Abstract
BackgroundDelays in the initiation of antiretroviral therapy (ART) in patients with HIV-associated tuberculosis (TB) are associated with increased mortality risk. We examined the timing of ART among patients receiving care provided by non-integrated TB and ART services in Cape Town, South Africa.MethodsIn an observational cohort study, we determined the overall time delay between starting treatment for TB and starting ART in patients treated in Gugulethu township between 2002 and 2008. For patients referred from TB clinics to the separate ART clinic, we quantified and identified risk factors associated with the two component delays between starting TB treatment, enrolment in the ART clinic and subsequent initiation of ART.ResultsAmong 893 TB patients studied (median CD4 count, 81 cells/μL), the delay between starting TB treatment and starting ART was prolonged (median, 95 days; IQR = 49-155). Delays were shorter in more recent calendar periods and among those with lower CD4 cell counts. However, the median delay was almost three-fold longer for patients referred from separate TB clinics compared to patients whose TB was diagnosed in the ART clinic (116 days versus 41 days, respectively; P < 0.001). In the most recent calendar period, the proportions of patients with CD4 cell counts < 50 cells/μL who started ART within 4 weeks of TB diagnosis were 11.1% for patients referred from TB clinics compared to 54.6% of patients with TB diagnosed in the ART service (P < 0.001).ConclusionsDelays in starting ART were prolonged, especially for patients referred from separate TB clinics. Non-integration of TB and ART services is likely to be a substantial obstacle to timely initiation of ART.
Highlights
Delays in the initiation of antiretroviral therapy (ART) in patients with HIV-associated tuberculosis (TB) are associated with increased mortality risk
The remaining 218 (24.4%) patients were already enrolled in the ART clinic and had TB diagnosed during the pre-ART screening period
Comparing patients referred to the ART clinic with TB to those with TB diagnosed in the ART clinic, the proportions who died pre-ART (6% versus 6%) and the proportions who were deferred (5% versus 8%) were similar
Summary
Delays in the initiation of antiretroviral therapy (ART) in patients with HIV-associated tuberculosis (TB) are associated with increased mortality risk. We examined the timing of ART among patients receiving care provided by non-integrated TB and ART services in Cape Town, South Africa. ART greatly improves survival, the optimal time to start ART during TB treatment has, for In response to these data, World Health Organization (WHO) ART guidelines have been updated on several occasions between 2002 and 2010, recommending progressively more rapid initiation of ART during TB treatment [4]. Data from subsequent randomised controlled trials show that patients with CD4 cell counts < 50 cells/μL have a high mortality risk and should receive ART within 2 weeks [9,10,11] Despite these policy changes, the operational feasibility of rapid initiation of ART in patients accessing routine services in resource-limited settings is not known. We discuss the major obstacle that non-integration of TB and ART services is likely to represent with regard to implementation of the 2010 WHO guidelines for the timing of ART
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