2. Integration of TB and HIV Care Across Two Time Periods in Three (sub) Districts in South Africa J Sumitani 1,2, S Jed 1,2, S Galagan 2, J Gilvydis 1,2, E Naidoo 1, M Weaver 2 1 I-TECH South Africa 2 University of Washington

3. Start with a quote… La sante se lespwa, lespwa se tout bagay (Health is hope, hope is everything) - Haitian proverb

4. Background: TB/HIV in SA (2) Antiretroviral therapy (ART) plays a critical role in the treatment of TB in people infected with HIV Current South African guidelines state all HIV-positive patients co- infected with drug sensitive or resistant TB be initiated with lifelong ART, irrespective of CD4 count Co-infected patients with CD4 < 50 cells/mm 3 require ‘fast-track’ ART initiation within 7 days The number people co-infected with TB/HIV initiated on ART increased from 92,376 (44%) in 2012 to 141,755 (79%) in 2014. http://www.who.int/mediacentre/factsheets/fs104/en//http://www.who.int/mediacentre/factsheets/fs104/en// (Accessed 24 November, 2015)

5. Background: TB/HIV Program Stakeholder & Partner Involvement & Consultation

6. Methods 76 healthcare facilities across 2 Provinces 1 District, 2 Sub-Districts Primary health clinics/community health centers where TB/HIV services provided by professional nurses Two samples from patient registers (paper/electronic) ART register TB treatment register 15-16 files per sample per category per facility (up to 25 files) Patient level data extracted from files and entered on tablets using standardized data collection forms

7. Methods: ART Files (N = 2,122) ART Initiation 2011-2012 1,704 ART Files Training 2013 Mentoring 2013-2014 ART Initiation 2013 1,048 ART Files Baseline Patient Records Follow-Up Patient Records

8. Methods: TB Files (N = 2,071) TB Treatment Initiation 2012-2013 1,063 TB Files Training 2013 Mentoring 2013-2014 TB Treatment Initiation 2013 1,008 TB Files Baseline Patient Records Follow-Up Patient Records

9. Methods: TB/HIV Integration Indicators ART Files TB symptom screening Isoniazid Preventive Therapy (IPT) screening IPT initiation (if applicable) TB treatment initiation (if applicable) TB Files HIV test (excluding known HIV+) ART initiation (if applicable) ART start date (if applicable) CD4 result (if applicable)

10. Results: TB/HIV Integration – ART Files p<0.001

11. Results: TB/HIV Integration – TB Files

12. Learning Points Training and Mentoring may have contributed to significantly improved outcomes in the documentation of: TB symptom screening among individuals on ART IPT screening and initiation among individuals on ART HIV testing among TB patients (*not statistically significant) Documentation and data quality were major limitations in data collection and analysis Controlled for confounding factors in analysis, but evaluation of interventions can be challenging in changing landscape of TB/HIV

13. Programmatic Implications Data quality and documentation among healthcare workers remains a priority Further emphasis on TB/HIV care integration – especially among TB patients “If you see TB, think HIV” Sufficient human resources capacitated to deliver integrated services Communicable and non-communicable diseases Increased collaboration and integration of TB/HIV administrative activities at the national level

14. Disclaimer This research and development of this presentation was supported by the Human Resources and Services Administration (HRSA) in support of the President’s Emergency Plan for AIDS Relief through Cooperative Agreement U91HA06801. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.

15. Acknowledgements Special thanks to all the clinicians, facility managers, and district/sub-district and provincial program managers for their participation National Department of Health Eastern and Northern Cape Departments of Health Centers for Disease Control and Prevention (CDC) South Africa  Annatjie Pieters US Department of Health and Human Resources Health Services and Resources Administration (HRSA) I-TECH South Africa  Suzanne Jed  Jeri Sumitani  Julia DeKadt  Evasen Naidoo  Shumani Makatu  Sipho Mazibuko  Fulufhelo Malamatsho  Zanele Ramuse  Doctor Khoza  Elijah Chadzamira University of Washington  Marcia Weaver  Sean Galagan Consultant  Andrea Mayer

16. End with a quote. "No one is born hating another person because of the color of his skin, or his background, or his religion. People must learn to hate, and if they can learn to hate, they can be taught to love, for love comes more naturally to the human heart than its opposite." - Nelson Rolihlahla Mandela