using health system navigators, phone support and text message reminders did
not improve rates of people living with HIV initiating antiretroviral therapy (ART) or
completing treatment for tuberculosis (TB), investigators report in the Journal of Acquired Immune Deficiency
diagnosed with HIV in Durban, South Africa, were randomised to receive support
from trained health navigators or to receive the standard of care. The
intervention showed no benefit, with rates of antiretroviral initiation, TB treatment
completion and mortality similar between the intervention and standard-of-care
“We did not find
an effect of time-limited health system navigation on rates of ART initiation
and TB treatment completion among people newly diagnosed with HIV in Durban,”
write the authors. “Further studies are urgently needed to identify strategies
for improving entry to HIV/TB care in high-burden settings.”
Over 6.3 million
people are living with HIV in South Africa and approximately 200,000
individuals die each year because of HIV. The country has the largest
antiretroviral treatment programme in the world but 60% of people living with HIV in South Africa are not on therapy. The severity of the HIV epidemic
in South Africa is exacerbated by the TB epidemic, with an estimated 42% of all deaths
in people with HIV due to this infection.
significant attrition at each stage of the HIV treatment cascade in South
Africa and many other health settings. In the US, the use of health system
navigators has been shown to be effective in helping people overcome barriers
wanted to see if a similar intervention involving people newly diagnosed with
HIV or HIV and TB co-infection was effective at increasing rates of
antiretroviral initiation and completion of TB treatment.
designed a study involving 4903 individuals presenting for HIV testing at four
healthcare facilities in Durban. People testing positive for HIV also underwent
screening for TB and were randomised to the intervention arm or to receive
standard of care.
consisted of an interview with a health system navigator during which
barriers and facilitators to entering care were discussed and steps in the
HIV/TB care pathway were described. The navigator provided participants in the study with
ongoing support, including five scheduled phone calls (weeks 1, 4, 8, 12 and 16
after enrolment) and four text message reminders to attend appointments and collect
test results. People receiving standard of care were told to return to their
treatment centre for their CD4 cell count result within two weeks of diagnosis and
were contacted for referral to TB services if diagnosed.
A total of 1899 participants (39%) were newly diagnosed with HIV; 51% were randomised to the
intervention arm, the others received usual care. Overall, 49% were female and
the mean age was 35 years.
completion of three months of HIV therapy, completion of six months of TB
treatment and mortality.
count monitoring showed that 60% of the newly diagnosed people were eligible for ART (median CD4 cell count 112 cells/mm3). TB was
diagnosed in 25% of people in the intervention arm and in 30% of people receiving usual care.
intervention arm, 22% of people eligible for ART completed three
months of therapy and 41% of people with TB completed six months of TB
treatment. This was no different from the treatment rates observed among
people receiving usual care, with 28% of eligible people starting HIV
therapy and 44% of people with TB co-infection completing six months of
Nor did the
intervention have a benefit in terms of mortality rates: during nine months of
follow-up, 14% of people in the intervention arm died compared to 13% of
people who received the standard of care.
Individuals in the
intervention arm received an average of 3.5 calls from the navigator, with each
call lasting an average of 17 minutes. Analysis of participants alive at the end of
the study showed that 22% of those receiving fewer than five calls reached
the composite outcome (three months of HIV therapy/six months TB treatment)
compared to 30% of people who received all five calls. Mortality rates also
differed according to phone contact, and were 22% among people receiving
fewer than five calls but just 2.5% among people who received all five calls.
“A health system
navigator intervention complemented by SMS reminders did not show efficacy at
improving ART initiation or TB treatment completion,” conclude the authors.
“Interventions for linkage to HIV and TB care may require higher intensity, more
reliable 2-way communication between patients and more providers and provision
of more tangible means of overcoming barriers.”