Attrition between TB / HIV testing and linkage to care in South Africa’s correctional facilities. 01 December 2015 Vincent Zishiri, Salome Charalambous, Liesl Page-Shipp and Christopher J Hoffmann

Background The Aurum institute and other NGO partners have been tasked with implementing mass TB/HIV screening programs for inmates in South Africa. The benefits of the intensified case finding programs can only be realized with successful linkage and retention in care There are important aspects of the care cascade that are specific in correctional settings, yet there is an absence of data to inform and strengthen health service programmes.

TB / HIV testing Inmates were administered WHO four symptoms questionnaire. Presence of any of a cough, fever unintended weight loss and night sweats triggered TB investigation on Xpert MTB/Rif. Supervised spot sputum was collected from those with ≥ 1 symptoms At each TB screening episode, inmates were also offered HCT Point-of-care HIV followed by confirmatory HIV test kits Newly diagnosed HIV+ patients referred for blood draws for CD4 count testing at the nearest referral laboratory Previously described procedures incl. cost of implementing mass TB screening in correctional services (ref: Open Forum Infectious Diseases.2015; /ofid/ofu121)

Objectives To quantify the proportion of inmates diagnosed with TB/HIV entering care. To identify drivers for patients falling off the continuum of care cascade in a TB active case finding programme CONTINUUM OF CARE Linkage to care Retention HIV testing Staging Pre-ART / ART Care Viral Load suppression

Methods Data was collected between January and December 2014 in five correctional centres across four provinces in South Africa. We extracted data from three source documents to generate a database for the analysis: (1) clinical data from case report forms containing demographics and TB screening and HIV testing results (2) laboratory data from GeneXpert test and CD4 count test result and (3) TB, pre ART, and ART registers. TB and HIV screening data were linked via a barcode assigned to an inmate at screening. Data were stripped of personal identifiers and analyzed on aggregate. We used descriptive statistics to describe attrition rates

Overview of the data TB symptoms N = 9170 (22%) TB positive on Xpert MTB/Rif N =165 / 7922 (2%) Tested for HIV N = (53%) HIV-positive result N =2945 (14%) Study population N = Gender: 95% male Median age: 29 years [IQR: 25 – 35] Duration: < 1 year [IQR: 0 – 1 year] Rif resistant TB N =10 (6%) Already Known HIV+ N = 349 (12%)

HIV continuum data

Greater attrition in HIV care was due to initial failure to deliver a CD4 count result to an inmate 38% (999/ 2596) of newly diagnosed HIV cases did not receive their CD4 result 47% (468/999) of those who did receive their CD4 result was because they did not have blood drawn for CD4 testing With 51% (504/999) of them due to release prior to receiving CD4 result CD4 results could not be tracked for 2% (21/999) of the patients Long turn-around time with off-site CD4 testing (The median time to CD4 result was 5 days [IQR: 2 – 8]) was seen. HIV continuum data

TB continuum data

Summary reasons for Attrition Loss to follow up is largely due to inmates’ movement within the corrections system and release to the community There is a lack of health information systems linking patient care within corrections and with communities Incomplete documentation of patient records Patients having no record on treatment record Specimen records missing in the laboratory tracking system Health care staff shortages in the DCS make providing comprehensive patient care a challenge. M&E (Records and patient tracking systems) Clinical Management

Recommendations Provide point of care testing to accelerate entry into care and offset loss to follow due to inmate movement Provide operational support for retention in care required particularly for inmates changing correctional centers or returning to communities Increase capacity of corrections to offer comprehensive TB/HIV care by upskilling or task shifting and increasing the number of health care workers.

Acknowledgements Department of Correctional Services Department of Health National Health Laboratory Service John Hopkins The Aurum Institute staff Inmates in correctional facilities