Integrating a TB screening tool into the adult clinical record (ACR) in HIV treatment facilities in South Africa’s Eastern Cape has resulted in a significant increase in the number of HIV-positive people diagnosed with TB, say researchers from the International Centre for AIDS Care and Treatment Programs (ICAP).
Screening for TB is critical in HIV-positive people, given the increased risk of infection and differences in clinical presentation.
Researchers Sabine Verkuijl and Jeanette Wessels from ICAP piloted the integration of TB screening into the adult clinical record in public health facilities in three subdistricts in the Eastern Cape.
The first step in completing the adult clinical record involves assessing if the patient enrolled into HIV or ARV care is symptomatic for TB, using a screening questionnaire.
Those patients who screen positive, meaning that they have one or more of six listed symptoms or signs, are then further investigated to confirm active TB. This includes investigations for pulmonary TB (sputum smears and/or culture, chest X-ray) and for extra-pulmonary TB (lymph-node aspirates, pleural taps, abdominal ultrasound and other measures). If active TB is confirmed, TB treatment is started and these patients also receive cotrimoxazole prophylactic treatment.
Overall, the percentage of ARV patients who were screened for TB increased from 73.2 % to 95% between 2007 and 2008.
Of those screened, the percentage of patients with a positive symptom screen remained approximately the same: around 49% in both 2007 and 2008.
Out of those with a positive screen, the percentage of patients diagnosed with TB dropped from 40.6% to 23.8%.
The data collected from the ACR allows for comparison of TB screening practices across regions and between facilities. In the ICAP-supported districts, clear differences can be seen in the extent to which TB screening is routinely done. In Nelson Mandela Bay almost all patients are routinely screened at enrolment into HIV care. In Buffalo City LSA (East London), only 35% of patients are screened, and less than 60% of those with a positive screen are investigated for TB.
The availability of these data allows for increased monitoring of the extent of TB screening for people in HIV care.
The proportion of HIV-positive people being screened for TB in South Africa is exceptionally low, with an average of only 40% in 2007. For the Eastern Cape Department of Health, this is significantly lower at 27% in 2007.
The main advantages of the integrated screening tool in the clinical record are the quality and continuity of care it allows. It reminds clinicians to screen for active TB at each and every visit for patients enrolled in HIV care and on antiretroviral treatment (ART).
It also prevents unmasking of TB through immune reconstitution inflammatory syndrome (IRIS) in patients with lower CD4 counts.
The ruling out of TB through the ACR is also crucial for the correct implementation of isoniazid preventive therapy (IPT).
The ACR also allows the clinician to monitor TB investigation results, TB treatment progress and TB treatment outcome. Essentially, the ACR improves practical integration between the HIV and TB programme.
In order to get feedback from users in the facilities, an eight-question questionnaire was administered in facilities in the Nelson Mandela Bay Municipality. Respondents were asked to indicate on a scale from 1 to 5 whether or not they agreed with different statements regarding the ease of use of the ACR and the perceived impact on the quality of care. Feedback was generally very positive, with scores between 4.6 and 5.
The operating characteristics of the TB screening questionnaire, including the sensitivity and specificity of the symptoms and signs included, will be evaluated in a public health evaluation in two ICAP-supported facilities.
Wessels J et al. Integration of a TB screening tool into a comprehensive HIV adult clinical record in the Eastern Cape, South Africa. Fourth South African AIDS Conference, Durban, abstract 485, 2009.