The presence of tuberculosis (TB) at the initiation of antiretroviral therapy (ART) predicts retention in care, according to a study presented by Dr Enegela at the 17th International Conference on AIDS and STIs in Africa (ICASA), held in Cape Town, South Africa from 7 to 11 December 2013.
Adults with TB at ART initiation were 2.85 times less likely to be retained in care (p = 0.0014; 95% CI, 1.2-6.4), according to the cross-sectional review of 1262 people who had initiated ART across 12 ARV sites in Nigeria. The review was conducted with people who had been on ART for at least nine months.
Of the 1262 study participants, 123 (9.75%) had active TB disease at ART initiation. Of these, 115 (93.5%) were retained in care, while 8 (6.5%) were not. Of the people not retained in care, three (37.5%) died, four were transferred out and one was lost to follow up.
Of the 1139 adults who did not have TB at ART initiation, 1113 (97.7%) were retained in care while 26 (2.3%) were not. Eight (30.8%) of these died during the study period, nine (34.6%) were transferred out, one (3.8%) stopped taking ART and eight (30.8%) were lost to follow-up.
“Patients with TB and HIV co-infection at ART initiation should have closer monitoring and follow up, given this study’s results. Further studies may be necessary to examine the association between concurrent vertical disease programmes on patient outcomes”, said Dr Enegela.
Successful active screening and testing for TB and HIV in a South African prison
TB/HIV Care Association has been supporting the Department of Correctional Services in South Africa since 2008 by providing HIV counselling and testing (HCT) and TB and STI (sexually transmitted infection) screening, mentorship for TB/HIV care including nurse-initiated and managed antiretroviral treatment (NIMARt), intensified TB case finding and isoniazid preventive therapy, supporting the tracking of referrals to the Department of Health and medical male circumcision since 2012.
Between March and October 2013, TB/HIV Care Association screened 17,001 prisoners for TB symptoms at Pollsmoor Prison, situated on the outskirts of Cape Town.
During the same period, 9998 prisoners were tested for HIV, compared to 5061 in the previous six months (October 2012 to March 2013). Of the 9998 people tested, 675 (7%) tested HIV positive. Although 100% of these were referred for CD4 cell count testing, only 77% (n = 520) had blood drawn for CD4 cell count testing and only 474 (91%) of these received their CD4 results.
Of those who received their CD4 count results, 180 (38%) were eligible for ART. Only 69% of these (n = 125) started ART. This represents 19% of those who were diagnosed with HIV.
In February 2013, an Xpert MTB/RIF machine, used for the rapid detection of multidrug-resistant TB, was installed in the prison. A professional nurse, a laboratory technician and a data capturer were employed at the same time. TB/HIV Care Association also provided monitoring support.
The proportion of new prison admissions screened for TB increased from 88% in April 2013 to 100% from July to October 2013. Of the 17,101 prisoners who were screened for TB symptoms over the study period, 3315 (19%) had TB symptoms. During the study period, 246 people (1.4% of those screened and 7.4% of those with TB symptoms) were diagnosed with TB using the Xpert MTB/RIF machine. Of those, 235 (95.5%) were diagnosed with rifampicin-sensitive TB, while 11 (4.5%) were diagnosed with rifampicin-resistant TB. All 246 people were initiated on appropriate TB treatment.
The mean time from sputum collection to starting TB treatment decreased from 6.5 days between July and September 2012 to 1.6 days between March and October 2013 among drug-susceptible TB cases. For drug-resistant TB cases, the mean time decreased from 26.5 days to 7.3 days over the same periods.
Household contact tracing was also implemented over the period: 74 household visits were done and 143 household contacts were reached. Of these, 125 (87%) were adults, 15 (12%) of whom displayed TB symptoms and were referred for testing, and 18 (13%) were children who were referred for isoniazid preventive therapy.
Challenges with TB/HIV integration
Record keeping, skills development, human resources management to support integrated models of TB and HIV care and administration to increase collaboration between the TB and HIV directorates of the Department of Health have been identified as areas needing improvement for successful TB and HIV integration, according to a study of 56 primary health care facilities in two provinces of South Africa, presented by Dr Sumitani, at the conference.
The study aimed to assess TB/HIV integration in South Africa, given past shortfalls such as only 54% of eligible people with TB/HIV co-infection starting ART in 2012. The study was conducted between February and March 2013 using the TB clinic registers as primary data sources and TB and ART patient files as secondary data sources. The study examined whether people with TB were initiated on TB treatment, if their HIV status was documented, initiation of ART where eligible and the CD4 count at TB diagnosis.
Of 123 people in the TB clinic register, 46% had HIV co-infection and 9% had an unknown HIV status. Of 172 TB patients, 61% also had HIV, while 3% had unknown HIV status. There was variable HIV data availability in the TB data sources, with ART status more reliably documented in patient files (78%) than in the registers (50%). A CD4 count was available for 89% of HIV-positive TB patients and 84% of people with TB and HIV co-infection were initiated on ART within eight weeks of TB treatment start date.
Enegela J et al. The presence of Tuberculosis at the initiation of antiretroviral therapy predicts retention in care. 17th International Conference on AIDS and STIs in Africa, Cape Town, abstract ADS049, 2013.
Hausler H et al. Active screening and testing for TB and HIV in Pollsmoor Correctional Facility in the Western Cape, South Africa. 17th International Conference on AIDS and STIs in Africa, Cape Town, abstract ADS048, 2013.
Sumitani J et al. ART initiation in TB/HIV co-infection: Challenges in TB/HIV management observed in 56 Primary Healthcare Facilities in South Africa. 17th International Conference on AIDS and STIs in Africa, Cape Town, abstract ADS047, 2013.