BACKGROUND : South Africa’s tuberculosis burden is the third highest globally and is closely associated with the
country’s devastating HIV epidemic. The separation of HIV and TB services in primary healthcare services in South
Africa hampers TB case finding in patients who are co-infected with HIV and TB. This operational proof of concept
study assessed an approach to improving tuberculosis detection and treatment by integrating tuberculosis
management into HIV care.
METHODS : The intervention involved workforce re-engineering accompanied by changes to the physical
environment in three primary healthcare facilities in Gert Sibande district, Mpumalanga Province, that allowed HIV
providers to test their HIV patients for TB and initiate and monitor TB treatment when indicated. To assess the
proof of concept we compared the management of TB patients by HIV and TB providers, by reviewing the records
of all facility patients who tested positive for tuberculosis between July 2015 and February 2016. We also
considered the perceptions of healthcare providers and facility managers about the intervention through
RESULTS : Approximately 30% of the 1855 patients with presumed TB in the three clinics had been identified
by HIV providers. The percentage of patients consecutively tested for TB was 81.0% and 85.0% (p = 0.0551) for
HIV and TB providers, respectively. Of the patients identified with TB by HIV and TB providers, 75.4% and 79.
2% (p = 0.2876), respectively, were initiated on treatment. The defaulter rate was higher among HIV, compared
to TB, providers
(12.8% versus 4.2%). Overall, healthcare providers and facility managers had positive views of the intervention
but raised concerns regarding potential increase in workload and administrative issues, as well as infection
CONCLUSIONS : The results of this proof-of-concept study indicate that the full spectrum of TB services can be
easily and effectively integrated into existing HIV care programs. However, a possible shift in the service providers’ workload, including administrative tasks, must be tackled and effective infection control must be
ensured. Further research is needed to assess the impact of TB service integration into the scope of HIV care
(or other chronic care programs) on patient outcomes, including analysis of routine data.
Additional file 1: Screening outcomes. Full analysis of screening
Additional file 2: GenXpert testing outcomes. Full analysis of GenXpert
Additional file 3: Treatment outcomes. Full analysis of treatment
Additional file 4: Provider questionnaire. Instrument used to interview
providers and program managers.