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Journal Article > Research

Time to ART initiation among patients treated for rifampin-resistant tuberculosis in Khayelitsha, South Africa: Impact on mortality and treatment success

Daniels J, Khogali MA, Mohr E, Cox V, Moyo S, Edginton ME, Hinderaker SG, Meintjes GA, Hughes J, De Azevedo V, van Cutsem G, Cox HS
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Abstract
SETTING
Khayelitsha, South Africa, with high burdens of rifampicin-resistant tuberculosis (RR-TB) and HIV co-infection.

OBJECTIVE
To describe time to antiretroviral treatment (ART) initiation among HIV-infected RR-TB patients initiating RR-TB treatment and to assess the association between time to ART initiation and treatment outcomes.

DESIGN
A retrospective cohort study of patients with RR-TB and HIV co-infection not on ART at RR-TB treatment initiation.

RESULTS
Of the 696 RR-TB and HIV-infected patients initiated on RR-TB treatment between 2009 and 2013, 303 (44%) were not on ART when RR-TB treatment was initiated. The median CD4 cell count was 126 cells/mm3. Overall 257 (85%) patients started ART during RR-TB treatment, 33 (11%) within 2 weeks, 152 (50%) between 2-8 weeks and 72 (24%) after 8 weeks. Of the 46 (15%) who never started ART, 10 (21%) died or stopped RR-TB treatment within 4 weeks and 16 (37%) had at least 4 months of RR-TB treatment. Treatment success and mortality during treatment did not vary by time to ART initiation: treatment success was 41%, 43%, and 50% among patients who started ART within 2 weeks, between 2-8 weeks, and after 8 weeks (p = 0.62), while mortality was 21%, 13% and 15% respectively (p = 0.57). Mortality was associated with never receiving ART (adjusted hazard ratio (aHR) 6.0, CI 2.1-18.1), CD4 count ≤100 (aHR 2.1, CI 1.0-4.5), and multidrug-resistant tuberculosis (MDR-TB) with second-line resistance (aHR 2.5, CI 1.1-5.4).

CONCLUSIONS
Despite wide variation in time to ART initiation among RR-TB patients, no differences in mortality or treatment success were observed. However, a significant proportion of patients did not initiate ART despite receiving >4 months of RR-TB treatment. Programmatic priorities should focus on ensuring all patients with RR-TB/HIV co-infection initiate ART regardless of CD4 count, with special attention for patients with CD4 counts ≤ 100 to initiate ART as soon as possible after RR-TB treatment initiation.
Countries
South Africa
Subject Area
antibiotic resistancetuberculosisinfections, viralantimicrobial resistanceHIV/AIDS
DOI
10.1371/journal.pone.0142873
Published Date
10-Nov-2015
PubMed ID
26555134
Languages
English
Journal
PLOS One
Volume / Issue / Pages
Volume 10, Issue 11, Pages e0142873
Issue Date
10-Nov-2015
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