Linkage to care among adults being investigated for tuberculosis in South Africa: pilot study of a case manager intervention

Abstract

ObjectivesWe piloted an intervention to determine if support from a case manager would assist adults being investigated for tuberculosis (TB) to link into TB and HIV care.DesignPilot interventional cohort study.Participants and settingPatients identified by primary healthcare clinic staff in South Africa as needing TB investigations were enrolled.InterventionParticipants were supported for 3 months by case managers who facilitated the care pathway by promoting HIV testing, getting laboratory results, calling patients to return for results and facilitating treatment initiation.Outcomes measuredLinkage to TB care was defined as starting TB treatment within 28 days in those with a positive test result; linkage to HIV care, for HIV-positive people, was defined as having blood taken for CD4 count and, for those eligible, starting antiretroviral therapy within 3 months. Intervention implementation was measured by number of attempts to contact participants.ResultsAmong 562 participants (307 (54.6%) female, median age: 36 years (IQR 29–44)), most 477 (84.8%) had previously tested for HIV; of these, 328/475 (69.1%) self-reported being HIV-positive. Overall, 189/562 (33.6%) participants needed linkage to care (132 HIV care linkage only; 35 TB treatment linkage only; 22 both). Of 555 attempts to contact these 189 participants, 407 were to facilitate HIV care linkage, 78 for TB treatment linkage and 70 for both. At the end of 3-month follow-up, 40 participants had not linked to care (29 of the 132 (22.0%) participants needing linkage to HIV care only, 4 of the 35 (11.4%) needing to start on TB treatment only and 7 of the 22 (31.8%) needing both).ConclusionMany people testing for TB need linkage to care. Despite case manager support, non-linkage into HIV care remained higher than desirable, suggesting a need to modify this intervention before implementation. Innovative strategies to enable linkage to care are needed.

Linkage to care and treatment outcomes for patients diagnosed with drug-susceptible tuberculosis using Xpert MTB/RIF assay in Thaba-Tseka district in Lesotho

“…The low linkage to care rate observed in this study is similar to rates reported in various studies in Southern Africa ( Maraba et al., 2018 ; Bassett et al., 2019 ; Vanqa et al., 2021 ). A multi-centre study conducted in South Africa and Uganda reported a linkage to care rate of 55% (12/22) amongst HIV-positive patients diagnosed with active drug-susceptible TB, while a study in Malawi reported a linkage to care rate of 40% (23/58) amongst hospitalized patients diagnosed with TB in Lilongwe ( Chawla et al., 2016 ; Shapiro et al., 2018 ).…”

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

“…Interventions to identify PLHIV receiving care for concomitant TB could facilitate timely entry to the HIV care cascade and ART initiation. In South Africa, a pilot cohort study examined case managers who promoted HIV testing, followed up laboratory results, contacted patients to return for results and facilitated treatment initiation for patients being investigated for TB, resulting in 74% of eligible PLHIV initiating ART [48].…”

Early interactions with newly diagnosed TB patients in hospital can support linkage to care

“…In South Africa, studies have implemented elements of patient engagement to reduce patient ILTFU through additional case support managers, various text message reminders and strengthening of ward-based outreach teams. [28][29][30] These patient engagement interventions involve resource-intensive processes focusing on the needs of patients. Our comparatively simple patient interaction process focusing on updating patient contact details, providing practical information and allowing patients the opportunity to ask questions was also aimed at improving the health outcomes of patients.…”