Proactive identification of TB/HIV co-infected clients not on ART, coupled with proactive referral to HIV care and ART points improves percentage of TB/HIV co-infected clients on both TB treatment and ART

Dr. Oboth Ronald, Sr. Nakazibwe Gertrude, Sr. Annet Florence, Mwase Abbey
Tuesday, October 28, 2014
Context: What was the issue or process affected? What was the root cause of the challenge?: 

For the period of October - December 2013, only 67% of the registered TB/HIV co-infected clients at Jinja TB unit were started on or linked to ART. The national target is 100%.

Root causes of low performance

  • Gaps in mechanisms for identification of TB/HIV co-infected clients. Staff concentrated mostly on treating TB and did not always inquire about the HIV status of clients or provide an HIV test as part of the care package.
  • Sometimes, clients who tested positive were neither enrolled on ART nor linked to ART clinic for initiation on treatment
  • Most co-infected clients received chronic care from other lower facilities and therefore could not be initiated on ART at the hospital
  • Incomplete documentation– sometimes TB/HIV co-infected clients were actually started on ART but the ART status column in the TB register was not updated
What Happened: How was the challenge or gap addressed or improved?: 

The Jinja TB ward team:

  • Started to actively work with the District TB and Leprosy Supervisor (DTLS) to get contact lists of TB clients receiving HIV care and treatment at lower level healthcare facilities 
  • Started to actively inquire about ART status in TB/HIV co-infected clients. Those without known HIV status were tested for HIV and clients who tested HIV-positive physically escorted to the ART clinic for ART initiation. Clients who received ART treatment from lower level healthcare facilities were given written notices to deliver to service providers at those facilities as reminders for immediate ART initiation 
  • Developed a duty roster with responsibilities assigned to individuals: Emphasis was put on  weekly updating of the TB register and particularly  the ART status column for TB/HIV co-infected clients already started on ART
  • Introduced active transfer-out of TB/HIV co-infected clients to receive both TB and HIV services at a lower level healthcare facility where they already were getting ART
Nugget: What is the lesson for others?: 

To improve enrolment of TB/HIV co-infected clients on ART, actively screen TB clients for HIV and refer co-infected clients to receive both TB care and ART at a single healthcare facility.

Impact: What are the results of applying the nugget?: 
  • In March 2014, enrolment and linkage of TB/HIV co-infected clients on ART at Jinja RRH improved to 75.5%, and reached 81.3% at the end of June 2014
  • The HIV status of every TB client is determined, making appropriate management of TB/HIV co-infected clients much easier 
Implementation: What steps are needed to apply the lesson?: 

Review data to determine performance. If the performance is below the recommended standard or target, for linkage of TB/HIV clients to and enrollment on ART, consider the following:

  • Organize a meeting (include the District TB and Leprosy Supervisor, ART team, records/data officers and TB care team) to identify causes of the low performance and possible solutions
  • In this meeting, agree on the roles and responsibilities of each cadre; for example:

    • Collects and compiles list of all TB/HIV care focal persons in lower level healthcare facilities in the district
    • Informs the respective focal persons at lower level healthcare facilities of the clients referred or lost to follow


b) TB Unit Nurse and Volunteer
    • Posts the contact list for the lower level healthcare facilities and focal persons on the wall/noticeboard
    • Offers Provider Initiated Testing and Counselling for HIV to all TB clients with unknown HIV sero status
    • Immediately enters all HIV test results into TB register
    • Escorts any HIV-positive client who has completed at least two weeks of TB treatment to the ART Clinic for initiation of ART
    • Called lower level healthcare facilities where clients get chronic care and find out if patients are on initiated on ART to update the ART column in the TB register


c) Data officer
    • Cross-checks TB register weekly for completion of HIV status and ART column entries
    • Notifies TB Unit Nurse of the gaps identified


d) Clinicians, Nurse In-charges
    • Does active TB and HIV screening, respectively

Action: Who is this for? Where does this nugget to go next?: 

All TB and ART Clinics, Clinicians, nurses, DTLS

Dr. Oboth Ronald, Medical officer, ART clinic; Sr. Nakazibwe Gertrude, Nursing officer, TB ward Sr. Annet Florence, Senior nursing officer, TB ward Mwase Abbey, Counsellor volunteer
Knowledge nugget photo
Another photo of a knowledge nugget