The Effect of Complete Integration of HIV and TB Services on Time to Initiation of Antiretroviral Therapy: A Before-After Study

Abstract

BackgroundStudies have shown that early ART initiation in TB/HIV co-infected patients lowers mortality. One way to implement earlier ART commencement could be through integration of TB and HIV services, a more efficient model of care than separate, vertical programs. We present a model of full TB/HIV integration and estimate its effect on time to initiation of ART.Methodology/Principal FindingsWe retrospectively reviewed TB registers and clinical notes of 209 TB/HIV co-infected adults with a CD4 count <250 cells/µl and registered for TB treatment at one primary care clinic in a South African township between June 2008 and May 2009. Using Kaplan-Meier and Cox proportional hazard analysis, we compared time between initiation of TB treatment and ART for the periods before and after full, “one-stop shop” integration of TB and HIV services (in December 2009). Potential confounders were determined a priori through directed acyclic graphs. Robustness of assumptions was investigated by sensitivity analyses. The analysis included 188 patients (100 pre- and 88 post-integration), yielding 56 person-years of observation. Baseline characteristics of the two groups were similar. Median time to ART initiation decreased from 147 days (95% confidence interval [CI] 85–188) before integration of services to 75 days (95% CI 52–119) post-integration. In adjusted analyses, patients attending the clinic post-integration were 1.60 times (95% CI 1.11–2.29) more likely to have started ART relative to the pre-integration period. Sensitivity analyses supported these findings.Conclusions/SignificanceFull TB/HIV care integration is feasible and led to a 60% increased chance of co-infected patients starting ART, while reducing time to ART initiation by an average of 72 days. Although these estimates should be confirmed through larger studies, they suggest that scale-up of full TB/HIV service integration in high TB/HIV prevalence settings may shorten time to ART initiation, which might reduce excess mortality and morbidity.

Timing of antiretroviral therapy in Cambodian hospital after diagnosis of tuberculosis: impact of revised WHO guidelines

“…An increasing number of studies from routine services in resource-limited settings have reported increased and expedited ART uptake, [26][27][28][29][30][31][32][33][34][35] especially after the introduction of a package of interventions aiming at achieving integration of tuberculosis and HIV care. These studies generally precede the 2010 WHO ART guidelines.…”

“…Median ART delays of 7 and 11 weeks in Uganda and South Africa, respectively, were still observed after integration in recent studies. 29,32 An interesting aspect of our study is that early ART initiation was implemented as a single intervention, without major concurrent changes in the tuberculosis/ HIV service delivery model. This makes it possible to better quantify the effect of the revised guidelines and to demonstrate their impact when coordination of tuberculosis/HIV activities is fairly well organized.…”

“…[26][27][28][29][30][31][32][33][34][35][36] However, there has been no formal evaluation of the operational feasibility and impact of the revised WHO guidelines on the timing of ART initiation within routine clinical settings. The main objective of this study was to assess the change in time to ART initiation following the implementation of the 2010 WHO ART guidelines in a programmatic setting in a resource-limited area.…”

Integrating HIV services with other health services to improve care, retention and adherence

“…A study in Capetown, South Africa assesses the impact of adding ART initiation to a TB clinic that already offered HIV testing, CD4 counts, co-trimoxazole prophylaxis and FP, but previously referred treatment-eligible patients to a separate ART clinic for treatment (Kerschberger et al 2012). The study finds that adding ART initiation to the range of services improved the probability of initiation (1.6 adjusted HR, 95% CI: 1.11 to 2.29) and may have also improved the time between HIV testing and ART initiation, which decreased from 147 days (95% CI: 85 to 188) to 75 days (95% CI: 52 to 119).…”

Impact of Integrating HIV and TB Care and Treatment in a Regional Tuberculosis Hospital in Rural Guatemala

“…This heightens the operational importance of integrated TB/HIV services. Integrated care was shown to increase ART initiation by 60 % among co-infected patients, reducing time to initiation by more than 2 months (72 days) on average [10]. Randomized trials have shown that early ART initiation (2 weeks after the onset of anti-TB treatment) vs later ART initiation (8 weeks after) reduces mortality among advanced immunodeficient (B50 CD4 cells/mm 3 ) HIVpositive patients who are smear positive for acid-fast bacilli [5,6,9].…”