Impact of Combination Antiretroviral Therapy Initiation on Adherence to Antituberculosis Treatment

Background: Healthcare workers are often reluctant to start combination antiretroviral therapy (ART) in patients receiving tuberculosis (TB) treatment because of the fear of high pill burden; immune reconstitution inflammatory syndrome; and side-effects.Object: To quantify changes in adherence to tuberculosis treatment following ART initiation.Design: A prospective observational cohort study of ART-naive individuals with baseline CD4 count between 50 cells/mm3 and 350 cells/mm3 at start of TB treatment at a primary care clinic in Johannesburg; South Africa. Adherence to TB treatment was measured by pill count;self-report; and electronic Medication Event Monitoring System (eMEMS) before and after initiation of ART.Results: ART tended to negatively affect adherence to TB treatment; with an 8% - 10% decrease in the proportion of patients adherent according to pill count and an 18% - 22% decrease in the proportion of patients adherent according to eMEMS in the first month following ART initiation; independent of the cut-off used to define adherence (90%; 95% or 100%). Reasons for non-adherence were multi factorial; and employment was the only predictor for optimal adherence (adjusted odds ratio 4.11; 95% confidence interval 1.06-16.0).Conclusion: Adherence support in the period immediately following ART initiation could optimise treatment outcomes for people living with TB and HIV

Lost opportunities to Complete CD4+ Lymphocyte Testing among Patients who Tested Positive for HIV in South Africa

Objective:To estimate rates of completion of CD4+ lymphocyte testing (CD4 testing) within 12 weeks of testing positive for human immunodeficiency virus (HIV) at a large HIV/AIDS clinic in South Africa, and to identify clinical and demographic predictors for completion.Methods:In our study, CD4 testing was considered complete once a patient had retrieved the test results. To determine the rate of CD4 testing completion, we reviewed the records of all clinic patients who tested positive for HIV between January 2008 and February 2009. We identified predictors for completion through multivariate logistic regression.Findings:Of the 416 patients who tested positive for HIV, 84.6% initiated CD4 testing within the study timeframe. Of these patients, 54.3% were immediately eligible for antiretroviral therapy (ART) because of a CD4 cell count ≤ 200/µl, but only 51.3% of the patients in this category completed CD4 testing within 12 weeks of HIV testing. Among those not immediately eligible for ART (CD4 cells > 200/µl), only 14.9% completed CD4 testing within 12 weeks. Overall, of HIV+ patients who initiated CD4 testing, 65% did not complete it within 12 weeks of diagnosis. The higher the baseline CD4 cell count, the lower the odds of completing CD4 testing within 12 weeks.Conclusion:Patient losses between HIV testing, baseline CD4 cell count and the start of care and ART are high. As a result, many patients receive ART too late. Health information systems that link testing programmes with care and treatment programmes are needed