Integrated Tuberculosis/Human Immunodeficiency Virus Community-Based Case Finding in Rural South Africa: Implications for Tuberculosis Control Efforts.

BACKGROUND: Intensive case finding is endorsed for tuberculosis (TB) control in high-risk populations. Novel case-finding strategies are needed in hard-to-reach rural populations with high prevalence of TB and human immunodeficiency virus (HIV). METHODS: We performed community-based integrated HIV and TB intensive case finding in a rural South African subdistrict from March 2010 to June 2012. We offered TB symptom screening, sputum collection for microbiologic diagnosis, rapid fingerstick HIV testing, and phlebotomy for CD4 cell count. We recorded number of cases detected and calculated population-level rates and number needed to screen (NNS) for drug-susceptible and -resistant TB. RESULTS: Among 5615 persons screened for TB at 322 community sites, 91.2% accepted concurrent HIV testing, identifying 510 (9.9%) HIV-positive individuals with median CD4 count of 382 cells/mm3 (interquartile range = 260-552). Tuberculosis symptoms were reported by 2049 (36.4%), and sputum was provided by 1033 (18.4%). Forty-one (4.0%) cases of microbiologically confirmed TB were detected for an overall case notification rate of 730/100000 (NNS = 137); 11 (28.6%) were multidrug-resistant or extensively drug-resistant TB. Only 5 (12.2%) TB cases were HIV positive compared with an HIV coinfection rate of 64% among contemporaneously registered TB cases (P = .001). CONCLUSION: Community-based integrated intensive case finding is feasible and is high yield for drug-susceptible and -resistant TB and HIV in rural South Africa. Human immunodeficiency virus-negative tuberculosis predominated in this community sample, suggesting a distinct TB epidemiology compared with cases diagnosed in healthcare facilities. Increasing HIV/TB integrated community-based efforts and other strategies directed at both HIV-positive and HIV-negative tuberculosis may contribute to TB elimination in high TB/HIV burden regions.

What motivates use of community-based human immunodeficiency virus testing in rural South Africa?

Despite substantial progress in implementing HIV testing, challenges remain in achieving widespread uptake particularly in rural resource-limited settings. We sought to understand motivations for HIV testing in a community-based HIV testing programme in rural South Africa. We conducted a questionnaire survey in participants undergoing voluntary HIV testing within an ongoing community-based integrated HIV/tuberculosis intensive case finding programme at congregate rural settings. Participants responded to a six-item non-mutually exclusive motivations survey which included the topics of feeling ill, recent HIV exposure, risky lifestyle, illness in a family member, and pregnancy. Among 2068 respondents completing the survey, 1393 (67.4%) were women, median age was 40 years (IQR 19-56), and 1235 (59.7%) were first-time testers. Among all testers, 142 (6.9%) were HIV-positive with median CD4 count was 346 cells/mm(3) (IQR 218-542). Community-based testing for HIV is acceptable and meets the needs of community members in rural South Africa. Motivations for HIV testing at the community level are complex and differ according to gender, age, site of community testing, and HIV status. These differences can be utilised to improve the focus and yield of community-based HIV screening.

An intervention to improve respiratory therapists' comfort with end-of-life care.

BACKGROUND: Respiratory therapists (RTs) are often involved in treating seriously ill and dying patients, but receive little instruction in end-of-life care. Prompted by several difficult cases, we developed an interdisciplinary program to introduce practicing RTs to ethical and end-of-life issues, and evaluated the program with a dedicated survey instrument. METHODS: A convenience sample of RTs from a university hospital and nearby community hospitals participated in a one-day interactive program, in 2005 (n = 49) and in 2008 (n = 36), that included role-play and didactic components. The questionnaire completed before and after the program included scales on comfort with end-of-life care and role in end-of-life care, and knowledge indices. RESULTS: Nearly all the RTs had recently encountered end-of-life situations, yet most had not received dedicated training and felt ill-prepared to deal with these situations; one third reported distress related to withdrawal of treatment. The 78 participants who completed both the before and after surveys had increased comfort with end-of-life care (P < .001) and their perception of their role in end-of-life care (P < .001). Knowledge about end-of-life care also increased (P < .001). CONCLUSIONS: A one-day interactive educational intervention can improve short-term RT comfort and role perception concerning end-of-life care. Evaluation of longer-term clinical outcomes and implementation in other venues is needed.