School of Public Health, University of the Western Cape, Modderdam Road, Bellville, 7535, Cape Town, South Africa.
BMC Health Serv Res. 2012 Aug 2;12:233. doi: 10.1186/1472-6963-12-233.
The implementation of collaborative TB/HIV activities may help to mitigate the impact of the dual epidemic on patients and communities. Such implementation requires integrated interventions across facilities and levels of government, and with communities. Engaging Community Care Workers (CCWs) in the delivery of integrated TB/HIV services may enhance universal coverage and treatment outcomes, and address human resource needs in sub-Saharan Africa.
Using pre-intervention research in Sisonke district, KwaZulu-Natal, South Africa as a case study, we report on three study objectives: (1) to determine the extent of the engagement of NGOs and CCWs in the implementation of collaborative TB/HIV including PMTCT; (2) to identify constraints related to provision of TB/HIV/PMTCT integrated care at community level; and (3) to explore ways of enhancing the engagement of CCWs to provide integrated TB/HIV/PMTCT services. Our mixed method study included facility and NGO audits, a household survey (n = 3867), 33 key informant interviews with provincial, district, facility, and NGO managers, and six CCW and patient focus group discussions.
Most contracted NGOs were providing TB or HIV support and care with little support for PMTCT. Only 11% of facilities' TB and HIV patients needing care and support at the community level were receiving support from CCWs. Only 2% of pregnant women reported being counseled by CCWs on infant feeding options and HIV testing. Most facilities (83%) did not have any structural linkage with NGOs. Major constraints identified were system-related: structural, organizational and managerial constraints; inadequate CCW training and supervision; limited scope of CCW practice; inadequate funding; and inconsistency in supplies and equipment. Individual and community factors, such as lack of disclosure, stigma related to HIV, and cultural beliefs were also identified as constraints.
NGO/CCW engagement in the implementation of collaborative TB/HIV/PMTCT activities is sub-optimal, despite its potential benefits. Effective interventions that address contextual and health systems challenges are required. These should combine systematic skills-building, an enhanced scope of practice and consistent CCW supervision with a reliable referral and monitoring and evaluation system.
开展结核病/艾滋病合作活动有助于减轻双重流行对患者和社区的影响。这种实施需要在设施和各级政府以及社区之间进行综合干预。让社区护理人员（CCW）参与提供综合结核病/艾滋病服务，可能会提高普及程度和治疗效果，并解决撒哈拉以南非洲地区的人力资源需求。
利用南非夸祖鲁-纳塔尔省西松凯地区的干预前研究作为案例研究，我们报告了三个研究目标：（1）确定非政府组织和 CCW 在实施合作结核病/艾滋病（包括母婴传播预防）方面的参与程度；（2）确定在社区一级提供结核病/艾滋病/母婴传播综合护理方面的制约因素；（3）探索增强 CCW 参与提供综合结核病/艾滋病/母婴传播服务的途径。我们的混合方法研究包括设施和非政府组织审计、家庭调查（n=3867）、33 次与省级、地区、设施和非政府组织管理人员的关键知情人访谈，以及 6 次 CCW 和患者焦点小组讨论。
大多数签约非政府组织提供结核病或艾滋病支持和护理，对母婴传播预防的支持很少。只有 11%需要社区级护理和支持的结核病和艾滋病患者接受 CCW 的支持。只有 2%的孕妇报告曾接受 CCW 关于婴儿喂养选择和艾滋病毒检测的咨询。大多数设施（83%）与非政府组织没有任何结构联系。确定的主要制约因素是与系统相关的：结构、组织和管理方面的制约因素；CCW 培训和监督不足；CCW 实践范围有限；资金不足；以及用品和设备不一致。个人和社区因素，如缺乏披露、与艾滋病毒相关的耻辱感和文化信仰，也被确定为制约因素。
尽管非政府组织/CCW 参与合作结核病/艾滋病/母婴传播预防活动具有潜在效益，但参与程度仍不理想。需要采取有效的干预措施，应对具体情况和卫生系统挑战。这些措施应将系统的技能建设、增强的实践范围和一致的 CCW 监督与可靠的转介和监测评估系统相结合。
