Integration of tuberculosis (TB) and HIV services in Ghana

Integration of health services involves managing services to enhance quality for patient needs that cut across multiple services, providers and settings. The rapid growth of human immunodeficiency virus (HIV) has increased tuberculosis (TB) cases, and TB/HIV integration offers a unified strategy for control. This study evaluated TB/HIV integration in Ghana. The three sites evaluated applied varying degrees of integration. A mixed methods approach comprised an uncontrolled before-and-after study involving 1330 TB cases, and qualitative interviews with 29 providers and patients.

TB treatment success was 51% before and 69% after integration [p<0.01; OR(95% CI)=2.17 (1.72 to 2.74)]. Treatment success increased in all sites after integration: 43% to 53% at the one-stop shop (OSS), 69% to 78% at the partially integrated site (PIS), and 46% to 78% at the referral site (RS). The change was significant only at the RS [(Χ2=64.54; p<0.01; OR(95% CI)=4.28 (2.97 to 6.18)]. HIV screening was highest (99%) at the OSS (Χ2=68.26; p<0.01), HIV-positive cases on CPT were highest (93.8%) at the RS (Χ2=9.29; p<0.01), and the PIS had the highest number (59.5%) on ART (Χ2=95.00; p<0.01).

TB/HIV integration may improve TB treatment outcomes but effectiveness is difficult to ascertain due to study design limitations. TB treatment success and TB mortality might be more informative indicators for TB/HIV activities. TB/HIV outputs seemed unrelated to greater integration when compared across sites. This was probably due to existing barriers to integration including missed opportunities, provider fear of loss of influence, financial burden of illness, and stigma. Patient-provider interactions offered privacy and counselling but patients’ illness experiences were not explored, and there was lack of decision-sharing. Patients were also unaware of their right to dignity and respect, or their role in disease management. Facilitators of integration included direct supervision, mutual adjustment and standardisation.

Recommendations include conducting more rigorous evaluation studies, including TB mortality in TB/HIV monitoring, prioritising health system strengthening instead of increasing degrees of integration, and improving patient-centred care through provider communication and patient empowerment.