Abstract
ObjectiveTo assess the outcomes of linkage to TB and HIV care and identify risk factors for poor referral outcomes.DesignCohort study of TB patients diagnosed at an urban hospital.MethodsLinkage to care was determined by review of clinic files, national death register, and telephone contact, and classified as linked to care, delayed linkage to care (>7 days for TB treatment, >30 days for HIV care), or failed linkage to care. We performed log-binomial regression to identify patient and referral characteristics associated with poor referral outcomes.ResultsAmong 593 TB patients, 23% failed linkage to TB treatment and 30.3% of the 77.0% who linked to care arrived late. Among 486 (86.9%) HIV-infected TB patients, 38.3% failed linkage to HIV care, and 32% of the 61.7% who linked to care presented late. One in six HIV-infected patients failed linkage to both TB and HIV care. Only 20.2% of HIV-infected patients were referred to a single clinic for integrated care. A referral letter was present in 90.3%, but only 23.7% included HIV status and 18.8% CD4 cell count. Lack of education (RR 1.85) and low CD4 count (CD4≤50 vs. >250cells/mm3; RR 1.66) were associated with failed linkage to TB care. Risk factors for failed linkage to HIV care were antiretroviral-naïve status (RR 1.29), and absence of referral letter with HIV or CD4 cell count (RR1.23).ConclusionsLinkage to TB/HIV care should be strengthened by communication of HIV and CD4 results, ART initiation during hospitalization and TB/HIV integration at primary care.
Highlights
South Africa is one of the 22 countries with a high tuberculosis (TB) burden [1]
Linkage to TB/HIV care should be strengthened by communication of HIV and CD4 results, antiretroviral treatment (ART) initiation during hospitalization and TB/HIV integration at primary care
While treatment interruption during the course of TB treatment and antiretroviral treatment (ART) have been extensively studied [9,10,11,12,13], little is known about the linkage to care after the initial diagnosis [14], among people diagnosed with HIV-associated TB at a hospital facility [15,16]
Summary
South Africa is one of the 22 countries with a high tuberculosis (TB) burden [1]. In 2009, almost half a million new cases of tuberculosis were notified in South Africa, [2] corresponding to a rate of 971 cases per 100,000 population. The burden of HIVassociated tuberculosis in South Africa is enormous, with an estimated 73% of TB cases being HIV-infected, and one in four of all global HIV-associated TB cases occurring in South Africa [1]. While treatment interruption during the course of TB treatment and antiretroviral treatment (ART) have been extensively studied [9,10,11,12,13], little is known about the linkage to care after the initial diagnosis [14], among people diagnosed with HIV-associated TB at a hospital facility [15,16]. Rates of and reasons for failure to link TB and HIV diagnosis with care are not collected as part of routine monitoring and evaluation in TB and ART programs, making evidence-based decisions on how to improve linkage to care difficult [20]
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