Laboratory data for evaluating the national HIV and TB programs

As South Africa’s national antiretroviral therapy (ART) treatment program matures, it faces significant challenges in expanding access to harder to reach populations while also maintaining quality of care for those for whom HIV has become a manageable chronic disease. In light of these challenges, monitoring and evaluation of the treatment program is critical to its sustained improvement. However, as policy makers face decisions on how to improve their program, key national parameters on which to base decisions remain unknown for both HIV and tuberculosis. The answers to these questions are critical for planning for changes to national treatment guidelines, yet to date there has been no routine way to answer these questions at a national level and without being heavily influenced by losses from care, which can be significant. We are using the database of the National Health Laboratory Service to begin to provide answers.

HIV-focused projects using the National Health Laboratory Service database include:

• ENCORE: Monitoring and evaluating treatment in South Africa with National Health Laboratory Service Data
• HIV pregnancy cohort: evaluating continuity of care among women living with HIV
• ATRACT: Analysis of national lab database to evaluate the HIV treatment rollout in South Africa

TB-related projects using the National Health Laboratory Service database include:

• Creation of a National TB Cohort: The proposed research will use routinely collected South African laboratory data to track tuberculosis (TB) patients through time and space, incorporating HIV data. This will allow us to define the TB care cascade nationally and by facility (clinic/hospital), incorporating patients’ movements, thus enabling the targeting of these locations with locally appropriate interventions. We will also be able to evaluate the impact of HIV treatment scale-up and introduction of new TB diagnostics on TB morbidity and mortality. 
• Social and behavioral drivers of South Africa’s drug-resistant TB epidemic: New cases of DR-TB arise through two biologic pathways: 1. acquired resistance during treatment for a drug-susceptible strain due to development of new mutations or 2. transmitted resistance due to primary infection with an already-resistant strain. Although 70% of DR-TB strains appear to be due to transmission in high TB burden settings, little is known about the social and behavioral factors driving the global rise in drug resistant cases. Building on existing collaborations, our team is working with South Africa’s National Health Laboratory Service (NHLS) to construct a national TB cohort from routine laboratory tests, enabling – for the first time – longitudinal follow-up of all patients receiving TB and RR-TB care and treatment in the country.