Abstract
BackgroundHealthcare workers are often reluctant to start combination antiretroviral therapy (ART) in patients receiving tuberculosis (TB) treatment because of the fear of high pill burden, immune reconstitution inflammatory syndrome, and side-effects.ObjectTo quantify changes in adherence to tuberculosis treatment following ART initiation.DesignA prospective observational cohort study of ART-naïve individuals with baseline CD4 count between 50 cells/mm3 and 350 cells/mm3 at start of TB treatment at a primary care clinic in Johannesburg, South Africa. Adherence to TB treatment was measured by pill count, self-report, and electronic Medication Event Monitoring System (eMEMS) before and after initiation of ART.ResultsART tended to negatively affect adherence to TB treatment, with an 8% – 10% decrease in the proportion of patients adherent according to pill count and an 18% – 22% decrease in the proportion of patients adherent according to eMEMS in the first month following ART initiation, independent of the cut-off used to define adherence (90%, 95% or 100%). Reasons for non-adherence were multifactorial, and employment was the only predictor for optimal adherence (adjusted odds ratio 4.11, 95% confidence interval 1.06–16.0).ConclusionAdherence support in the period immediately following ART initiation could optimise treatment outcomes for people living with TB and HIV.
Highlights
Adhering to a lengthy course of medication is difficult and poses a challenge to achieving health in people with chronic diseases
Initiation of antiretroviral therapy (ART) can result in clinical deterioration related to immune reconstitution inflammatory syndrome (IRIS), toxic effects of drugs, or drug interactions, and increased pill burden
TB treatment outcome was successful in 82%
Summary
Adhering to a lengthy course of medication is difficult and poses a challenge to achieving health in people with chronic diseases. The 2012 World Health Organization (WHO) and 2015 South African antiretroviral therapy (ART) guidelines recommend initiating ART in people with TB as soon as possible, within the first 2 weeks of initiating TB treatment for those with profound immunosuppression (CD4 counts < 50 cells/mm3) and within the first 8 weeks of treatment in all TB patients.[3] Whilst initiating ART greatly improves the survival and quality of life of TB patients living with HIV,[4] it poses challenges to patients and healthcare workers.[5] Early initiation of ART can result in clinical deterioration related to immune reconstitution inflammatory syndrome (IRIS), toxic effects of drugs, or drug interactions, and increased pill burden. Healthcare workers are often reluctant to start combination antiretroviral therapy (ART) in patients receiving tuberculosis (TB) treatment because of the fear of high pill burden, immune reconstitution inflammatory syndrome, and side-effects.
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