Operational Research to Assess the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Health Facilities in Harare, Zimbabwe

Abstract

When COVID-19 was declared a pandemic, there was concern that TB and HIV services in Zimbabwe would be severely affected. We set up real-time monthly surveillance of TB and HIV activities in 10 health facilities in Harare to capture trends in TB case detection, TB treatment outcomes and HIV testing and use these data to facilitate corrective action. Aggregate data were collected monthly during the COVID-19 period (March 2020–February 2021) using EpiCollect5 and compared with monthly data extracted for the pre-COVID-19 period (March 2019–February 2020). Monthly reports were sent to program directors. During the COVID-19 period, there was a decrease in persons with presumptive pulmonary TB (40.6%), in patients registered for TB treatment (33.7%) and in individuals tested for HIV (62.8%). The HIV testing decline improved in the second 6 months of the COVID-19 period. However, TB case finding deteriorated further, associated with expiry of diagnostic reagents. During the COVID-19 period, TB treatment success decreased from 80.9 to 69.3%, and referral of HIV-positive persons to antiretroviral therapy decreased from 95.7 to 91.7%. Declining trends in TB and HIV case detection and TB treatment outcomes were not fully redressed despite real-time monthly surveillance. More support is needed to transform this useful information into action.

Real-Time Operational Research: Case Studies from the Field of Tuberculosis and Lessons Learnt

“…Overall ethics approval was obtained from the Union Ethics Advisory Group, the Kenya Medical Research Institute, and Zimbabwe’s Medical Research Council. The Malawi National Health Science Research Committee waived the need for formal ethics approval on the grounds that this was programmatic work [ 24 , 25 , 26 ].…”

“…The interventions put in place included: (i) integrated screening and fast-tracking of investigations for TB and COVID-19 in patients presenting with respiratory symptoms; (ii) improved contact tracing in selected facilities; and (iii) the promotion of strict infection control practices at health facilities to encourage symptomatic patients to attend. Unfortunately, the country had widespread industrial strike action in the health sector between July and September 2020, and between December 2020 and January 2021, there were stock-outs of TB diagnostic reagents, which greatly reduced the ability to diagnose TB [ 26 ].…”

“…The anticipated negative impact of COVID-19 on TB and HIV services in Kenya, Malawi and Zimbabwe was a case in point, where monthly instead of quarterly surveillance was welcomed and instituted by the disease control programmes to try and counteract the dramatic decreases in TB case detection and HIV testing. The data were also used to assess new strategies implemented to counteract the adverse effects of COVID-19 [ 24 , 25 , 26 ].…”

“…Doing this with paper-based records was going to be difficult, if not impossible. In the Kenya, Malawi and Zimbabwe studies [ 24 , 25 , 26 ], an EpiCollect5 application ( , accessed on 7 June 2021) was therefore used to collect the aggregate data and this was used in real-time to cross-check and validate data for the different variables and ensure that numbers added up. EpiCollect5 is a free application that can be downloaded to smartphones, and it was relatively easy to train all the data collectors in the country about how to use it.…”

“…In the first three case studies, interim stakeholder meetings with programme directors were held as the studies progressed, and importantly they were also held within a few weeks or months of the studies being completed leading to important national decisions being made long before the papers were published [ 10 , 15 , 23 ]. In the fourth case study, the data were put together each month as figures, tables and a narrative and sent as monthly reports to programme directors [ 24 , 25 , 26 ]. The monthly deadlines for submission were never missed, which allowed confidence to be built into the system, especially for trying out and monitoring new strategies.…”