An evaluation of management and monitoring of persons co-infected with tuberculosis and HIV in the Western Cape (that’sit)

Despite notable achievements in tuberculosis (TB) and HIV prevention and treatment over the last decade, the two diseases present a tremendous public health challenge for South Africa where 60% of patients diagnosed with TB in 2010 were also infected with HIV (1). The TB and HIV surveillance systems in South Africa were developed and implemented as vertical programs and have historically functioned independently. It is increasingly recognized that the integration of TB and HIV services is a necessary and critical step to prevent new infections, more effectively manage existing infections, and combat these devastating co-epidemics (2,3).

The TB, HIV/AIDS, Treatment Support and Integrated Therapy (that’sit) program was established in 2005 as a collaborative project between the South African Medical Research Council (MRC), the Foundation for Professional Development (FPD), and the National Department of Health (NDoH) with the explicit goal of supporting the NDoH in providing a comprehensive range of integrated services for persons with TB and HIV. In the study presented here and which was conducted  in the Eden District of the Western Cape  an evaluation of the TB and HIV surveillance systems was done by reviewing the records of TB/HIV co-infected patients simultaneously on  antiretroviral therapy (ART) and on TB treatment.  The completeness and concordance of demographic and clinical variables from 6 sources were measured:  the paper-based TB and HIV patient files, a paper-based TB register, electronic TB and HIV registers, and an integrated electronic database established by the that’sit program.

It was found that demographic variables had high completeness and concordance across the TB and HIV systems. Completeness and concordance for clinical variables were  considerably lower, particularly across the two systems; i.e.  TB variables in the HIV systems and HIV variables in the TB systems.

The separate TB and HIV systems make the surveillance of co-infected patients inherently more complicated than surveillance of patients infected with either TB or HIV ( not both). Patients often receive their TB and HIV care at separate facilities and different patient care forms are used without established means for communication or sharing of information between the sites. The integrated electronic patient management system in the that’sit database provides a single source for information critical to patient management. The benefits of the this system should be balanced against the extra resources necessary to maintain a parallel data collection system.

The findings of this evaluation provide additional momentum for the integration of TB and HIV surveillance systems. An integrated surveillance system should collect a uniform set of variables in a uniform manner to ensure simple and direct data transfer. National integration will allow for the elimination of parallel data collection systems, both within the NDoH and with partner organizations such as that’sit. However, integrated surveillance will continue to be a challenge in the absence of integrated patient management and clinical care at clinic level.

Ultimately, the integration of TB and HIV care and surveillance systems will eliminate duplication, enhance accurate data collection, and provide a better reflection of clinical management and outcomes of TB/HIV co-infected patients in South Africa.  At the same time it will pave the way for the integration of other chronic diseases in a more comprehensive data surveillance system urgently needed for consistent quality patient care.

Note that the above has been presented at the 3rd Southern African TB Conference, 12-15 June 2012, Durban. The co-authors of the abstract are hereby acknowledged for their contribution: SC Auld, L Kim, EK Webb and LJ Podewils.

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