The World Health Organization recommends integrating services for patients coinfected with tuberculosis (TB) and HIV. We assessed the effect of TB/HIV integration on antiretroviral therapy (ART) initiation and TB treatment outcomes among TB/HIV-coinfected patients using data collected from 14 rural health facilities during 2 previous TB and HIV quality of care studies.
A facility was considered to have integrated TB/HIV services if patients with TB/HIV had combined treatment for both illnesses by 1 provider or care team at 1 treatment location. We analyzed the effect of integration by conducting a cross-sectional analysis of integrated and nonintegrated facility periods comparing performance on ART initiation and TB treatment outcomes. We conducted logistic regression, with the patient as the unit of analysis, controlling for other intervention effects, adjusting for age and sex, and clustering by health facility.
From January 2012 to June 2014, 996 patients with TB were registered, 97% were tested for HIV, and 404 (42%) were HIV-positive. Excluding transfers, 296 patients were eligible for analysis with 117 and 179 from nonintegrated and integrated periods, respectively. Being treated in a facility with TB/HIV integration was associated with lower mortality [adjusted odds ratio (aOR) = 0.38, 95% confidence interval (CI): 0.18 to 0.77], but there was no difference in the proportion initiating ART (aOR = 1.34, 95% CI: 0.40 to 4.47), with TB treatment success (aOR = 1.43, 95% CI: 0.73 to 2.82), lost to follow-up (aOR = 1.64, 95% CI: 0.53 to 5.04), or failure (aOR = 1.21, 95% CI: 0.34 to 4.32).
TB/HIV service integration was associated with lower mortality during TB treatment even in settings with suboptimal proportions of patients completing TB treatment and starting on ART.
*Africare, Washington, DC;
†Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium;
‡Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda;
§Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, the Netherlands;
║Departments of Health Metrics Science and Global Health, University of Washington, Seattle, WA;
¶Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; and
#Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Correspondence to: Sarah M. Burnett, MPH, MPA Campus Drie Eiken, Building R, R2.23 Universiteitsplein 1, 2610 Wilrijk, Belgium (e-mail: firstname.lastname@example.org).
TB REACH was supported by a grant from the Stop TB Partnership through grant number T9-370-114UGA from the Canadian International Development Agency. MENTORS was made possible by the support from the US President's Emergency Plan for AIDS Relief through cooperative agreement 1U01GH000527 from the US Centers for Disease Control and Prevention, Division of Global HIV/AIDS. Salary support for research to Y.C.M. and S.Z.-M. was provided by Fogarty International Center, National Institutes for Health (grant #D43TW009771: HIV coinfections in Uganda: TB, Cryptococcus, and Viral Hepatitis). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The findings and conclusions contained within the manuscript are those of the authors and do not necessarily reflect positions or policies of the funders.
Salary support for research to Y.C.M. and S.Z.-M. was provided by Fogarty International Center, National Institutes for Health (grant #D43TW009771: HIV coinfections in Uganda: TB, Cryptococcus, and Viral Hepatitis). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The findings and conclusions contained within the manuscript are those of the authors and do not necessarily reflect positions or policies of the funders. The remaining authors have no conflicts of interest to disclose.
Y.C.M., S.Z.M., S.M.B., and S.M.H. designed the study. S.Z.M., the TB REACH team, and the MENTORS teams gathered the data. S.M.B., S.Z.M., S.M.H., and Y.C.M. designed the analysis, interpreted the data, and drafted the manuscript. All authors read and approved the final manuscript.
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Received March 30, 2018
Accepted August 27, 2018