Loss to follow up from isoniazid preventive therapy among adults attending HIV voluntary counseling and testing sites in Uganda

Increased uptake of tuberculosis preventive therapy (TPT) among people living with HIV following the 100-days accelerated campaign: A retrospective review of routinely collected data at six urban public health facilities in Uganda

Tuberculosis preventive therapy (TPT) effectively decreases rates of developing active tuberculosis disease in people living with HIV (PLHIV) who are at increased risk. The Uganda Ministry of Health launched a 100-day campaign to scale-up TPT in PLHIV in July 2019. We sought to examine the effect of the campaign on trends of TPT uptake and characteristics associated with TPT uptake and completion among persons in HIV care. We retrospectively reviewed routinely collected data from 2016 to 2019 at six urban public health facilities in Uganda. HIV care database and paper-based TPT registers at six public health facilities in Kampala, Uganda were retrospectively reviewed. Estimated trends of TPT (given as Isoniazid monotherapy) uptake and completion across the 4 years, among PLHIV aged 15 years and above, and factors associated, were examined using Poisson regression model with robust standard errors using generalized estimating equation (GEE) models. On average, a total of 39,774 PLHIV aged 15 years and above were eligible for TPT each calendar year at the six health facilities. Across all 4 years, more than 70% were females (range: 73.5% -74.6%) and the median age ranged from 33 to 34 years. From 2016 quarter one to 2019 quarter two, TPT uptake was consistently below 25%, but, as expected, the uptake significantly increased by about 3-folds from 22.1% to 61.2%, in 2019 quarter two (i.e. before the roll-out of the 100-day accelerated TPT intervention) and quarter three (i.e. after the roll-out of the 100-day accelerated TPT intervention) respectively. This increase remained highly significant even after adjusting for patients' baseline characteristics (adjusted prevalence ratio [aPR] = 2.58 [95%CI 2.45, 2.72], P-value<0.001). TPT completion was consistently high at above 70% at most of the time, but, it increased significantly among those initiated during 2018 quarter four and in the subsequent two quarters after the roll-out of the 100-day accelerated TPT intervention (i.e. TPT completion was: 83.2%, 95.3%, and 97.1% among individuals initiated during 2018 quarter4, and 2019 quarters 1 and 2, respectively). The increase in TPT completion during this period remained significant even after adjusting for patients' baseline characteristics (aPR [95%CI] = 1.09 [1.04, 1.14], P value<0.001, and 1.10 [1.05,1.15], P value<0.001, for individuals initiated during 2019 quarter 1, and 2, respectively compared to those initiated during 2018 quarter 4). Not on ART or newly started on ART compared to ART experienced, and pregnant at TPT initiation compared to not pregnant were associated with poor TPT completion, whereas older age (≥25 years versus 15-24 years) was associated with higher TPT completion. The targeted 100-day campaign dramatically increased TPT uptake and completion among PLHIV suggesting a viable catch up strategy to meet WHO guidelines. Future analysis with additional years of data post 100-days TPT intervention is required to evaluate the sustainability of the observed gains.

High burden of adverse drug reactions to Isoniazid Preventive Therapy in people living with HIV at three tertiary hospitals in Uganda: associated factors

BACKGROUND

HIV is one of the most important risk factors for TB-related morbidity and mortality. Isoniazid preventive therapy (IPT) is recommended to prevent latent TB reactivation in HIV patients. However, due to multiple therapies and comorbidities these patients are predisposed to adverse drug reactions (ADRs) which lead to increased morbidity and mortality. The aim of this study was to determine the prevalence and associated factors of suspected IPT-linked ADRs in HIV-positive patients using IPT.

METHODS

A cross-sectional study was conducted between February and March 2020 at three regional referral hospitals (RRHs) in central Uganda. We sampled 660 HIV-positive patients aged 10 years and older who received IPT between July and December 2019 inclusive. Patients were interviewed using a pre-tested structured questionnaire and their treatment records were reviewed. A modified poisson regression model with clustered robust standard errors was used to identify factors associated with suspected IPT-linked ADRs.

RESULTS

The prevalence of the suspected ADRs was 51 % (334/660; 95% CI: 18% - 83%). Patients' self-reported 7-fold more suspected ADRs than were documented by the Health Care Workers (HCWs). Musculoskeletal symptoms were the most frequently experienced reaction (14%) followed by dizziness (13%) and peripheral neuropathy (11%). Serious suspected ADRs were experienced by 12 % of the study participants; the most common were hepatotoxicity (26%), dizziness (23%) and neuropathy (17%). Female sex (aPR: 0.92, 95% CI = 0.88-0.95), study site (aPR: 1.09, 95% CI = 1.09-1.18), level of education (aPR: 0.94, 95% CI = 0.94-0.99) and history of TB (aPR: 0.93, 95% CI = 0.87-0.99), good IPT adherence (aPR: 1.16, 95% CI = 1.05-1.29) and use of protease inhibitor (PI)-based ART (aPR: 1.01, 95% CI = 1.00-1.02) were significantly associated with suspected IPT-linked ADRs.

CONCLUSION

The prevalence of suspected IPT-linked ADRs is high and hepatotoxicity is the most commonly reported serious suspected ADR. Patients self-reported more suspected ADRs than were documented by HCWs. Patient engagement could improve ADR detection and potentially strengthen the pharmacovigilance system. High ADR-risk patients ought to be monitored regularly to enable early detection and management.

Acceptance and completion of rifapentine-based TB preventive therapy (3HP) among people living with HIV (PLHIV) in Kampala, Uganda-patient and health worker perspectives

Background

A 12-dose, once-weekly regimen of isoniazid and rifapentine (3HP) is effective in preventing tuberculosis (TB) among people living with HIV (PLHIV). We sought to identify potential barriers to and facilitators of acceptance and completion of 3HP treatment from the perspective of people living with HIV (PLHIV) and health workers in a routine HIV care setting in Kampala, Uganda.

Methods

We conducted semi-structured interviews with 25 PLHIV and 10 health workers at an HIV/AIDS clinic in Kampala, Uganda. For both groups, we explored their understanding and interpretations of TB and TB preventive therapy (TPT), and perceptions about social and contextual factors that might influence the willingness of PLHIV to initiate and complete 3HP. We analyzed the data using an inductive thematic approach and aligned the emergent themes to the Behavior Change Wheel framework to identify sources of behavior and targeted behavior change interventions.

Results

Facilitators of acceptance and completion of 3HP treatment among PLHIV were fear of contracting TB, awareness of being at risk of getting TB, willingness to take TPT, trust in health workers, and the perceived benefits of directly observed therapy (DOT) and self-administered therapy (SAT) 3HP delivery strategies. Barriers included inadequate understanding of TPT, fear of potential side effects, concerns about the effectiveness of 3HP, and the perceived challenges of DOT or SAT. Among health workers, perceived facilitators included knowledge that TB is a common cause of mortality for PLHIV, fear of getting TB, and trust in the health workers by PLHIV, the advantages of once-weekly 3HP dosing, and the benefits of DOT and SAT 3HP delivery strategies. Health worker-reported barriers for PLHIV included inadequate understanding of TB and benefits of TPT, TB-associated stigma, potential side effects pill burden, and challenges of DOT and SAT 3HP delivery strategies. Lack of experience in the use of digital technology to monitor patient care was identified as a health worker-specific barrier. Identified intervention functions to address the facilitators or barriers included education, persuasion, environmental restructuring, enablement, and training.

Conclusions

Using a formative qualitative and comprehensive theoretical approach, we identified key barriers, facilitators, and appropriate interventions, including patient education, enhancing trust, and patient-centered treatment support that could be used to optimize the delivery of 3HP to PLHIV in our setting. These interventions are likely generalizable to other clinical interventions in similar populations in sub-Saharan Africa and other TB high-burden settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00173-2.

Predictors of retention in the prospective HIV prevention OKAPI cohort in Kinshasa

Retention is a key element in HIV prevention programs. In Sub-Saharan Africa most data on retention come from HIV clinical trials or people living with HIV attending HIV treatment and control programs. Data from observational cohorts are less frequent. Retention at 6-/12-month follow-up and its predictors were analyzed in OKAPI prospective cohort. From April 2016 to April 2018, 797 participants aged 15-59 years attending HIV Voluntary Counseling and Testing in Kinshasa were interviewed about HIV-related knowledge and behaviors at baseline and at 6- and 12-month follow-ups. Retention rates were 57% and 27% at 6- and 12-month follow up; 22% of participants attended both visits. Retention at 6-month was significantly associated with 12-month retention. Retention was associated with low economic status, being studying, daily/weekly Internet access, previous HIV tests and aiming to share HIV test with partner. Contrarily, perceiving a good health, living far from an antiretroviral center, daily/weekly alcohol consumption and perceiving frequent HIV information were inversely associated with retention. In conclusion, a high attrition was found among people attending HIV testing participating in a prospective cohort in Kinshasa. Considering the low retention rates and the predictors found in this study, more HIV cohort studies in Kinshasa need to be evaluated to identify local factors and strategies that could improve retention if needed.

Protocol for the 3HP Options Trial: a hybrid type 3 implementation-effectiveness randomized trial of delivery strategies for short-course tuberculosis preventive therapy among people living with HIV in Uganda

Background

Recently, a 3-month (12-dose) regimen of weekly isoniazid and rifapentine (3HP) was recommended by the World Health Organization for the prevention of tuberculosis (TB) among people living with HIV (PLHIV) on common antiretroviral therapy regimens. The best approach to delivering 3HP to PLHIV remains uncertain.

Methods

We developed a three-armed randomized trial assessing optimized strategies for delivering 3HP to PLHIV. The trial will be conducted at the Mulago Immune Suppression Syndrome (i.e., HIV/AIDS) clinic in Kampala, Uganda. We plan to recruit 1656 PLHIV, randomized 1:1 to each of the three arms (552 per arm). Using a hybrid type 3 effectiveness-implementation design, this pragmatic trial aims to (1) compare the acceptance and completion of 3HP among PLHIV under three delivery strategies: directly observed therapy (DOT), self-administered therapy (SAT), and informed patient choice of either DOT or SAT (with the assistance of a decision aid); (2) to identify processes and contextual factors that influence the acceptance and completion of 3HP under each delivery strategy; and (3) to estimate the costs and compare the cost-effectiveness of three strategies for delivering 3HP. The three delivery strategies were each optimized to address key barriers to 3HP completion using a theory-informed approach. We hypothesize that high levels of treatment acceptance and completion can be achieved among PLHIV in sub-Saharan Africa and that offering PLHIV an informed choice between the optimized DOT and SAT delivery strategies will result in greater acceptance and completion of 3HP. The design and planned evaluation of the delivery strategies were guided by the use of implementation science conceptual frameworks.

Discussion

3HP—one of the most promising interventions for TB prevention—will not be scaled up unless it can be delivered in a patient-centered fashion. We highlight shared decision-making as a key element of our trial design and theorize that offering PLHIV an informed choice between optimized delivery strategies will facilitate the highest levels of treatment acceptance and completion.

Trial registration

ClinicalTrials.gov: NCT03934931; Registered 2 May 2019.

Implementation of Isoniazid Preventive Therapy among People Living with HIV in Northwestern Nigeria: Completion Rate and Predictive Factors

BACKGROUND

Despite proven benefits of isoniazid preventive therapy (IPT) for people living with HIV (PLHIV), its implementation remains limited in low-resource settings. There are also programmatic concerns of the completion rate of IPT particularly when full integration with other HIV services has not been achieved.

AIM

The aim of this study was to determine the completion rate of IPT and predictive factors among PLHIV attending six government hospitals in Kebbi state, Northern Nigeria.

METHODS

This was a retrospective cohort study of program data spanning a 5-year period (December 2010-June 2016). Data were collected between January 2017 and June 2017.

RESULTS

A total of 1,134 IPT patients were enrolled of whom 740 (65.3%) were female. The mean age was 40.3 ± 3.7 years. Four hundred and fifty-four (40%) of those who initiated IPT completed the 6-month course. Of the 680 (60%) IPT noncompleters, 117 (17.2%) were lost to follow-up by month 1, 305 (44.9%) by month 2, 156 (22.9%) by month 3, 48 (7.1%) by month 4, and 54 (7.9%) by month 5. Being initiated on IPT by a pharmacist (adjusted odds ratio [aOR]: 23.7, 95% confidence interval [CI]: 16.5-33.9) and receiving ≤2 tuberculosis screening evaluation during IPT period (aOR: 0.58, 95% CI: 0.43-0.78) were associated with a higher and lower risk of completing IPT, respectively, whereas age, sex, and anti-retroviral therapy (ART) status were not significantly associated.

CONCLUSION

IPT completion rate among PLHIV is relatively low, highlighting the need to strengthen IPT rollout in public health facilities in Nigeria. Pharmacy-led IPT adherence education and regular clinical evaluation may improve IPT completion rates, along with synchronizing and prepackaging IPT and ART resupplies for PLHIV.

Predictors of loss to follow-up of tuberculosis cases under the DOTS programme in Namibia

Background

In Namibia, one out of every 25 cases of tuberculosis (TB) is “lost to follow-up” (LTFU). This has impacted negatively on national efforts to end the disease by 2035. The aim of this study was to determine the trends and predictors of LTFU under the directly observed treatment short-course (DOTS) programme in Namibia.

Methods

The study involved a retrospective longitudinal analysis of a nationwide cohort of TB cases registered under the DOTS programme in Namibia from 2006 to 2015. The trends and predictors of LTFU among cases in the National Electronic TB Register of the National TB and Leprosy Program were respectively determined by interrupted time series and multivariate logistic regression analyses using R-Studio software.

Results

Out of 104 203 TB cases, 3775 (3.6%) were LTFU. A quarter (26%) of cases with poor outcomes were due to LTFU. The annual decline in cases of LTFU was significant between the first (2005–2010) and second (2010–2015) medium-term plan period for TB programme implementation (p=0.002). The independent predictors of LTFU were male sex (p=0.004), 15–24 years age group (p=0.03), provider of treatment (p<0.001), intensive phase (p=0.047) and living in border/transit regions (p<0.001). HIV co-infection and TB regimen were not significant predictors of LTFU.

Conclusions

There were declining trends in LTFU in Namibia. DOTS programmes should integrate socioeconomic interventions for young and middle-aged adult male TB cases to reduce LTFU.

Loss to follow-up of tuberculosis patients is an important barrier to ending TB in high-TB-burden countries. The integration of social welfare among young and/or middle-aged men is critical in reducing loss to follow-up of TB patients.http://bit.ly/395WfBM

Predictors of isoniazid preventive therapy completion among adults newly diagnosed with HIV in rural Malawi

SETTING

To reduce the risk of tuberculosis (TB) among individuals with human immunodeficiency virus (HIV) infection, the World Health Organization recommends at least 6 months of isoniazid preventive therapy (IPT). Completion of IPT remains a major challenge in resource-limited settings.

OBJECTIVE

To evaluate predictors of IPT completion in individuals newly diagnosed with HIV.

DESIGN

Predictors of IPT completion among adults newly diagnosed with HIV in rural Malawi were evaluated using a multilevel logistic regression model.

RESULTS

Of 974 participants who screened negative for active TB and were started on IPT, 732 (75%) completed treatment. Only one IPT-eligible individual refused treatment. Participants who were aged <25 years (compared with those aged 45 years, adjusted OR [aOR] 0.33, 95%CI 0.18-0.60) and male (compared to non-pregnant females, aOR 0.57, 95%CI 0.37-0.88) had lower odds of IPT completion.

CONCLUSION

IPT provision at the time of initial HIV diagnosis was highly acceptable in rural Malawi; three quarters of those who initiated IPT successfully completed therapy. We observed lower odds of completion among males and among female participants aged <25 years. Additional efforts may be needed to ensure IPT completion among males and young females who have recently been diagnosed with HIV.

Predictors of isoniazid preventive therapy completion among HIV-infected patients receiving differentiated and non-differentiated HIV care in rural Uganda

Rates of Isoniazid Preventive Therapy (IPT) completion remain low in programmatic settings in sub-Saharan Africa. Differentiated HIV care models may improve IPT completion by addressing joint barriers to IPT and HIV treatment. However, the impact of differentiated care on IPT completion remains unknown. In a cross-sectional study of people with HIV on antiretroviral therapy in 5 communities in rural Uganda, we compared IPT completion between patients receiving HIV care via a differentiated care model versus a standard HIV care model and assessed multi-level predictors of IPT completion. A total of 103/144 (72%) patients received differentiated care and 85/161 (53%) received standard care completed IPT (p < 0.01). Adjusting for age, gender and community, patients receiving differentiated care had higher odds of completing IPT (aOR: 2.6, 95% CI: 1.5-4.5, p < 0.01). Predictors of IPT completion varied by the care model, and differentiated care modified the positive association between treatment completion and the belief in the efficacy of IPT and the negative association with side-effects. Patients receiving a multi-component differentiated care model had a higher odds of IPT completion than standard care, and the model's impact on health beliefs, social support, and perceived side effects to IPT may underlie this positive association.

Completion of isoniazid preventive therapy among human immunodeficiency virus positive adults in urban Malawi

SETTING:

Despite worldwide scale-up of human immunodeficiency virus (HIV) care services, relatively few countries have implemented isoniazid preventive therapy (IPT). Among other programmatic concerns, IPT completion tends to be low, especially when not fully integrated into HIV care clinics.

OBJECTIVE:

To estimate non-completion of 6-month IPT and its predictors among HIV-positive adults aged ⩾16 years.

DESIGN:

A prospective cohort study nested within a cluster-randomised trial of TB prevention was conducted between February 2012 and June 2014. IPT for 6 months was provided with pyridoxine at study clinics. Non-completion was defined as loss to follow-up (LTFU), death, active/presumptive TB or stopping IPT for any other reason. Random-effects logistic regression was used to determine predictors of non-completion.

RESULTS:

Of 1284 HIV-positive adults initiated on IPT, 885/1280 (69.1%) were female; the median CD4 count was 337 cells/μl (IQR 199–511); 320 (24.9%) did not complete IPT. After controlling for antiretroviral treatment status, IPT initiation year, age and sex, non-completion of IPT was associated with World Health Organization stage 3/4 (aOR 1.76, 95%CI 1.22–2.55), CD4 count 100–349 cells/μl (aOR 1.93, 95%CI 1.10–3.38) and any reported side effects (aOR 22.00, 95%CI 9.45–46.71).

CONCLUSION:

Completion of IPT was suboptimal. Interventions to further improve retention should target immunosuppressed HIV-positive adults and address side effects.

IPT during HIV treatment in Myanmar: high rates of coverage, completion and drug adherence

Setting: A southern Myanmar district providing isoniazid preventive therapy (IPT) in one of the last countries to formally recommend it as part of human immunodeficiency virus (HIV) care. Objective: To assess coverage and adherence and the feasibility of IPT scale-up in a routine care setting in Myanmar. Design: A retrospective analysis of people living with HIV (PLHIV) screened for tuberculosis (TB) and enrolled in IPT over a 3-year period (July 2011-June 2014) using clinical databases. Results: Among 3377 patients under HIV care and screened for TB, 2740 (81.1%) initiated IPT, with 2651 (96.8%) completing a 6- or 9-month course of IPT; 83 (3.1%) interrupted treatment for different reasons, including loss to follow-up (n = 41), side effects (n = 15) or drug adherence issues (n = 9); 6 (0.2%) died. Among the IPT patients, 33 (1.2%) were diagnosed with TB, including 9 (0.3%) while on IPT and 24 (0.9%) within 1 year of completion of therapy. Among the PLHIV who completed IPT, one case of isoniazid resistance was detected. Conclusion: Scaling up IPT in Myanmar HIV settings is feasible with high rates of drug adherence and completion, and a low rate of discontinuation due to side effects. IPT scale-up should be prioritised in HIV clinical settings in Myanmar.

Routine implementation of isoniazid preventive therapy in HIV-infected patients in seven pilot sites in Zimbabwe

Setting: Seven pilot sites in Zimbabwe implementing 6 months of isoniazid preventive therapy (IPT) for people living with the human immunodeficiency virus (PLHIV). Objectives: To determine, among PLHIV started on IPT, the completion rates for a 6-month course of IPT and factors associated with non-adherence. Design: A retrospective cohort study. Results: Of 578 patients, 466 (81%) completed IPT. Of the 112 patients who failed to complete IPT, 69 (60%) were lost to follow-up, 30 (27%) stopped treatment with no documented reasons, 8 (7%) developed toxicity/adverse reactions, 5 (5%) were documented as having drug stock-outs and the remainder transferred out or refused to continue treatment. Currently being on antiretroviral therapy (ART) (aOR 0.09, 95%CI 0.03-0.28) and receiving a ⩾2 month supply of isoniazid at the start of treatment were associated with a lower risk of not completing IPT, while missing clinic visits prior to starting IPT (aOR 5.25, 95%CI 2.10-13.14) was associated with a higher risk of non-completion. Conclusion: IPT completion rates in seven pilot sites of Zimbabwe were comparatively high, showing that IPT roll-out in public health facilities is feasible. Enhanced adherence counselling or active tracing among pre-ART patients and those with a history of loss to follow-up may improve IPT completion rates, along with synchronising IPT and ART resupplies.

Operational research training: the course and beyond

Insufficient operational research (OR) is generated within programmes and health systems in low- and middle-income countries, partly due to limited capacity and skills to undertake and publish OR in peer-reviewed journals. To address this, a three-module course was piloted by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières in 2009-2010, with 12 participants. Five received mentorship and financial support as OR Fellows. Eleven of 12 participants submitted a paper to a peer-reviewed journal within 4 weeks of the end of the course. Evaluation shows that participants continued OR activities beyond the course. During the subsequent year, they submitted and/or published 19 papers, made 10 posters and/or presentations, and many participated in training, mentoring and/or paper reviewing. Some described changes in policy and practice influenced by their research, and changes in their organisation's approach to OR. They provided recommendations for improving and expanding OR. We conclude that participants can, with certain enabling conditions, take research questions through to publication, use skills gained to undertake and promote OR thereafter and contribute to improvement in policy and practice. An internet-based network will provide participants and graduates with a platform for collection of course outcomes and ongoing mentor- and peer-based support, resources and incentives.

Acceptability and adherence to Isoniazid preventive therapy in HIV-infected patients clinically screened for latent tuberculosis in Dar es Salaam, Tanzania

Background

Proper adherence to isoniazid preventive therapy (IPT) may depend upon the results of tuberculosis (TB) screening test and patients’ understanding of their risk of developing active TB. We conducted a study to assess the acceptability, adherence and completion profile of IPT among HIV-infected patients who were clinically screened for latent TB Infection (LTBI).

Methods

A multicenter observational study was conducted in Dar es Salaam, Tanzania between February 2012 and March 2014. HIV-infected patients 10 years or older were clinically screened using a validated symptom-based screening tool to rule out active TB. Patients found to have no symptoms in the screening tool were given 300 mg of isoniazid (INH) daily for 6 months. Patients were followed up monthly at the National and Municipal hospital HIV clinics for INH refill and assessment of treatment adherence. Adherence was defined as consumption of 90 % or more of the monthly prescription of INH.

Results

All 1303 invited patients agreed to participate in the study. Of 1303 invited HIV-infected patients, 1283 (98.5 %) were recruited into the study. Twenty eight (2.2 %) did not complete treatment. Those who did not complete the treatment were exclusively adults aged 18 years or older, p = 0.302. The overall mean (±SD) adherence was 98.9 % (±2.9). Adherence level among children aged <18 years (92.2 %) was significantly lower than adherence level among patients aged 18–29 years (98.3 %), 30–49 years (98.8 %) and ≥ 50 years (98.5), p-value = 0.011. Sex, occupation, socio-economic status, duration of HIV infection, being on antiretroviral drugs (ARV) and duration of ARV use were not associated with adherence.

Conclusion

IPT is highly accepted by HIV infected patients. Patients demonstrated high level of adherence to IPT. The level of adherence among children was slightly lower than that among adults. IPT non-completers were exclusively adults. Children might need adult supervision in taking IPT.

Incidence and determinants of tuberculosis among adults initiating antiretroviral therapy--Mozambique, 2004-2008

Background

In Mozambique, tuberculosis (TB) is thought to be the most common cause of death among antiretroviral therapy (ART) enrollees. Monitoring proportions of enrollees screened for TB, and incidence and determinants of TB during ART can help clinicians and program managers identify program improvement opportunities.

Methodology/Principal Findings

We conducted a retrospective cohort study among a nationally representative sample of the 79,500 adults (>14 years old) initiating ART during 2004–2007 to estimate clinician compliance with TB screening guidelines, factors associated with active TB at ART initiation, and incidence and predictors of documented TB during ART follow-up. Of 94 sites enrolling >50 adults on ART, 30 were selected using probability-proportional-to-size sampling; 2,596 medical records at these sites were randomly selected for abstraction and analysis. At ART initiation, median age of patients was 34, 62% were female, median baseline CD4⁺ T-cell count was 153/µL, and 11% were taking TB treatment. Proportions of records with TB screening documentation before ART initiation improved from 31% to 66% during 2004–2007 (p<0.001). TB screening compliance varied widely by ART clinic [n = 30, 2%–98% (p<0.001)] and supporting non-Governmental Organization (NGO) [n = 7, 27%–83% (p<0.001)]. Receiving TB treatment at ART enrollment was associated with male sex (p<0.001), weight <45 kg (p<0.001) and CD4<50/µL (p = 0.001). Isoniazid preventive therapy (IPT) was prescribed to <1% of ART enrollees not taking TB treatment. TB incidence during ART was 2.32 cases per 100 person-years. Factors associated with TB incidence included adherence to ART <95% (AHR 2.06; 95% CI, 1.32–3.21).

Conclusion

Variations in TB screening by clinic and NGO may reflect differing investments in TB screening activities. Future scale-up should target under-performing clinics. Scale-up of TB screening at ART initiation, IPT, and ART adherence interventions could significantly reduce incident TB during ART.