Abstract
BackgroundA large and compelling clinical evidence base has shown that integrated TB and HIV services leads to reduction in human immunodeficiency virus (HIV)- and tuberculosis (TB)-associated mortality and morbidity. Despite official policies and guidelines recommending TB and HIV care integration, its poor implementation has resulted in TB and HIV remaining the commonest causes of death in several countries in sub-Saharan Africa, including South Africa. This study aims to reduce mortality due to TB-HIV co-infection through a quality improvement strategy for scaling up of TB and HIV treatment integration in rural primary healthcare clinics in South Africa.MethodsThe study is designed as an open-label cluster randomized controlled trial. Sixteen clinic supervisors who oversee 40 primary health care (PHC) clinics in two rural districts of KwaZulu-Natal, South Africa will be randomized to either the control group (provision of standard government guidance for TB-HIV integration) or the intervention group (provision of standard government guidance with active enhancement of TB-HIV care integration through a quality improvement approach). The primary outcome is all-cause mortality among TB-HIV patients. Secondary outcomes include time to antiretroviral therapy (ART) initiation among TB-HIV co-infected patients, as well as TB and HIV treatment outcomes at 12 months. In addition, factors that may affect the intervention, such as conditions in the clinic and staff availability, will be closely monitored and documented.DiscussionThis study has the potential to address the gap between the establishment of TB-HIV care integration policies and guidelines and their implementation in the provision of integrated care in PHC clinics. If successful, an evidence-based intervention comprising change ideas, tools, and approaches for quality improvement could inform the future rapid scale up, implementation, and sustainability of improved TB-HIV integration across sub-Sahara Africa and other resource-constrained settings.Trial registrationClinicaltrials.gov, NCT02654613. Registered 01 June 2015.
Highlights
A large and compelling clinical evidence base has shown that integrated TB and HIV services leads to reduction in human immunodeficiency virus (HIV)- and tuberculosis (TB)-associated mortality and morbidity
A similar trend was documented in the 2016 World Health Organization (WHO) global TB report which showed that the proportion of TB cases living with HIV was highest in the WHO African Region (31%) and exceeded 50% in parts of southern Africa [2]
The strategy could make a contribution to reducing TB-HIVassociated mortality and morbidity in South Africa and other regions of the world where co-infection with TB and HIV is a concern
Summary
A large and compelling clinical evidence base has shown that integrated TB and HIV services leads to reduction in human immunodeficiency virus (HIV)- and tuberculosis (TB)-associated mortality and morbidity. Tuberculosis (TB) is the commonest opportunistic infection and cause of death among human immunodeficiency virus (HIV)-infected patients in resource-limited countries [1]. Prior to the implementation of TB-HIV integration, the South African healthcare system provided separate vertical programmes for TB and HIV services delivered by different healthcare staff, often located in separate clinics [4,5,6]. The vertical model of delivering TB-HIV care to co-infected patients relied upon referral and linkage to care programmes (between TB and HIV programmes and vice versa). This proved problematic and inefficient as referral between programmes depended on patients’ resources and healthseeking behavior which was unmonitored [4, 6]
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