Tuberculosis screening and care delivery in pregnant and postpartum persons living with HIV in Botswana

Tuberculosis (TB) disease during pregnancy, particularly in persons living with HIV (PLHIV), is associated with poor maternal and neonatal outcomes. There are barriers to TB screening and care for PLHIV in the pregnant and postpartum period given atypical clinical presentation and service delivery challenges. Our objective was to understand barriers and facilitators to TB screening and care delivery during routine antenatal and postpartum care in Botswana government health centers among PLHIV and healthcare providers. In this mixed methods study conducted between April 2022 and November 2023, quantitative data was collected from PLHIV on frequency of TB screening at their antenatal and postpartum government health center visits. At a 2-month postpartum study visit, PLHIV were screened for TB symptoms by study staff, using the World Health Organization TB symptom screen, and referred to their local government health center if positive. Qualitative data was obtained from semi-structured interviews with maternal participants, who screened positive for TB and were referred to government clinics for evaluation, and medical staff from referral clinics. Ninety-five pregnant and postpartum PLHIV consented to study participation. Of the 95 pregnant PLHIV, 9 participants were referred to their local government health facility after screening positive for TB symptoms; 8 of these participants participated in qualitative interviews, along with 9 medical staff. TB screening and care facilitators and barriers for maternal and medical staff participants were identified according to the environmental and population level guided by Andersen's Behavioral Model. Facilitators to TB screening and care included HIV diagnosis, pregnancy, and proximity to clinics. Barriers included challenges with diagnostic workup, resource limitations, and knowledge gaps. Our findings highlight challenges of TB screening and care for pregnant and postpartum PLHIV. Further studies are needed to evaluate interventions to improve and support TB screening and care delivery for pregnant and postpartum PLHIV.