Background:
The implementation of collaborative TB/HIV activities requires interventions beyond facility fences in order to mitigate the impact of the dual epidemic on patients and communities at large. Engagement of Community Care Workers (CCWs) in delivery of integrated TB/HIV services is a potential avenue to enhance universal coverage and treatment outcomes and address human resource for health crisis in sub-Saharan Africa. In South Africa, CCWs are employed by nongovernmental organization (NGO) with Health Department contracts funded by government to provide various TB/ HIV community based activities. Using South Africa as a case, we report on engagement of NGOs and CCWs in the implementation of collaborative TB/HIV/PMTCT activities in rural South Africa, including extent of participation and constraints and opportunities to enhance effective participation. Our mixed method study in Sisonke district, KwaZulu-Natal included facility and NGO audits, a household survey (n=3867), 33 key informants with provincial, district and facility managers, NGOs managers and six CCW focus group discussions. Results: The findings indicate that most contracted NGOs were providing TB or HIV support and care with little support for PMTCT. Only 11% of TB and HIV patients needing care and support at the community level were receiving support from CCWs, while 2% of pregnant women were counseled by CCWs on infant feeding options and HIV testing. Most facilities (83%) did not have referral mechanisms or any linkage with NGOs. Major constraints identified were system-related: structural, organizational and managerial constraints; inadequate CCW training and supervision; limited scope of CCW practice, inadequate funding, and inconsistency in supplies and equipment. Individual and community factors such as lack of disclosure and stigma related to HIV; and cultural beliefs were also identified as constraints. Conclusions: We conclude that sub-optimal NGO/CCW engagement exists in implementation of collaborative TB/HIV/PMTCT activities, despite its potential benefits to enhance provision of integrated TB/HIV/PMTCT services at community level. Effective interventions that address contextual and health systems challenges are required and these interventions should combine systematic skills-building and consistent CCW supervision with a reliable referral and M&E system. Policy review to harmonise and expand the scope of CCW practice with task shifting to include home-based HIV counseling and testing is vital.