Abstract
BackgroundSwaziland has the highest HIV prevalence in the world and the highest estimated tuberculosis incidence rate in the world. An estimated 80% of TB patients are also infected with HIV. TB detection through intensified case finding (ICF) has yet to become a routine aspect of integrated tuberculosis and HIV care. The purpose of this study was to evaluate implementation of ICF for TB into routine integrated tuberculosis and HIV care at 16 community clinics and one district hospital in Swaziland.MethodsNurses and lay counsellors conducted ICF using a TB screening tool and patient pathway at all HIV service entry points in clinics and the hospital. The patient pathway had three-stages; screening, sputum smear diagnosis and TB treatment initiation. Outcomes and losses to follow up were monitored at each stage. Patient demographics, access, and service feasibility and effectiveness were compared at hospital and clinic sites.Results1467 HIV patients at clinics and the hospital were screened over a 3 month period. Large losses to follow up occurred prior to the sputum diagnosis stage; only 47% (n = 172) of TB suspects provided a specimen. 28 cases of smear positive TB were diagnosed and 24 commenced treatment. People screened at clinics were significantly more likely to be female, older, and from rural or geographically remote areas (p < 0.001). There was no significant difference between the hospital and clinics sites in the proportion of all participants screened who were smear positive (x2 = 1.909; p = 0.16). The number needed to screen to detect one sputum positive TB case was 34 at clinics and 63 at the district hospital.ConclusionsICF was operationally feasible and became established as a routine aspect of tuberculosis and HIV integrated care. ICF in community clinics was potentially more accessible to an underserved, rural population and was as effective as the hospital service in detecting smear positive TB.
Highlights
Swaziland has the highest HIV prevalence in the world and the highest estimated tuberculosis incidence rate in the world
A response to this global challenge was outlined by the World Health Organisation (WHO) in its “Three Is” policy: Intensified case finding (ICF), isoniazid prevention therapy (IPT), and infection control [6]
The intensified case finding (ICF) programme was implemented at the one district hospital which serves the region and the 16 community clinics which provided HIV services
Summary
Swaziland has the highest HIV prevalence in the world and the highest estimated tuberculosis incidence rate in the world. TB detection through intensified case finding (ICF) has yet to become a routine aspect of integrated tuberculosis and HIV care. The purpose of this study was to evaluate implementation of ICF for TB into routine integrated tuberculosis and HIV care at 16 community clinics and one district hospital in Swaziland. Of the 1.37 million people with active TB who are co-infected with HIV worldwide, 80% live in Sub-Saharan Africa [2]. In 2007 the tuberculosis case detection rate in the Africa Region was 47%. This remains far short of the Global Stop TB Strategy target of 70% of incident smear-positive cases detected and. Lack of data to inform policies, poor system infrastructure and concerns about feasibility and human resources have constrained wider implementation in high HIV prevalence settings [5,9]
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