The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study

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dc.contributor.authorKerschberger, Bernharden_ZA
dc.contributor.authorHilderbrand, Katherineen_ZA
dc.contributor.authorBoulle, Andrew Men_ZA
dc.contributor.authorCoetzee, Daviden_ZA
dc.contributor.authorGoemaere, Ericen_ZA
dc.contributor.authorAzevedo, Virginia Deen_ZA
dc.contributor.authorCutsem, Gilles Vanen_ZA
dc.date.accessioned2015-11-16T04:09:35Z
dc.date.available2015-11-16T04:09:35Z
dc.date.issued2012en_ZA
dc.description.abstractBACKGROUND: Studies 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 FINDINGS: We 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/Significance Full 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.en_ZA
dc.identifier.apacitationKerschberger, B., Hilderbrand, K., Boulle, A. M., Coetzee, D., Goemaere, E., Azevedo, V. D., & Cutsem, G. V. (2012). The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study. <i>PLoS One</i>, http://hdl.handle.net/11427/14996en_ZA
dc.identifier.chicagocitationKerschberger, Bernhard, Katherine Hilderbrand, Andrew M Boulle, David Coetzee, Eric Goemaere, Virginia De Azevedo, and Gilles Van Cutsem "The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study." <i>PLoS One</i> (2012) http://hdl.handle.net/11427/14996en_ZA
dc.identifier.citationKerschberger, B., Hilderbrand, K., Boulle, A. M., Coetzee, D., Goemaere, E., De Azevedo, V., & Van Cutsem, G. (2012). The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study. PloS one, 7(10), e46988. doi:10.1371/journal.pone.0046988en_ZA
dc.identifier.ris TY - Journal Article AU - Kerschberger, Bernhard AU - Hilderbrand, Katherine AU - Boulle, Andrew M AU - Coetzee, David AU - Goemaere, Eric AU - Azevedo, Virginia De AU - Cutsem, Gilles Van AB - BACKGROUND: Studies 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 FINDINGS: We 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/Significance Full 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. DA - 2012 DB - OpenUCT DO - 10.1371/journal.pone.0046988 DP - University of Cape Town J1 - PLoS One LK - https://open.uct.ac.za PB - University of Cape Town PY - 2012 T1 - The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study TI - The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study UR - http://hdl.handle.net/11427/14996 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/14996
dc.identifier.urihttp://dx.doi.org/10.1371/journal.pone.0046988
dc.identifier.vancouvercitationKerschberger B, Hilderbrand K, Boulle AM, Coetzee D, Goemaere E, Azevedo VD, et al. The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study. PLoS One. 2012; http://hdl.handle.net/11427/14996.en_ZA
dc.language.isoengen_ZA
dc.publisherPublic Library of Scienceen_ZA
dc.publisher.departmentInstitute of Infectious Disease and Molecular Medicineen_ZA
dc.publisher.facultyFaculty of Health Sciencesen_ZA
dc.publisher.institutionUniversity of Cape Town
dc.rightsThis 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.en_ZA
dc.rights.holder© Kerschberger et alen_ZA
dc.rights.urihttp://creativecommons.org/licenses/by/4.0en_ZA
dc.sourcePLoS Oneen_ZA
dc.source.urihttp://journals.plos.org/plosoneen_ZA
dc.subject.otherTuberculosisen_ZA
dc.subject.otherHIVen_ZA
dc.subject.otherAntiretroviral therapyen_ZA
dc.subject.otherHIV epidemiologyen_ZA
dc.subject.otherInfectious disease controlen_ZA
dc.titleThe effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after studyen_ZA
dc.typeJournal Articleen_ZA
uct.type.filetypeText
uct.type.filetypeImage
uct.type.publicationResearchen_ZA
uct.type.resourceArticleen_ZA
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