Time to ART initiation among patients treated for rifampicin-resistant tuberculosis in khayelitsha, South Africa: Impact on mortality and treatment success
Medecins Sans Frontieres, Khayelitsha, Cape Town, South Africa; Medecins Sans Frontieres, Luxembourg; Human Sciences Research Council, HIV/AIDS, STIs and TB Programme, Cape Town, South Africa; International Union Against TB and Lung Disease, Paris, France; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; University of Bergen, Bergen, Norway; Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; City of Cape Town Department of Health, Cape Town, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa; Division of Medical Microbiology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
Setting Khayelitsha, South Africa, with high burdens of rifampicin-resistant tuberculosis (RR-TB) and HIV co-infection. Objective To describe time to antiretroviral treatment (ART) initiation among HIV-infected RR-TB patients initiating RR-TB treatment and to assess the association between time to ART initiation and treatment outcomes. Design A retrospective cohort study of patients with RR-TB and HIV co-infection not on ART at RRTB treatment initiation. Results Of the 696 RR-TB and HIV-infected patients initiated on RR-TB treatment between 2009 and 2013, 303 (44%) were not on ART when RR-TB treatment was initiated. The median CD4 cell count was 126 cells/mm3. Overall 257 (85%) patients started ART during RR-TB treatment, 33 (11%) within 2 weeks, 152 (50%) between 2-8 weeks and 72 (24%) after 8 weeks. Of the 46 (15%) who never started ART, 10 (21%) died or stopped RR-TB treatment within 4 weeks and 16 (37%) had at least 4 months of RR-TB treatment. Treatment success and mortality during treatment did not vary by time to ART initiation: treatment success was 41%, 43%, and 50% among patients who started ART within 2 weeks, between 2-8 weeks, and after 8 weeks (p = 0.62), while mortality was 21%, 13% and 15% respectively (p = 0.57). Mortality was associated with never receiving ART (adjusted hazard ratio (aHR) 6.0, CI 2.1-18.1), CD4 count 100 (aHR 2.1, CI 1.0-4.5), and multidrug-resistant tuberculosis (MDR-TB) with second-line resistance (aHR 2.5, CI 1.1-5.4). Conclusions Despite wide variation in time to ART initiation among RR-TB patients, no differences in mortality or treatment success were observed. However, a significant proportion of patients did not initiate ART despite receiving 4 months of RR-TB treatment. Programmatic priorities should focus on ensuring all patients with RR-TB/HIV co-infection initiate ART regardless of CD4 count, with special attention for patients with CD4 counts 100 to initiate ART as soon as possible after RR-TB treatment initiation. © 2015 Daniels et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
antiretrovirus agent; rifampicin; adult; age distribution; Article; CD4 lymphocyte count; clinical effectiveness; cohort analysis; controlled study; drug resistant tuberculosis; female; high risk population; human; Human immunodeficiency virus infection; major clinical study; male; mixed infection; mortality; newborn; outcome assessment; retrospective study; South Africa; treatment duration; tuberculosis