Research Article: Successes and Challenges in an Integrated Tuberculosis/HIV Clinic in a Rural, Resource-Limited Setting: Experiences from Kericho, Kenya

Date Published: February 16, 2012

Publisher: Hindawi Publishing Corporation

Author(s): Douglas N. Shaffer, Eunice T. Obiero, Josphat B. Bett, Ignatius N. Kiptoo, Jonah K. Maswai, Fredrick K. Sawe, E. Jane Carter.


Objective. To describe TB/HIV clinic outcomes in a rural, Ministry of Health hospital.
Design. Retrospective, secondary analyses. Descriptive statistics and logistic regression analyses evaluated baseline characteristics and outcomes.
Results. Of 1,911 patients, 89.8% were adults aged 32.0 (±12.6) years with baseline CD4 = 243.3 (±271.0), 18.2% < 50 cells/mm3. Pulmonary (84.8%, (32.2% smear positive)) exceeded extrapulmonary TB (15.2%). Over 5 years, treatment success rose from 40.0% to 74.6%, lost to follow-up dropped from 36.0% to 12.5%, and deaths fell from 20.0% to 5.4%. For patients starting ART after TB treatment, those with CD4 ≥ 50 cells/mm3 were twice as likely to achieve treatment success (OR = 2.0, 95% CI = 1.3–3.1) compared to those with CD4 < 50 cells/mm3. Patients initiating ART at/after 2 months were twice as likely to achieve treatment success (OR = 2.0, 95% CI = 1.3–3.3). Yearly, odds of treatment success improved by 20% (OR = 1.2, 95% CI = 1.0–1.5). Conclusions. An integrated TB/HIV clinic with acceptable outcomes is a feasible goal in resource-limited settings.

Partial Text

Tuberculosis (TB) remains the leading cause of death among persons living with HIV/AIDS with nearly 25% of HIV mortality attributable to TB and 380,000 deaths in 2009 related to HIV-associated TB [1]. In 2009, there were an estimated 1.1 million HIV-positive TB patients globally with nearly 80% living in sub-Saharan Africa [1]. While guidelines [2–5] and peer-reviewed journals [6–12] call for integrated TB/HIV services and clinical trials demonstrate early antiretroviral therapy (ART) in patients with TB/HIV coinfection result in better outcomes [13–16], experience from field implementation of TB/HIV integration is now critical.

Our experience demonstrates that integrated TB/HIV care is feasible at a rural, public MoH hospital in Kenya. Our integrated clinic, staffed primarily by clinical officers and nurses with backup assistance by medical officers and consultants, successfully administered TB and ART care with acceptable TB treatment success frequencies that improved over time. Overall mortality was low in the TB/HIV clinic for both adult and pediatric patients. However, lost-to-followup frequencies were high and occurred early in care, particularly in those presenting with advanced HIV. Many of these patients lost to followup likely account for additional deaths. Our data suggest that achieving Kenyan national TB targets of 85% cure and 90% treatment completion rates regardless of HIV status can only be achieved if loss to followup is aggressively and promptly addressed.

TB/HIV patients with advanced HIV disease can be successfully managed in integrated TB/HIV MoH clinics in rural Kenya. Treatment outcomes improve with time, likely reflecting a variety of factors certainly including additional expertise that follows experience. Baseline CD4+ T-cell count is a driving force in predicting outcomes. Loss to followup remains a critical challenge in care delivery that demands attention and innovation. With high loss to followup occurring early in care and likely representing further deaths, the benefits and challenges of early ART initiation in TB treatment in nonclinical trial, resource-limited, rural settings are underscored. This “TB/HIV timeline” conundrum underscores the need for increased efforts for early detection of TB/HIV coinfected patients combined with innovative case holding interventions. An integrated TB/HIV clinic (one patient, one clinic) is a feasible goal in resource-constrained settings.




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