Health system barriers affecting the implementation of collaborative TB-HIV services in Uganda.

Abstract

SETTING: Despite Uganda's efforts to improve tuberculosis and human immunodeficiency virus (TB-HIV) collaborative services, implementation remains low and operational barriers have not been systematically identified and documented. OBJECTIVE: To assess barriers to implementation of TB-HIV collaborative services in five districts in Uganda. DESIGN: In this qualitative study, focus groups and key informant and in-depth interviews were conducted for patients (HIV, TB), health providers and community members. TB registers were also assessed for data on use of TB-HIV collaborative services. RESULTS: Of 333 adult TB patients registered between July and September 2006, 185 (56%) were tested for HIV, of whom 134 were HIV-co-infected. Of these, 52% were on cotrimoxazole preventive therapy (CPT), 12% were on antiretroviral therapy (ART) and CPT, while 36% had not received any HIV service. Health system barriers identified included poor TB-HIV planning, coordination and leadership, inadequate dissemination of policy, inadequate provider knowledge, limited TB-HIV interclinic referral, poor service integration and recording, logistical shortages, high costs of services and provider shortages amidst high patient loads. CONCLUSION: Implementation and utilisation of collaborative TB-HIV services remains suboptimal. The barriers identified highlight the need for TB and HIV programmes to support districts to plan, coordinate and invest resources in TB-HIV collaborative services, especially in policy dissemination, training health providers, integration of TB-HIV services, logistical management and monitoring.