Research question
What is the burden and impact of TB on HIV-infected patients?

Fit with Africa Centre research portfolio
This research fits in Objective 1 of the Africa Centre’s current research activities – understanding the impact of ART roll-out at individual, household, clinic and community level.

Data sources used
Data sources used include ARTemis, ACDIS, TB database, retrospective case note study of those initiating ART between Jan 2005-March 2006.

Methods/study design
Analysis of patients in the TB database March 2008-February 2009. Analysis of 801 HIV-infected adults initiating ART between January 2005 to March 2006. Analysis of cases who initiated community-based MDR-TB treatment between March and December 2008 were compared with patients who initiated MDR-TB treatment under the traditional hospital-based model of care between January 2001 and February 2008.

Preliminary findings
The TB notification rate in 2008 was approximately 1,700 per 100,000. Of 2,953 patients starting TB treatment in the programme, 53% were female, 91.9% had pulmonary TB of whom 16.7% were smear positive. At the end of the observation period, HIV status was available for 88% of patients; overall prevalence was 76%.

TB prevalence at ART initiation in the 801 individuals was 25.3%, significantly associated with lower CD4 count and prior TB. Incidence after ART initiation was 6.89 per 100 person years from 81 cases over 1706 person-years analysis time and was highest in the first 3 months on treatment.

Analysis of the MDR-TB cases included 50 cases in the community-based MDR-TB programme (CM) and 57 cases receiving MDR-TB treatment under the traditional hospital-based model of care (TM).  39/50 CM cases (78.0%) were HIV positive. The median time to initiation of treatment was 84 days for CM and 106.5 days for TM (p= 0.002). Median time to sputum smear conversion was shorter for CM than TM (59 days vs. 92 days; p = 0.055) as was time to sputum culture conversion (85 days vs. 119 days; p = 0.002)

Policy implications
With simple measures high uptake of HIV testing in TB patients can be achieved in public-sector primary care in rural South Africa, a first step towards integrating TB and HIV.  Community-based treatment for MDR-TB can be implemented within the existing TB control programme in rural South Africa and should be scaled up where resources allow. Further work to investigate a molecular point-of-care TB diagnostic system for MDR-TB would be taken forward in a PhD fellowship by Dr Richard Lessells.