1. JA Peters1, M van Der Walt2, JC Heunis3, S Masuku2, T Osoba1
Outcomes of and barriers to integrated TB-HIV services at an antenatal care facility in Frances Baard District, Northern Cape, South Africa
JA Peters1, M van Der Walt2, JC Heunis3, S Masuku2, T Osoba1
1University of Liverpool, Faculty of Public Health, School of Medicine, United Kingdom
2Medical Research Council South Africa, TB Epidemiology & Intervention Unit, South Africa
3University of the Free State, Centre for Health System Research and Development, South Africa

2. South Africa, Northern Cape Province and Frances Baard District

3. Background TB = major infectious killer of women of all ages worldwide
HIV = main driver of TB in women of reproductive age
± 23% HIV prevalence in pregnant women in Frances Baard District
± 40% of maternal mortality related by TB-HIV in South Africa over past decade
Sources: WHO 2009; NDoH 2011

4. Pregnant women = key target population for national TB-HIV responses
ANC services = ideal platform for integrated TB-HIV services
However, in South Africa, not only AIDS denialism, but marked verticalisation of TB and HIV programmes
In fact, until June 2010 no integration of TB-HIV and maternal health services
South Africa now (belatedly) has progressive policies…
Sources: NDoH 2010; DeLuca et al 2010; Gounder et al 2011
MENTION HORISONTAL SYSTEM BITS>>>>>>>
Traditionally, TB and HIV programmes operated in a vertical manner and had little to do with each other at the local, national and global levels (Tsiouris, et al., 2008; Harries, et al., 2010).
Globally, TB programmes were public health-based and focused on case finding and the treatment of active TB alone.
HIV/AIDS programmes, on the contrary, underscored individual rights, did not prioritize HIV-diagnosis and focused primarily on HIV prevention (Anderson & Maher, 2001; WHO, 2010; Harries, et al., 2010).
However, in 2004, the WHO Interim Policy on Collaborative TB/HIV Activities (2004) was established, and specified that both TB and HIV disease control programmes should incorporate testing, diagnosis, treatment and care for both diseases, with “coordinated interventions and activities at multiple levels of the health system, from the level of the community and provider, to that of the policymaker” (Harries, et al., 2010)

5. Implementation of these policies in South Africa has been slow
BUT…
Implementation of these policies in South Africa has been slow
Delivery of integrated TB and HIV services to pregnant women has been delayed
Source: Chehab et al 2011

6. South Africa is one of only twelve countries where maternal mortality rates have INCREASED since MDG baselines were set
Barriers preventing implementation of integrated TB/HIV services in ANC services are unknown
Sources: Chopra et al 2009; Statistics South Africa 2010
(FB has high TB/HIV co- infection rates, poor and sparse populations, as well as great distances between health facilities)

7. Aims
Primary aim: to determine the proportion of patients receiving integrated TB-HIV services during ANC
Secondary aim: to assess possible barriers to delivery of such integrated services

8. Methods: Part A
Retrospective record review of all pregnant women with/without TB and/or HIV attending ANC over 13-month period:
Random sampling (n = 308 [59%])
Data collected from ANC registers (including TB and HIV service activities)
Extracted data compared with corresponding patient records
Participants
Two sets of participants:
Group A pregnant women with/without TB and/or HIV who attended ANC at GDH in FB for the first time between 1 April 2011 and 29 February 2012
Group B – Three senior staff members, including the operational manager, head of ANC and the head of HIV/TB care. Each of these have of one year at each given unit to ensure sufficient knowledge of the operational arrangements at that unit.

9. Methods: Part B
Survey of senior clinic staff (n = 3) on the application of the WHO-recommended TB/HIV collaborative activities at ANC level:
CDC South Africa interview schedule with closed ended questions
Responses systematically compared among the respondents
The characteristics of the health facility and barriers to quality care provision relating to the WHO-recommended mechanisms for collaboration applied at the facility;
The level of availability of TB services at the ANC unit of this facility;
The level of availability of HIV services at the ANC unit of this facility
The method of delivery of each of these services

10. Results: Part A

11. Results (Part A) 51% (31/61) with CD4 count > 350 cells/mm3
13% (4/31) of all eligible patients started on ART prophylaxis (on-site)
0% (0/71) received CPT
100% (308/308) received HCT
23% (71/308) HIV positive
86% (61/71) received CD4 counting
Just more than third were referred, but not known whether they actually received this treatment modality
Here you cansee that the concerning findings are coloured in red
55% (39/71) Newly diagnosed HIV positive
42% (10/24) previously initiated on ART
49% (30/61) with CD4 count < 350 cells/mm3
36% (5/14) of all eligible patients referred to ART unit for ART initiation

12. Results (Part A)
Only 42% (30/71) of HIV positive patients were screened for TB
13% (4/30) HIV positive patients screened positive for TB
100% (4/4) of non-eligible patients wrongly started on IPT
27% (60/220) of screened patients were HIV positive
87% (26/30) HIV positive patients screened negative for TB
71% (220/308) patients screened for TB
44% (11/26) of eligible patients started on IPT
73% (160/220) of screened patients were HIV negative
10% (30/308) patients screened positive for TB
0% (0/30) TB suspects received further investigation and/or treatment

13. Results (Part A)
A significant relationship existed between HIV status (HIV-negative or positive) and TB screening (whether or not TB screening was performed) (p = 0.001)
Surprisingly, the odds of receiving a TB screening were almost three times higher for HIV-negative patients than for HIV-positive patients [OR = 2.63 (95% CI: )].
No significant relationship, however, existed between HIV status and TB screening outcomes (in terms of being a TB suspect or not) (p = 1.157).
Therefore, there was an independent relationship between HIV status and TB screening, which was not confounded by the TB screening outcomes;
thus, no multiple logistical regression was deemed necessary [38].
No relationship between HIV status and IPT uptake was calculated, as only HIV-positive patients should have received this service.
No association could be made between TB screening and further TB investigations/diagnoses/treatment, as none of the HIV-positive or -negative patients received any further TB investigations/diagnoses/treatment.

14. Results (Part B) Poor coordination and referral systems
Shortage of up-to-date policies/guidelines
Lack of joint TB/HIV/ANC planning
No M&E strategy in place
Lack of awareness of TB/HIV collaborative activities
Improperly trained health-care workers
Logistical (testing kits) and treatment shortages (CPT)
HIV-service availability at ANC unit
TB-service availability at ANC unit
Infection control arrangements at ANC unit

15. Conclusions: Part A Strengths: Positive HCT efforts (100%)
Encouraging CD4 count testing (86%)
Weaknesses:
Insufficient on-site ART prophylaxis (13%)
Inadequate ART initiation (36%)
Complete lack of CPT (0% received)
Lack of screening for TB of HIV positive pregnant women (58% not screened)
Poor IPT provisioning (only 44% received)
No follow-up of possible TB suspects (0%)

16. Conclusions: Part B Wide range of barriers, particularly:
Lack of availability/awareness of policy guidelines
Dearth of planning
Insufficient training

17. Acknowledgements
Medical Research Council: ethical clearance and fieldwork
Northern Cape Department of Health: ethical clearance
University of Liverpool: study guidance and ethical clearance
CDC: Provision of instrument
ANC facility respondents