Increasing testing for HIV in TB patients feasible without additional resources

The implementation of programmatic strengthening activities to promote HIV voluntary counselling and testing (VCT) for TB patients can yield a higher uptake of VCT and antiretroviral (ARV) initiation among TB patients and have a positive impact on patient care, according to a study presented at the 2^nd South African TB conference in Durban last week by Dr Athmanundh Dilraj of the South African Medical Research Council (MRC).

The strengthening activities were implemented at 16 TB primary health care facilities in two high-burden districts in KwaZulu-Natal in South Africa.

The percentage of TB patients counselled for HIV testing rose to 94.8% during the study period, from 79.2% during a similar period of the previous year.

The percentage of TB patients who tested for HIV similarly rose to 89.5% from 66% in the previous year. This increased the case detection of HIV among TB patients, with the prevalence of HIV among the TB patients rising from 55.4% in the previous year, to 74.7% while the strengthening activities were implemented.

The study included 847 newly diagnosed TB patients registered between May and July 2009, who were followed up for two months to facilitate VCT, CD4 testing, ARV literacy classes and initiation of ARV treatment.

Strengthening activities included: improvement in documentation and logistics, motivational counselling for patients and facility staff, training data capturers, and greater involvement of management.

Study nurses and counsellors visited the facilities frequently to monitor progress of patient care according to the guidelines of HIV testing in TB patients by checking the TB registers and patients records to ensure that all TB patients were counselled and tested for HIV.

Attempts were made to contact patients and set up facility appointments if patients had not been counselled and tested for HIV.

The concept of ‘motivational counselling’ was adopted, which included providing education on the benefits of VCT such as knowing one’s HIV status in order to receive cotrimoxazole preventive therapy, treatment for opportunistic infections, CD4 count testing, and ARV treatment when necessary.

The logistics and staff roles and attitudes towards patients with HIV were also examined, and attempts were made to improve these where necessary.

If CD4 results were not recorded, checks were performed to ascertain whether blood samples for CD4 counting had been collected and the date of collection when done.

Attempts were also made to contact patients to return for CD4 testing when necessary.

If the blood samples had been collected, the reasons for delays were investigated and addressed. All CD4 results that had not been received were obtained from the laboratory and patients were also contacted to verify if they had been given their CD4 results.

448 of the 600 HIV positive patients (74.7%) had a recorded CD4 result. 296 of these 448 patients (66.1%) had a CD4 of less than 200 cells/mm³.

CD4 testing records were not kept for 2008, so no comparison with the previous period could be made.

Patients with a CD4 of less than 200 cells/mm³ (the threshold for ARV initiation in South Africa) were followed up to ensure that they were enrolled onto ARV literacy classes, so as to guarantee prompt initiation of ARV treatment.

The challenges faced by the health facilities were examined in order to ensure that strengthening activities had the greatest impact. It was found that in most of the clinics there was poor recording of patient contact details and a lack of follow-up for counselling and the collection of CD4 results.

TB and HIV services were not integrated which created logistical problems. For example, TB clinics and VCT centres were often in different locations; initial CD4 tests were conducted on a separate day from the HIV test; and there was also a lack of linkage between the TB and VCT registers. There was also initial hesitation among staff to conduct voluntary counselling and testing, and inadequate managerial oversight from facility managers and TB supervisors at the district level.

"Our study shows that the effective management of HIV in a TB setting, including the provision of ARVs is feasible and replicable without additional resources," said Dr Dilraj of the South African Medical Research Council.