Integration and task shifting for TB/HIV care and treatment in highly resource-scarce settings: One size may not fit all

Annelies Van Rie, Monita R. Patel, Mbonze Nana, Koen Vanden Driessche, Martine Tabala, Marcel Yotebieng, Frieda Behets

Research output: Contribution to journalArticle

16 Citations (Scopus)

Abstract

BACKGROUND:: A crucial question in managing HIV-infected patients with tuberculosis (TB) concerns when and how to initiate antiretroviral therapy (ART). The effectiveness of CD4-stratified ART initiation in a nurse-centered, integrated TB/HIV program at primary care in Kinshasa, Democratic Republic of Congo, was assessed. METHODS:: Prospective cohort study was conducted to assess the effect of CD4-stratified ART initiation by primary care nurses (513 TB patients, August 2007 to November 2009). ART was to be initiated at 1 month of TB treatment if CD4 count is <100 cells per cubic millimeter, at 2 months if CD4 count is 100-350 cells per cubic millimeter, and at the end of TB treatment after CD4 count reassessment if CD4 count is >350 cells per cubic millimeter. ART uptake and mortality were compared with a historical prospective cohort of 373 HIV-infected TB patients referred for ART to a centralized facility and 3577 HIV-negative TB patients (January 2006 to May 2007). RESULTS:: ART uptake increased (17%-69%, P < 0.0001) and mortality during TB treatment decreased (20.1% vs 9.8%, P < 0.0003) after decentralized, nurse-initiated, CD4-stratified ART. Mortality among TB patients with CD4 count >100 cells per cubic millimeter was similar to that of HIV-negative TB patients (5.6% vs 6.3%, P = 0.65), but mortality among those with CD4 count <100 cells per cubic millimeter remained high (18.8%). CONCLUSIONS:: Nurse-centered, CD4-stratified ART initiation at primary care level was effective in increasing timely ART uptake and reducing mortality among TB patients but may not be adequate to prevent mortality among those presenting with severe immunosuppression. Further research is needed to determine the optimal management at primary care level of TB patients with CD4 counts <100 cells per cubic millimeter.

Original languageEnglish (US)
Pages (from-to)e110-e117
JournalJournal of Acquired Immune Deficiency Syndromes
Volume65
Issue number3
DOIs
StatePublished - Mar 1 2014
Externally publishedYes

Fingerprint

Tuberculosis
HIV
Primary Health Care
CD4 Lymphocyte Count
Therapeutics
Mortality
Nurses
Democratic Republic of the Congo
Immunosuppression
Cohort Studies
Prospective Studies
Research

Keywords

  • antiretroviral therapy
  • delay
  • integration
  • nurses
  • timing
  • tuberculosis

ASJC Scopus subject areas

  • Infectious Diseases
  • Pharmacology (medical)

Cite this

Integration and task shifting for TB/HIV care and treatment in highly resource-scarce settings : One size may not fit all. / Van Rie, Annelies; Patel, Monita R.; Nana, Mbonze; Vanden Driessche, Koen; Tabala, Martine; Yotebieng, Marcel; Behets, Frieda.

In: Journal of Acquired Immune Deficiency Syndromes, Vol. 65, No. 3, 01.03.2014, p. e110-e117.

Research output: Contribution to journalArticle

Van Rie, Annelies ; Patel, Monita R. ; Nana, Mbonze ; Vanden Driessche, Koen ; Tabala, Martine ; Yotebieng, Marcel ; Behets, Frieda. / Integration and task shifting for TB/HIV care and treatment in highly resource-scarce settings : One size may not fit all. In: Journal of Acquired Immune Deficiency Syndromes. 2014 ; Vol. 65, No. 3. pp. e110-e117.
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abstract = "BACKGROUND:: A crucial question in managing HIV-infected patients with tuberculosis (TB) concerns when and how to initiate antiretroviral therapy (ART). The effectiveness of CD4-stratified ART initiation in a nurse-centered, integrated TB/HIV program at primary care in Kinshasa, Democratic Republic of Congo, was assessed. METHODS:: Prospective cohort study was conducted to assess the effect of CD4-stratified ART initiation by primary care nurses (513 TB patients, August 2007 to November 2009). ART was to be initiated at 1 month of TB treatment if CD4 count is <100 cells per cubic millimeter, at 2 months if CD4 count is 100-350 cells per cubic millimeter, and at the end of TB treatment after CD4 count reassessment if CD4 count is >350 cells per cubic millimeter. ART uptake and mortality were compared with a historical prospective cohort of 373 HIV-infected TB patients referred for ART to a centralized facility and 3577 HIV-negative TB patients (January 2006 to May 2007). RESULTS:: ART uptake increased (17{\%}-69{\%}, P < 0.0001) and mortality during TB treatment decreased (20.1{\%} vs 9.8{\%}, P < 0.0003) after decentralized, nurse-initiated, CD4-stratified ART. Mortality among TB patients with CD4 count >100 cells per cubic millimeter was similar to that of HIV-negative TB patients (5.6{\%} vs 6.3{\%}, P = 0.65), but mortality among those with CD4 count <100 cells per cubic millimeter remained high (18.8{\%}). CONCLUSIONS:: Nurse-centered, CD4-stratified ART initiation at primary care level was effective in increasing timely ART uptake and reducing mortality among TB patients but may not be adequate to prevent mortality among those presenting with severe immunosuppression. Further research is needed to determine the optimal management at primary care level of TB patients with CD4 counts <100 cells per cubic millimeter.",
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AU - Patel, Monita R.

AU - Nana, Mbonze

AU - Vanden Driessche, Koen

AU - Tabala, Martine

AU - Yotebieng, Marcel

AU - Behets, Frieda

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