Increasing partner HIV testing and linkage to care in TB settings: findings from an implementation study in Pwani, Tanzania.

Couples HIV testing for tuberculosis (TB) patients and their partners may be an effective means to identify HIV-positive persons and strengthen linkage to HIV care. We evaluated an intervention to increase HIV testing and linkage to care (LTC) of newly diagnosed persons and re-linkage for TB/HIV patients in Pwani, Tanzania. In 2014, 12 TB settings within two regional clusters participated; each cluster included ≥1 referral hospital, health center, and directly observed therapy center. Three months after introducing tools to record HIV service delivery, TB clinic staff and peer education volunteers in Cluster 1 received training on HIV partner testing and linkage/re-linkage, and staff in the second cluster received training 3 months thereafter. Twelve months after tools were introduced, clinic records were abstracted to assess changes in couples HIV testing, LTC, and re-linkage. Staff interviews assessed the feasibility and acceptability of the service delivery model. HIV prevalence was high among TB patients during the study period (44.9%; 508/1132), as well as among others who received HIV testing (19.8%; 253/1288). Compared to pre-implementation, couples HIV testing increased in both clusters from 1.8% to 35.2%. Documented LTC increased (from 5.7% to 50.0%) following the introduction of the tools. Additional increases in LTC (from 57.9% to 79.3%) and re-linkage (from 32.9% to 53.7%) followed Cluster 1 training, but no additional increases after Cluster 2 training. Staff perceived little burden associated with service delivery. This study demonstrated a feasible, low-burden approach to expand couples HIV testing and linkage of HIV-positive persons to care. TB settings in sub-Saharan Africa serve populations at disproportionate risk for HIV infection and should be considered key venues to expand access to effective HIV prevention strategies for both patients and their partners. HIV services in TB settings should include HIV testing, condom distribution, and linkage to appropriate additional services.

Evaluation of community-based interventions to improve TB case detection in a rural district of Tanzania.

In Tanzania, people with tuberculosis (TB) commonly self-medicate or visit traditional healers before seeking formal medical care. Between 2009 and 2011, we piloted a community-based project in Kisarawe District to improve TB case notification. The project trained 15 traditional healers and 15 pharmacists to identify and refer individuals with TB symptoms to diagnostic facilities. In addition, the project trained 2 community members to collect and fix sputum from symptomatic individuals onto slides, which they then delivered by bicycle to the nearest diagnostic facility. To determine effectiveness, we analyzed routine case detection data and referrals from traditional healers and pharmacists and conducted a cross-sectional survey of recently diagnosed smear-positive TB patients (N = 150) to understand their treatment-seeking behavior. From 2009 to 2011, smear-positive TB case notification increased by 68% in Kisarawe District, from 28/100,000 to 47/100,000, even while TB case notification nationally stayed the same (at approximately 14/100,000). The traditional healers and pharmacists referred 434 people with presumptive TB to diagnostic facilities, 419 of whom (97%) went to the facilities; of those who went to facilities for testing, 104 people (25%) were diagnosed with TB. The percentage of new TB case notifications that were referred through the network ranged from 38% to 70% per reporting quarter. Sputum fixers collected and delivered specimens from 178 individuals, 17 of whom (10%) were diagnosed with TB. Almost 60% of surveyed smear-positive TB patients first visited a pharmacist or traditional healer before seeking care at a diagnostic facility. These results prompted scale up of community interventions to 9 more districts in 2011 and to another 26 districts in 2013. Establishing referral networks that bring TB information and services closer to community members can contribute to improved TB case notification.