Complete integration of TB and HIV care in our urban HIV clinic contributed to an increase in the proportion of patients who completed TB treatment alive and to a decrease in treatment default. It also led to earlier and more prioritized ART initiation in ART-naïve HIV-infected patients diagnosed with TB with a decrease in the time to initiation of ART, especially in patients with a CD4 count <100/mm3
who are most likely to benefit from timely ART initiation 6-8
Different models of integrated delivery of TB and HIV care in resource-limited settings have been described in the literature. Legido-Quigley et al. performed a systematic review of 60 papers and 70 abstracts describing HIV and TB service integration in low- and middle-income countries, and categorized these into 5 models: a TB clinic with referral for HIV testing and treatment; a TB clinic with on-site HIV testing but with referral for HIV treatment; an HIV clinic with referral for TB testing and treatment; an HIV clinic with on-site TB screening and with referral for TB treatment and a “single facility” with provision of TB and HIV services in the same clinic 10
. They also described benefits and weaknesses of the different models. These range from easy implementation but failing referral mechanisms due to poor communication in less integrated models to improved staff morale and retention, but more logistical challenges such as human resource limitations, increased need for staff training and additional infrastructure in models with higher levels of integration.
Despite the rationale for integrated service delivery, the evidence to support it is limited 4, 10
. Few reports include TB and/or HIV treatment outcomes 10
. Decreased default rates after integrating TB services into home-based care were found in Zambia.16
. Two studies of fully integrated care models in Kenya (HIV services added to a TB clinic) and Malawi (TB services added to an HIV clinic) found no decrease in TB treatment default but an increase in ART usage 17-18
. To our knowledge, our evaluation of our integrated clinic model study is the first to present results on ART prescribing behavior including timing of ART initiation.
We feel several aspects were crucial to the success of the integrated care delivery in our clinic. The formation of a dedicated team of health care workers who were convinced of the need for integrated care was paramount. Weekly team meetings and opportunities for personal growth motivated team members and gave them a feeling of empowerment. Training of the TB/HIV clinic staff by the learning forms allowing continuous repetitive emphasis on core treatment concepts, having one clinician take care of both diseases and continuous quality improvement by ongoing supervision by senior team members were essential to the delivery of high-quality standardized care. The setup of a compact open air clinic with few staff members allowed for easy communication and treatment continuity for the patients.
The recently concluded TB-Control Assistance Program (TB-CAP) to strengthen TB/HIV collaboration in Uganda recommended a health service delivery model based on offering comprehensive TB and HIV services in one health facility 19
. At baseline, our clinic represented the siloed situation of the highly standardized TB care setting with minimal communication with the more patient-centered HIV care setting 20
. Our results offer an insight into TB and HIV care outcomes that are attainable by integrating services for both diseases. Our model would need to be adapted further for general out patients settings which include HIV-uninfected patients. We are currently testing this in a WHO funded TB REACH project. As suggested by others, having a point person responsible for TB/HIV integrated care in each health center will help continued communication between the TB and the HIV health care systems 18, 21
. In our view, there is no need for separate staff; in a traditional setting with separate TB and HIV outpatient clinics, usually run on different days, staff from these could be trained and deployed on separate TB/HIV outpatient clinic days.
The proportion of patients defaulting TB treatment in sub-Saharan Africa varies from 11.3% to 29.6% 22-26
, and could be higher in HIV-positive patients. As mentioned earlier, two integrated care models reported different effects on default rates 16-17
. In our clinic, active tracing of patients who missed their appointment improved ascertainment of patients’ outcomes. The increase in proportion of deaths in 2009 compared to 2007 is likely attributable to this improved ascertainment rather than a real increase in mortality; a large proportion of patients classified as lost to follow-up before the intervention might have died. However, more effort is needed to reduce loss to follow up; 10% of patients still did not complete TB treatment after integration of services. Contrary to other studies the majority of our patients default during the intensive phase 22-26
, suggesting that interventions during the first 2 months of treatment could drastically reduce the number of patients lost to follow-up in our clinic.
Recent evidence strongly suggests that initiation of ART during TB treatment rather than after completion of TB treatment leads to improved survival, and that patients with very low CD4 counts (<50 cells/mm3
) should be started on ART within 2-4 weeks after initiation of TB treatment 5-8
. This evidence has been incorporated into the WHO ART guidelines 9
. Our results show that integrating HIV and TB care feasibly allows for timely initiation of ART (the time to ART initiation reduced from 103 to 45 days). Restricted funding and therefore ART availability prohibited initiation of all TB patients on ART in our setting, but trained medical staff were able to appropriately assess ART eligibility and triage ART access which led to a more prioritized ART initiation in patients most in need of ART. Interestingly, no difference in mortality and loss-to-follow-up was seen in patients who had been initiated on ART across periods. Improvement in these outcomes was found in patients not initiated on ART, particularly in the intermediate CD4 count group. The small numbers prompt careful interpretation; we attribute this to an overall higher quality of care after the integration.
National guidelines formed the basis of the TB and HIV care provided both before and after implementation of the integrated clinic, and had not changed between 2007 and 2009 with respect to any of the reported outcomes. Data to support ART initiation during TB treatment came out early 2009 27
, which might have increased awareness among clinicians to adhere to existing national guidelines. However, we feel that the most important factor underlying the more timely ART initiation in 2009 was that the ART prescribing clinician and the TB treating clinician were the same.
The integrated clinic was set up with a minimal use of resources, of which the majority was used for the construction of the outdoor clinic specifically for improvement of infection control, an outcome which we could not measure. Although we lack data on nosocomial TB transmission rates, we believe the creation of an outdoor waiting area and clinic could have averted infections compared to the situation prior to integration. The additional cost to provide the integrated care service was minimal and consisted mainly of efforts to create training, clinic, monitoring & evaluation materials, and to train the HIV/TB clinic staff. Other limitations of our analysis were the use of routinely collected data with issues of missing data and outcome ascertainment. Data on the type of TB diagnosed and TB treatment outcomes were collected differently in 2007 and 2009. The digitalized NTLP register was used in 2007 and the new clinic database validated by the NTLP register in 2009. The HIV and laboratory data was uniformly collected across both study periods, however. The data in both datasets underwent extensive validation through cross-checking with the clinical notes. Therefore, we do not think these differences could explain the observed outcome differences between the two years.
In conclusion, the integration of TB and HIV care in our large, urban HIV clinic has led to improved TB treatment outcomes and earlier and more prioritized ART initiation. There is need for data on nosocomial TB transmission rates in integrated care settings. This data supports the roll-out of a fully integrated TB/HIV service delivery model throughout high-prevalence TB and HIV settings.