TABLE 4

Health Systems Weaknesses Identified and Associated Change Ideas for a Quality Improvement Intervention for HIV/TB Service Integration in KwaZulu-Natal, South Africa

HIV-TB Process	Health Systems’ Weaknesses Identified	Change Concepts
HTS	Relying only on patient requests or referrals for HIV testing.	Introduced strategies to enhance provider-initiated testing: 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
	Missed opportunities to offer HTS to all patients Acute patients were overlooked for HTS services (e.g., wound care patients)	Redesigned clinic patient flow 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
	HTS data inaccuracies caused by: Not completing HTS registers in real-time Misplacing HTS registers	Daily data quality control checks Daily quality control of HTS registers and frequent audits of patient files and electronic data to ensure HIV status is known for all patients
	Overdependence on lay counselors HTS viewed as the work of lay counselors Lack of counseling skills among nurses to relieve/stand-in for lay counselors	Increasing the accountability and responsibility for the HTS program 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
TB screening among PHC clinic attendees	Missed opportunities to offer TB screening to all clinic attendees	Centralized TB screening 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
TB screening among PHC clinic attendees	Inaccurate TB screening data	Data quality control checks 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
IPT initiation among new ART patients	Ambiguity in IPT initiation guidelines Nurses lack clarity on timing of IPT initiation Individual nurses use own discretion to start IPT	Clarify IPT initiation timing and arrive at mutually agreed upon timing for initiation 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
	Confusion about roles and responsibilities of clinic staff	Enhancing accountability and responsibility for IPT program Roles and responsibilities were assigned to all staff categories and documented
	No system for identifying patients eligible for IPT	Strategies to identify patients returning at the agreed upon time for IPT 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
	Poor recording of IPT initiation date in clinic chart notes	Refresher training on clinic stationery to document IPT Nurses directed to document start date in designated fields and data capturers shown where to find the start date
	Nurses lack confidence to rule out TB	Host a training for nurses, lay counselors, and data capturers highlighting the importance and potential benefit of IPT for HIV-infected patients Link this training with the TB screening training (above) to boost confidence to rule out TB
ART initiation among HIV-TB coinfected patients	Patient chart notes for TB and ART kept separately TB and ART files not integrated No unique identifier for TB and ART file	Combining ART and TB files 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
ART initiation among HIV-TB coinfected patients	Poor coordination between NIMART and TB nurses regarding ART and TB treatment initiation	Refresher training for nurses Clarified patient flow for ART initiation visits in TB/HIV coinfected patients Improved chart notes for ART and TB treatment start dates
VL monitoring at month 12 after ART initiation	No system to identify patients eligible for month 12 VL tests	Generate report from electronic system of patients due for VL 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

Abbreviations: ART, antiretroviral therapy; HTS, HIV testing services; IPT, isoniazid preventive therapy; NIMART, Nurse Initiated Management of Antiretroviral Therapy; PHC, primary health care; VL, viral load.
↵a Vitals assessments refers to general measures of well-being which typically include weight, body temperature, blood pressure measurements.
↵b Xpert/MTB RIF a rapid, molecular, cartridge-based test used for TB diagnostics that provides an immediate rifampicin resistance result.
↵c Clinic headcount refers to the total number of patients who accessed the clinic for any type of clinical service.