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Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial

BMJ 2011; 342 doi: (Published 21 April 2011) Cite this as: BMJ 2011;342:d2022
  1. Merrick Zwarenstein, senior scientist12810,
  2. Lara R Fairall, researcher24,
  3. Carl Lombard, director3,
  4. Pat Mayers, scientist25,
  5. Angeni Bheekie, senior lecturer6,
  6. René G English, senior lecturer2,
  7. Simon Lewin, senior scientist2711,
  8. Max O Bachmann, professor29,
  9. Eric Bateman, professor4
  1. 1Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5
  2. 2Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
  3. 3Biostatistics Unit, Medical Research Council, Cape Town
  4. 4Department of Medicine, University of Cape Town, Cape Town
  5. 5Division of Nursing and Midwifery, University of Cape Town, Cape Town
  6. 6School of Pharmacy, University of the Western Cape, Bellville, South Africa
  7. 7Norwegian Knowledge Centre for the Health Services, Oslo, Norway
  8. 8Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
  9. 9School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
  10. 10IHCAR, Karolinska Institute, Stockholm, Sweden
  11. 11Health Systems Research Unit, Medical Research Council, Cape Town
  1. Correspondence to: M Zwarenstein merrick.zwarenstein{at}
  • Accepted 14 January 2011


Objective To investigate whether PALSA PLUS, an on-site educational outreach programme of non-didactic, case based, iterative clinical education of staff, led by a trainer, can increase access to and comprehensiveness of care for patients with HIV/AIDS.

Design Cluster randomised trial.

Setting Public primary care clinics offering HIV/AIDS care, antiretroviral treatment (ART), tuberculosis care, and ambulatory primary care in Free State province, South Africa.

Participants Fifteen clinics all implementing decentralisation and task shifting were randomised. The clinics cared for 400 000 general primary care patients and 10 136 patients in an HIV/AIDS/ART programme. There were 150 nurses.

Intervention On-site outreach education in eight clinics; no such education in seven (control).

Main outcome measures Provision of co-trimoxazole prophylaxis among patients referred to the HIV/AIDS/ART programme, and detection of cases of tuberculosis among those in the programme. Proportion of patients in the programme enrolled through general primary care consultations.

Results Patients referred to the HIV/AIDS programme through general primary care at intervention clinics were more likely than those at control clinics to receive co-trimoxazole prophylaxis (41%, (2253/5523) v 32% (1340/4210); odds ratio 1.95, 95% confidence interval 1.11 to 3.40), and tuberculosis was more likely to be diagnosed among patients with HIV/AIDS/ART (7% (417/5793) v 6% (245/4343); 1.25, 1.01 to 1.55). Enrolment in the HIV/AIDS and ART programme through HIV testing in general primary care was not significantly increased (53% v 50%; 1.19, 0.51 to 2.77). Secondary outcomes were similar, except for weight gain, which was higher in the intervention group (2.3 kg v 1.9 kg, P<0.001).

Conclusion Though outreach education is an effective and feasible strategy for improving comprehensiveness of care and wellbeing of patients with HIV/AIDS, there is no evidence that it increases access to the ART programme. It is now being widely implemented in South Africa.

Trial registration Current Controlled Trials ISRCTN 24820584.


  • We thank P Shai-Mhatu, formerly senior HIV programme manager in the Free State Department of Health, for support and help with design and implementation of the intervention; the PALSA PLUS trainers from the Free State Department of Health (Leona Smith, Ruth Marumo, Sandra Korkie, Khasiane Tumahole, Seipati Mothlanke, Mojola Mokokoane, Jacqui Sishuba, Sinah Samusho, Kuki Mokoena, and Elizabeth Bolofo) for support and guidance; Yolisa Tsibolane from the Free State Department of Health’s tuberculosis programme and Lindiwe Mvusi from the National Department of Health’s tuberculosis programme; Sonja Botha for supporting the initial training of PALSA PLUS trainers and for training the Free State’s nurses in completion of structured clinical records and data capturers in their electronic capturing; Glenn Campbell and Val Myburgh for guideline layout and illustration of training materials; Chris Seebregts, Clive Seebregts, and Gillian Staniland, from the Biomedical Informatics Research Division, Medical Research Council of South Africa, for data collection support, database design, collation, and initial extraction of data for analysis; Gloria Rembe and Thulani Mazibuko for data collection, checking, and cleaning; Debbie Bradshaw, from the Burden of Disease Unit, Medical Research Council, for facilitating linkage with the national mortality register; Venessa Timmerman, from the University of Cape Town Lung Institute, for assistance with extraction of data for analysis and Jani Brett Driskell, from the University of Cape Town Lung Institute, for administrative assistance throughout; and Ronald Chapman, formerly of the Free State Department of Health, for crucial early support and guidance.

  • Contributors: MZ and LRF led the design of the trial protocol and application for funding with help from CL and EB. LRF led the data collection, CL led the analysis, and MZ led the interpretation and write-up, with help from SL, MOB, and EB. LRF led the design and implementation of the intervention with help from PM, AB, RGE, MZ, MOB, and EB. All authors had full access to the data on request and approved the final version. MZ is guarantor.

  • Funding: The study was funded by the International Development Research Centre (IDRC) of Canada, who had no role in study design, in the collection, analysis, and interpretation of data, in the writing of the article, or in the decision to submit it for publication. The researchers were completely independent of IDRC.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was approved by the human research ethics committee at the University of Cape Town.

  • Data sharing: No additional data available.

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