Interventions to Improve Health Services and Prevent Tuberculosis for People Living with Human Immunodeficiency Virus in South Africa
Embargo until
2023-08-01
Date
2022-07-07
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Publisher
Johns Hopkins University
Abstract
Background: South Africa is home to nearly seven million people living with human immunodeficiency virus (PLHIV), for whom tuberculosis (TB) is the leading cause of death. Although national guidelines include effective tactics to prevent TB for PLHIV, implementation has been suboptimal.
Objectives: The goal of this dissertation was to evaluate interventions to improve TB prevention for PLHIV in South Africa. We delivered patients' lab results via mobile phone to more quickly recall people with TB or other medically concerning results (Chapter 2). We then sought to improve prescriptions of TB preventive therapy (TPT) with an alternative diagnostic for latent TB infection (LTBI, Chapter 3) and with education campaigns and nurse mentorship (Chapter 4).
Methods: For Aim 1, we implemented a non-randomized pilot to compare delivering test results via MatlaMobile versus the standard-of-care. For Aim 2, we conducted a cluster randomized trial to evaluate whether a Quantiferon Gold In-Tube (QGIT) test resulted in more LTBI results being documented and TPT prescriptions than standard-of-care. For Aim 3, we directly observed an intervention and conducted qualitative interviews to characterize implementation outcomes.
Results: In Aim 1, patients who received their results via phone were more likely to return to the clinic within seven days, if instructed that their result was medically concerning (20%, n=14/70) than the control group, who were all instructed to return to the clinic to retrieve their results (9%, n=15/174, p=0.02). In Aim 2, clinics documented an absolute 60% (95% CI: 51–68; p <0.001) more LTBI results and 12% (95% CI: –6, 31, p = 0.179) more TPT in QGIT clinics than the standard-of-care, after adjusting for baseline covariates. In Aim 3, the intervention was implemented with moderate fidelity and high uptake, however, nurses questioned whether the intervention could sustain its impact without structural changes.
Conclusions: These interventions improved retention-in-care and TB prevention for PLHIV. However, none persuaded patients and nurses to fully adhere to recommended TB/HIV guidelines. Future work should incorporate structural-level interventions, like increased staffing and improved TPT stock management, to better prevent TB among PLHIV.
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Keywords
tuberculosis, HIV, prevention, South Africa, cluster randomized controlled trial, qualitative, quantitative, mHealth, digital health