessing services in clinics provided with standard support for implementing TB HIV clinical guidelines. The anticipated eventual product arising from this study is a set of principles/model on how integrated TB HIV services maybe embedded in primary health care clinics in resource constrained settings. This study has the potential to elucidate which resources (inputs), processes (steps) and outputs lead to fully integrated TB HIV services hence impacting on improving the survival of co-infected patients.