With one of the world's most severe HIV and TB epidemics and an economy dependent upon labor migration to South African mines, Lesotho is an optimal setting to study the effectiveness of TB/HIV integration strategies. HIV prevalence in Lesotho is 23%, the world's second highest; the TB incidence rate of 852 per 100,000 is the world's highest; 72% of TB patients are HIV positive. Basotho migrant miners, who travel between their homes in Lesotho and work in South African mines, and their families are among those with elevated risk of HIV and TB. We found that 32% of miners and miners' family members tested for HIV in three TEBA mining employment offices in Lesotho in 2014-15 were newly diagnosed with HIV; an additional 7% were known to be HIV positive. The TB incidence rate in South African miners is estimated at 3,000-7,000 per 100,000 per year, several-fold higher than that in the populations from which they originate. Testing, linkage, and retention of miners and their families along the TB/HIV care continuum are suboptimal, and TB treatment outcomes are also poor compared with the general population. Implementation science research is urgently needed to determine an effective strategy for improving early detection of HIV and early initiation of antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) among migrant miners and their families. The PROvide MIner-friendly SErvices for Integrated TB/HIV Care (PROMISE) Study aims to evaluate the effectiveness, feasibility and acceptability of integrated TB/HIV services for migrant miners and their family members provided in miner-friendly service venues (MF). A prospective cohort study design will be used to compare the effectiveness of the MF intervention, which includes provision of family-focused, integrated TB/HIV diagnosis, care and treatment services at TEBA offices six days per week, to public sector health facilities, which deliver usual integrated care for TB and HIV. Additionally, we will assess HIV testing yield to identify PLHIV with CD4 count >500 cells/l, time spent accessing ART and IPT services, and costs associated with delivery of the MF intervention. We will also explore patients' and providers' perceived barriers, facilitators and preferences to understand how they impact uptake and delivery of the MF intervention. The study will leverage long-standing collaborations between ICAP, the Lesotho Ministry of Health, National University of Lesotho and TEBA and a well-trained, highly productive team with substantial experience in implementation science research in sub-Saharan Africa to identify an effective, feasible and acceptable TB/HIV service delivery model for migrant miners and their families that addresses barriers to implementation of early ART and IPT. The ultimate goals of the project are to 1) improve health outcomes among migrant miners and their families, a hard-to-reach population that represents a hotspot of TB/HIV transmission, in Lesotho and in PEPFAR programs more broadly; and 2) strengthen the implementation science research capacity of national and local institutions.
The proposed study aims to identify an effective, feasible and acceptable TB/HIV service delivery model for migrant miners and their families that addresses barriers to implementation of early antiretroviral therapy and isoniazid preventive therapy. The ultimate goals of the project are to 1) improve health outcomes among migrant miners and their families, a hard-to-reach population that represents a hotspot of TB/HIV transmission, in Lesotho and in PEPFAR programs more broadly; and 2) strengthen the implementation science research capacity of national and local institutions.
