title: Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection.
abstract: METHODS
  Five primary health care clinics in Kinshasa, Democratic Republic of Congo.
  
  
  OBJECTIVE
  To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment.
  
  
  METHODS
  Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm(3) or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100-350 cells/mm(3), or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤ 350 cells/mm(3) or patient has WHO Clinical Stage 4.
  
  
  RESULTS
  Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm(3)), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and non-disclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation.
  
  
  CONCLUSIONS
  Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.
authors.affiliation: Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: M R
authors.initials: MR
authors.lastname: Patel
authors.affiliation: School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
authors.forename: M
authors.initials: M
authors.lastname: Nana
authors.affiliation: Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: M
authors.initials: M
authors.lastname: Yotebieng
authors.affiliation: School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
authors.forename: M
authors.initials: M
authors.lastname: Tabala
authors.affiliation: Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: F
authors.initials: F
authors.lastname: Behets
authors.affiliation: Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
authors.forename: A
authors.initials: A
authors.lastname: Van Rie
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D000995:Antitubercular Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D016009:Chi-Square Distribution; D060085:Coinfection; D019033:Delivery of Health Care, Integrated; D015023:Democratic Republic of the Congo / Q000453:epidemiology; D004334:Drug Administration Schedule; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014376:Tuberculosis / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents