Medical Records Documentation of HIV/AIDS Clinical Services at Primary Health Care (PHC) Facilities and Its Implications on Continuum of Care and Operational Research in South Africa

Background: Patients medical records are used to document care processes for communication amongst healthcare workers for continued patient management. Incomplete or inaccurate documentation can adversely affect the quality of patients’ care, leading to medication and treatment errors, increased morbidity, and mortality. Quality documentation in medical records is therefore an essential component of optimal healthcare and facilitates an individual’s continuity of care. This study aimed to assess the quality of documentation of clinical data through the review of the accuracy and completeness of clinical records among newly diagnosed HIV-positive persons. The study is a sub analysis of a prospective longitudinal study that followed a cohort of 12,413 persons who were newly diagnosed with HIV infection. Severe limitations in retrieving reliable information and data became an obstacle to our research and led the study team to conduct medical records documentation and data audit to verify the accuracy and completeness of the data for newly diagnosed HIV positive persons. Methods: A cross-sectional study was conducted using routine data generated from 75 randomly selected newly diagnosed HIV positive persons aged 12-years-old and above between June 1, 2014 and March 31, 2015 in 36 purposively selected primary health care (PHC) clinics in South Africa. The facilities were selected from three high HIV-burden districts of South Africa (Gert Sibande, uThukela and City of Johannesburg). Results: Significant differences in the accuracy and completeness of clinical records were observed between data generated through the self-assessment by the facility managers and data primarily collected through review of the patients’ clinical stationery and facility registers. 80% of the newly diagnosed HIV positive persons were not documented as screened for tuberculosis (TB) on the clinical chart and 69% of newly diagnosed clients were not clinically staged (WHO staging). Furthermore, 80% of newly diagnosed HIV positive persons’ follow up visit dates were not documented in the patient’s clinical chart. Completeness of the data elements on the case record forms ranged from as low as 26% to a maximum of 66%. It was noteworthy that all the clients’ information documented in HIV counselling and testing registers, continuum of care registers and clinical charts were only partially completed. Conclusion: Each of the health care facilities under study had some significant gaps in medical records documentation of clinical data on newly diagnosed HIV positive persons. Data and information accuracy and completeness were a serious challenge in most facilities during the period under investigation. Of interest was the inconsistency of data recorded in the HCT registers, continuum of care and clinical charts of individual patients. This is a major impediment to HIV/AIDS comprehensive care.

Initiation of Isoniazid Prophylactic Therapy among Newly Diagnosed HIV-Positive Persons in Three High HIV-Burden Districts of South Africa

Background: South Africa is experiencing the worst HIV-driven tuberculosis (TB) epidemic in the world. More than 300,000 new cases of active TB are reported in the country each year with 60% co-infected with HIV. Isoniazid preventive therapy (IPT) is a key public health intervention for the prevention of TB among people living with HIV (PLHIV) and is recommended as part of a comprehensive HIV and AIDS care strategy. However, program data suggests that coverage of IPT service to be very low. This study aims to assess IPT initiation rate among newly diagnosed HIV-positive persons in three high HIV-burden districts of South Africa. Methods: A cross-sectional study was conducted using routine data generated from pre-ART and ART programs in 35 purposively selected primary health care (PHC) clinics in South Africa. The facilities were selected from three high HIV-burden districts with a mix of urban and rural settings. TB screening and IPT initiation status was assessed within a window period of one-year post HIV diagnosis. Initiation rate of IPT services among newly diagnosed HIV-positive persons was assessed. The chi-squared test was used to determine whether there was a significant difference in the proportion of newly diagnosed HIV-positive persons who were initiated on IPT by sex, age group, pregnancy status, health facility, district and location of facility. Results: We identified 12,413 newly diagnosed HIV patients aged 12-years-old and above between June 1, 2014 and March 31, 2015. TB screening was not conducted among 33% of newly diagnosed HIV-positive persons to rule out or confirm the presence of active TB. IPT was initiated in 42.2% of known IPT-eligible HIV-positive persons. Initiation of IPT services was lower in younger patients aged 12 to 20-years-old compared to older patients. The proportion of pregnant women who were initiated on IPT was higher compared to the proportion in non-pregnant women (51.0% and 40.1% respectively;P < 0.05). Health care clinics located in uThukela health district registered the highest initiation rates of IPT care (48.1%;CI: 46.2%, 50.1%) compared to clinics located in Gert Sibande (40.4%;CI: 38.7%, 42.2%) health district and Johannesburg Health District (38.5%;CI: 36.4%, 40.7%). Conclusion: This analysis shows that initiation rate of IPT services among newly diagnosed HIV positive persons was low in the 35 participating facilities during the period under investigation. There was variability in IPT initiation rates across the facilities included in this study and among different sub-groups of the study sample. This study has identified specific population groups and geographic settings that should be targeted by programs to improve IPT services. There is a need to identify factors that contributed to the low initiation rate of IPT services among young HIV positive persons, women with unrecorded pregnancy status and in facilities located in inner city of Johannesburg. Customized interventions tailored to the specific needs of facilities and population groups should be instituted to strengthen uptake of IPT services.