Abstract
BackgroundThere is uncertainty about how directly observed treatment (DOT) support for tuberculosis (TB) can be delivered most effectively and how DOT support can simultaneously be used to strengthen human immunodeficiency virus (HIV) prevention and control among TB patients. This study describes how DOT support by community health workers (CHWs) was used in four municipalities in the Free State province – a high TB/HIV burden, poorly-resourced setting – to provide HIV outreach, referrals, and health education for TB patients.MethodsThe study was part of a larger cross-sectional study of HIV counselling and testing (HCT) among 1101 randomly-selected TB patients registered at 40 primary health care (PHC) facilities (clinics and community health centres) across small town/rural and large town/urban settings. Univariate analysis of percentages, chi-square tests and t-tests for difference in means were used to describe differences between the types of TB treatment support and patient characteristics, as well as the types of – and patient satisfaction with – HIV information and referrals received from various types of treatment supporters including home-based DOT supporters, clinic-based DOT supporters or support from family/friends/employers. Multivariate logistic regression was used to predict the likelihood of not having receiving home-based DOT and of never having received HIV counselling. The independent variables include poverty-related health and socio-economic risk factors for poor outcomes. Statistical significance is shown using a 95% confidence interval and a 0.05 p-value.ResultsDespite the fact that DOT support for all TB patients was the goal of South African health policy at the time (2012), most TB patients were not receiving formal DOT support. Only 155 (14.1%) were receiving home-based DOT, while 114 (10.4%) received clinic-based DOT. TB patients receiving home-based DOT reported higher rates of HIV counselling than other patients.ConclusionsPublic health providers should train DOT supporters to provide HIV prevention and target DOT to those at greatest risk of HIV, particularly those at greatest socio-economic risk.
Highlights
There is uncertainty about how directly observed treatment (DOT) support for tuberculosis (TB) can be delivered most effectively and how DOT support can simultaneously be used to strengthen human immunodeficiency virus (HIV) prevention and control among TB patients
This study describes how DOT support by community health worker (CHW) was used in one province of South Africa, the Free State, to provide HIV outreach, referrals, and education for TB patients in 2012
The study was limited to TB patients who received treatment in primary health care (PHC) facilities, which is the primary source of health care for a majority of South Africans, historically-disadvantaged persons in particular [40]
Summary
There is uncertainty about how directly observed treatment (DOT) support for tuberculosis (TB) can be delivered most effectively and how DOT support can simultaneously be used to strengthen human immunodeficiency virus (HIV) prevention and control among TB patients. As highlighted in the Sustainable Development Goals (SDGs) [1], the world continues to face high rates of poverty and associated population health challenges, including the joint epidemics of tuberculosis (TB) and human immunodeficiency virus (HIV) [2]. Howell et al BMC Health Services Research (2018) 18:255. Both the link between TB and poverty [5,6,7] and the link between HIV and poverty [8,9,10] are well established. Just more than 5% of the national public health-sector dependent population – of whom more than 80% are African and historically and socioeconomically disadvantaged – live in the Free State [3]. In 2016, the Free State had the lowest life expectancy for both males and females of all the provinces [14]
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