title: Timing of antiretroviral therapy in Cambodian hospital after diagnosis of tuberculosis: impact of revised WHO guidelines.
abstract: OBJECTIVE
  To determine if implementation of 2010 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) initiation reduced delay from tuberculosis diagnosis to initiation of ART in a Cambodian urban hospital.
  
  
  METHODS
  A retrospective cohort study was conducted in a nongovernmental hospital in Phnom Penh that followed new WHO guidelines in patients with human immunodeficiency virus (HIV) and tuberculosis. All ART-naïve, HIV-positive patients initiated on antituberculosis treatment over the 18 months before and after guideline implementation were included. A competing risk regression model was used.
  
  
  RESULTS
  After implementation of the 2010 WHO guidelines, 190 HIV-positive patients with tuberculosis were identified: 53% males; median age, 38 years; median baseline CD4+ T-lymphocyte (CD4+ cell) count, 43 cells/µL. Before implementation, 262 patients were identified; 56% males; median age, 36 years; median baseline CD4+ cell count, 59 cells/µL. With baseline CD4+ cell counts ≤ 50 cells/µL, median delay to ART declined from 5.8 weeks (interquartile range, IQR: 3.7-9.0) before to 3.0 weeks (IQR: 2.1-4.4) after implementation (P < 0.001); with baseline CD4+ cell counts > 50 cells/µL, delay dropped from 7.0 (IQR: 5.3-11.3) to 3.6 (IQR: 2.9-5.3) weeks (P < 0.001). The probability of ART initiation within 4 and 8 weeks after tuberculosis diagnosis rose from 23% and 65%, respectively, before implementation, to 62% and 90% after implementation. A non-significant increase in 6-month retention and antiretroviral substitution was seen after implementation.
  
  
  CONCLUSIONS
  Implementation of 2010 WHO recommendations in a routine clinical setting shortens delay to ART. Larger studies with longer follow-up are needed to assess impact on patient outcomes.
authors.affiliation: Sihanouk Hospital Centre of Hope, St. 134, Sangkat Vealvong, Khan 7 Makara, Phnom Penh, Cambodia.
authors.forename: Kimcheng
authors.initials: K
authors.lastname: Choun
authors.forename: Reaksmey
authors.initials: R
authors.lastname: Pe
authors.forename: Sopheak
authors.initials: S
authors.lastname: Thai
authors.forename: Natalie
authors.initials: N
authors.lastname: Lorent
authors.forename: Lutgarde
authors.initials: L
authors.lastname: Lynen
authors.forename: Johan
authors.initials: J
authors.lastname: van Griensven
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D002160:Cambodia / Q000453:epidemiology; D015897:Comorbidity; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D012044:Regression Analysis; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014376:Tuberculosis / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D014944:World Health Organization
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents