A Cluster-Randomized Trial of Provider-Initiated (Opt-Out) HIV Counseling and Testing of Tuberculosis Patients in South Africa

Abstract

Objective-To determine whether implementation of provider-initiated HIV counseling would increase the proportion of tuberculosis patients that received HIV counseling and testing. Design-Cluster-randomized trial with clinic as unit of randomizationSetting-Twenty, medium-sized primary care TB clinics in the Nelson Mandela Metropolitan Municipality, Port Elizabeth, Eastern Cape Province, South Africa Subjects-A total of 754 adults (≥ 18 years) newly registered as tuberculosis patients the twenty study clinics Intervention-Implementation of provider-initiated HIV counseling and testing. Main outcome measures-Percentage of TB patients HIV counseled and tested.Secondary-Percentage of patients HIV test positive and percentage of those that received cotrimoxazole and who were referred for HIV care.Results-A total of 754 adults newly registered as tuberculosis patients were enrolled. In clinics randomly assigned to implement provider-initiated HIV counseling and testing, 20.7% (73/352) patients were counseled versus 7.7% (31/402) in the control clinics (p = 0.011), and 20.2 % (n = 71) versus 6.5% (n = 26) underwent HIV testing (p = 0.009). Of those patients counseled, 97% in the intervention clinics accepted testing versus 79% in control clinics (p =0.12). The proportion of patients identified as HIV-infected in intervention clinics was 8.5% versus 2.5% in control clinics (p=0.044). Fewer than 40% of patients with a positive HIV test were prescribed cotrimoxazole or referred for HIV care in either study arm.Conclusions-Provider-initiated HIV counseling significantly increased the proportion of adult TB patients that received HIV counseling and testing, but the magnitude of the effect was small. Additional interventions to optimize HIV testing for TB patients urgently need to be evaluated.

Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia

“…[31][32][33][34][35] Although data from Botswana suggest that introducing PITC into primary care clinics increased the uptake of HIV testing, 22,36-39 the country's small population and status as a middle-income country make the findings difficult to generalize. Additional supporting evidence for the effectiveness of PITC in outpatient settings in sub-Saharan Africa comes from experience in tertiary health-care in Uganda 23,40 and South Africa.…”

“…To date, evidence that PITC can improve case-finding of HIV+ patients and increase the number who proceed to HIV treatment and care has come primarily from controlled studies 25,31,32 and from specific intervention programmes: for example, studies targeting patients with tuberculosis or sexually transmitted infections or programmes to prevent mother-to-child transmission of HIV. [31][32][33][34][35] Although data from Botswana suggest that introducing PITC into primary care clinics increased the uptake of HIV testing, 22,36-39 the country's small population and status as a middle-income country make the findings difficult to generalize.…”

From caution to urgency: the evolution of HIV testing and counselling in Africa

“…15,[42][43][44] A cluster randomized trial conducted in tuberculosis clinics in South Africa in 2005 found that the introduction of opt-out PITC increased the uptake of HIV testing by 13.7%, from 6.5% when HIV testing was carried out on an opt-in basis to 20.2% with opt-out PITC. 45 The 2011 WHO report on global tuberculosis control stated that HTC is now standard for tuberculosis patients in many countries, especially in Africa. In 2010, more than 75% of tuberculosis patients knew their HIV status in 68 countries and territories, including 22 countries in the WHO African Region.…”

Community-Based Rapid Oral Human Immunodeficiency Virus Testing for Tuberculosis Patients in Lima, Peru

“…In one study, this strategy was shown to significantly increase testing uptake (20.2% among intervention clinics versus 6.5% among control clinics; P = 0.009) in South Africa. 19 However, in this study, most persons remained untested (79.3%) because TB staff failed to offer counseling. A similar approach of opt-out HIV testing in Zambia was somewhat more successful, but still low with HIV testing in 50% of TB patients.…”