Almost universal coverage: HIV testing among TB patients in a rural public programme

With many tuberculosis (TB) patients also human immunodeficiency virus (HIV) infected, testing all TB patients for HIV is important so that HIV treatment can be initiated promptly. HIV testing in TB patients is one important route into combined HIV and TB treatment and care.¹

We collected data as part of a multi-site cross-sectional study, Researching Equity in Access to Healthcare (REACH), to examine HIV testing coverage in TB patients, administering a structured questionnaire to 300 patients accessing TB treatment in five primary health care clinics in Hlabisa sub-district, KwaZulu-Natal, South Africa. These clinics operate within the Hlabisa HIV Treatment and Care Programme, with separate, vertically structured TB and HIV services devolved to the primary health care level.² In 2009, the TB notification rate in the area was approximately 928 per 100 000 population and HIV prevalence among adults in 2010 was 24%; the rate of co-infection was 76%.³

Fifty-three per cent of patients accessing TB care were female; the median age of the patients was 37 years. The majority (75%) were receiving care for a first TB episode, mostly pulmonary TB. Although most patients were on DOTS, a substantial proportion (20%) did not take their medication under observation. Almost all patients (94%) reported that they had been offered HIV testing during their current TB treatment episode. The majority (97%) used the clinic closest to their homes; those who did were more likely to be offered HIV testing than those using a clinic further away (aOR 16.22, P < 0.01).^* Among the 17 patients not offered HIV testing, 10 (59%) were female, and the median age was 33 years (18–75 years). There was no statistically significant difference in age and sex between those offered and those not offered HIV testing, but the limited sample size would have reduced statistical power.

We demonstrate high HIV testing rates among TB patients in a rural public programme in a high TB and HIV burden area, suggesting that TB-HIV co-infected patients can be managed appropriately for treatment of both infections.⁴ The decentralised programme appears largely successful in attaining universal HIV testing in TB patients⁵ in this resource-limited setting. Our testing rate of 94% was slightly higher than the 88% seen previously in the area.³ However, there is scope for further improvement such as in DOTS delivery, a sustainable and effective way of ensuring good adherence to TB treatment. Patients mostly use the closest clinic for both TB treatment and HIV testing, suggesting a receding fear of stigma of HIV. However, the small number of patients not using the closest clinic are far less likely to undergo HIV testing, possibly indicating vulnerability expressed both in the location of seeking TB treatment and HIV testing uptake. Policy makers should encourage integration of services and cross-testing in HIV-TB facilities.