Abstract
BackgroundThe implementation of collaborative TB-HIV services is challenging. We, therefore, assessed TB treatment outcomes in relation to HIV infection and antiretroviral therapy (ART) among TB patients attending a primary care service with co-located ART and TB clinics in Cape Town, South Africa.MethodsIn this retrospective cohort study, all new TB patients aged ≥ 15 years who registered and initiated TB treatment between 1 October 2009 and 30 June 2011 were identified from an electronic database. The effects of HIV-infection and ART on TB treatment outcomes were analysed using a multinomial logistic regression model, in which treatment success was the reference outcome.ResultsThe 797 new TB patients included in the analysis were categorized as follows: HIV- negative, in 325 patients (40.8 %); HIV-positive on ART, in 339 patients (42.5 %) and HIV-positive not on ART, in 133 patients (16.7 %). Overall, bivariate analyses showed no significant difference in death and default rates between HIV-positive TB patients on ART and HIV-negative patients. Statistically significant higher mortality rates were found among HIV-positive patients not on ART compared to HIV-negative patients (unadjusted odds ratio (OR) 3.25; 95 % confidence interval (CI) 1.53–6.91). When multivariate analyses were conducted, the only significant difference between the patient categories on TB treatment outcomes was that HIV-positive TB patients not on ART had significantly higher mortality rates than HIV-negative patients (adjusted OR 4.12; 95 % CI 1.76–9.66). Among HIV-positive TB patients (n = 472), 28.2 % deemed eligible did not initiate ART in spite of the co-location of TB and ART services. When multivariate analyses were restricted to HIV-positive patients in the cohort, we found that being HIV-positive not on ART was associated with higher mortality (adjusted OR 7.12; 95 % CI 2.95–18.47) and higher default rates (adjusted OR 2.27; 95 % CI 1.15–4.47).ConclusionsThere was no significant difference in death and default rates between HIV-positive TB patients on ART and HIV negative TB patients. Despite the co-location of services 28.2 % of 472 HIV-positive TB patients deemed eligible did not initiate ART. These patients had a significantly higher death and default rates.
Highlights
The implementation of collaborative TB-Human immunodeficiency virus (HIV) services is challenging
While antiretroviral therapy (ART) and TB services were not fully integrated in this clinic, the adherence support and the monitoring and evaluation systems were partially integrated and all patients starting ART or TB treatment were reviewed at a weekly multidisciplinary team meeting which was attended by TB and HIV staff
The new TB patients (n = 61) for whom HIV status was unknown; tuberculosis treatment completion status was inconclusive or who failed tuberculosis treatment were exclude from the analysis (Fig. 1)
Summary
The implementation of collaborative TB-HIV services is challenging. We, assessed TB treatment outcomes in relation to HIV infection and antiretroviral therapy (ART) among TB patients attending a primary care service with co-located ART and TB clinics in Cape Town, South Africa. In terms of optimal case management, both patient groups require standardized anti-tuberculosis treatment, while HIV-positive TB patients require trimethoprim-sulphamethoxazole (co-trimoxazole) prophylaxis and antiretroviral treatment (ART). ART results in a 64–95 % reduction in mortality risk [5] and should be initiated early after starting anti-tuberculosis treatment [6,7,8]. Compared to their HIV-negative peers, HIV-positive TB patients are a challenge to TB services, as they are more likely to have diagnostic delays, are more likely to be infectious for longer and, if not properly managed, may have poorer TB treatment outcomes [9]. HIV infection has the potential to profoundly impact on TB treatment outcomes and is often the main reason for failure to meet control targets in high HIV settings
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