Academic journal article Bulletin of the World Health Organization

Timing of Antiretroviral Therapy in Cambodian Hospital after Diagnosis of Tuberculosis: Impact of Revised WHO guidelines/Calendrier Du Traitement Antiretroviral Dans Un Hopital Cambodgien Apres le Diagnostic De la Tuberculose: Impact Des Lignes Directrices Revisees De l'OMS/La Coordinacion De la Terapia Antirretroviral En Un Hospital (Amboyano Tras El Diagnostico De Tuberculosis: El Impacto De Las Directrices Revisadas De la OMS

Academic journal article Bulletin of the World Health Organization

Timing of Antiretroviral Therapy in Cambodian Hospital after Diagnosis of Tuberculosis: Impact of Revised WHO guidelines/Calendrier Du Traitement Antiretroviral Dans Un Hopital Cambodgien Apres le Diagnostic De la Tuberculose: Impact Des Lignes Directrices Revisees De l'OMS/La Coordinacion De la Terapia Antirretroviral En Un Hospital (Amboyano Tras El Diagnostico De Tuberculosis: El Impacto De Las Directrices Revisadas De la OMS

Article excerpt

Introduction

Tuberculosis remains one of the major causes of death in patients infected with the human immunodeficiency virus (HIV) in resource-limited settings. (1) Initiating antiretroviral therapy (ART) during the treatment of tuberculosis has been shown to reduce mortality across a wide range of CD4+ T-lymphocyte (CD4+ cell) counts better than waiting until completion of antituberculosis treatment. (2) However, in programmes in low-resource settings, ART uptake is often poor or treatment is delayed. (3-8) The 2010 revision of the World Health Organization (WHO) guidelines for ART in low-resource settings, which recommend ART in HIV-positive patients with tuberculosis, irrespective of CD4+ cell count, has been a major step forward. According to these guidelines ART should be initiated as soon as the antituberculosis therapy is tolerated, which could be as early as two weeks but ideally not more than eight weeks after the start of treatment. (9) These revised guidelines were followed by the publication of three clinical trials comparing early and late ART initiation (2-4 weeks versus (8-12) weeks after commencing antituberculosis treatment). (10-12) Overall, these studies demonstrated that early ART can be safely implemented and that it is associated with a survival benefit mainly concentrated among individuals with baseline CD4+ cell counts of < 50 cells/[micro]L. (13)

Several factors could preclude the implementation of these revised guidelines in routine clinical settings in resource-limited areas. First, good integration of tuberculosis and HIV care programmes, which has proved challenging, is required. (14-18) Operational issues or non-compliance with the guidelines at the level of the health care system or provider could delay ART initiation. (19) Second, the rates of early death and loss to follow-up before ART initiation are usually higher in programme settings than in controlled study settings. (6,20-25) Third, early initiation in routine care may be delayed by the management of co-morbid conditions and opportunistic infections.

Several recent studies have reported the impact of integrating tuberculosis and HIV services on improved and accelerated ART uptake. (26-36) However, there has been no formal evaluation of the operational feasibility and impact of the revised WHO guidelines on the timing of ART initiation within routine clinical settings. The main objective of this study was to assess the change in time to ART initiation following the implementation of the 2010 WHO ART guidelines in a programmatic setting in a resource-limited area. The secondary objective was to monitor trends in HIV infection treatment outcomes (retention on ART) and toxicity-driven antiretroviral drug substitutions. In this operational study, no reliable data on the occurrence of the immune reconstitution inflammatory syndrome could be obtained.

Methods

Study design and population

In March 2003, Sihanouk Hospital Centre of Hope started providing comprehesive HIV care free of charge in Phnom Penh, Cambodia, as part of the national ART programme. Patients presenting at this nongovernmental hospital come from both rural and urban areas (around 50% each) and are almost universally poor. We conducted a retrospective cohort study with a before-after design. We included in the study all ART-naive HIV-positive adults who initiated antituberculosis treatment as inpatients or outpatients over the 18 months that preceded and the 18 months that followed the implementation of the 2010 WHO guidelines in June 2010. The pre-implementation period extended from 1 December 2008 to 3i May 2010 and the post-implementation period, from 1 June 2010 to 30 November 2011. Before June 2010 the hospital had followed the 2006 WHO guidelines.

Organization of tuberculosis and HIV care

The tuberculosis and HIV care clinics were located within close vicinity of each other in the hospital. …

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