A Quality Improvement Intervention to Inform Scale-Up of Integrated HIV-TB Services: Lessons Learned From KwaZulu-Natal, South Africa

Offered group pretest counseling in all patients’ waiting areas

Implemented a daily roster system of staff to conduct pre-test counseling

Nurse in charge or designee to check accountability log daily

Acute patients were overlooked for HTS services (e.g., wound care patients)

Ensure that acute patients are directed to lay counselors after vitals assessments^a are conducted

If above not possible, then staff caring for acute patients were (i) trained in HIV testing and counseling and (ii) provided with the appropriate HTS stationery

Not completing HTS registers in real-time

Misplacing HTS registers

Daily quality control of HTS registers and frequent audits of patient files and electronic data to ensure HIV status is known for all patients

HTS viewed as the work of lay counselors

Lack of counseling skills among nurses to relieve/stand-in for lay counselors

On-site HTS refresher training was held which addressed: pre- and post-test counseling messages, conducting HIV rapid tests, and data recording

Awareness of clinic target set by the district health office was disseminated

Made TB screening mandatory at an identified strategic point visited by all patients, such as, vitals assessment^a station

Visual prompts and reminders to conduct TB screening included large and colorful TB posters, printed and easily accessible signs, and symptoms checklists

Made TB screening mandatory for acute patients

Daily data quality control checks conducted by nurse in charge or designee to check:

• Completeness and accuracy of daily TB screening register

• Number of symptomatic patients and number of sputum samples sent for Xpert/ MTB Rif^b testing

Quality control of clinic headcount^c data:

• Exclude patient representatives or family members

• Subtract TB confirmed patients from the clinic headcount

• Mass TB screening campaigns conducted in communities must be distinguishable from screening conducted in the clinic

Nurses lack clarity on timing of IPT initiation

Individual nurses use own discretion to start IPT

Each clinic team arrived at a common time to start IPT (e.g., 7,14, or 30 days after starting ART)

Agreed upon timing was documented and standardized for entire clinic

Roles and responsibilities were assigned to all staff categories and documented

The “box system” -eligible patients’ files placed in a decorated box for easy identification, OR

Tagged files of eligible patients with stickers or red ink OR

The “diary system” reminder note in clinic diary to initiate IPT at next visit and note attached to patient file

Nurses directed to document start date in designated fields and data capturers shown where to find the start date

Link this training with the TB screening training (above) to boost confidence to rule out TB

TB and ART files not integrated

No unique identifier for TB and ART file

For HIV-TB coinfected patients, ART and TB chart notes were physically combined

The district health office agreed upon a common unique identifier to be used

The TB module on the electronic ART database was activated to accommodate TB and ART data

Clarified patient flow for ART initiation visits in TB/HIV coinfected patients

Improved chart notes for ART and TB treatment start dates

Address the data capturing backlog of VL results and ART initiation

Draw on the assistance of local nongovernmental organizations and support partners for assistance with data capture

Generate VL reports from the data system to determine which patients have not had or are due for VL test (filter out deceased and transferred-out patients)

Tag/mark the files of patients due for VL for easy identification

Trace patients who were missed for a VL test