title: Successful Tuberculosis Treatment Outcomes among HIV/TB Coinfected Patients Down-Referred from a District Hospital to Primary Health Clinics in Rural South Africa.
abstract: BACKGROUND
  HIV and tuberculosis (TB) coinfection remains a major public health threat in sub-Saharan Africa. Integration and decentralization of HIV and TB treatment services are being implemented, but data on outcomes of this strategy are lacking in rural, resource-limited settings. We evaluated TB treatment outcomes in TB/HIV coinfected patients in an integrated and decentralized system in rural KwaZulu-Natal, South Africa.
  
  
  METHODS
  We retrospectively studied a cohort of HIV/TB coinfected patients initiating treatment for drug-susceptible TB at a district hospital HIV clinic from January 2012-June 2013. Patients were eligible for down-referral to primary health clinics(PHCs) for TB treatment completion if they met specific clinical criteria. Records were reviewed for patients' demographic, baseline clinical and laboratory information, past HIV and TB history, and TB treatment outcomes.
  
  
  RESULTS
  Of 657(88.7%) patients, 322(49.0%) were female, 558(84.9%) were new TB cases, and 572(87.1%) had pulmonary TB. After TB treatment initiation, 280(42.6%) were down-referred from the district level HIV clinic to PHCs for treatment completion; 377(57.4%) remained at the district hospital. Retained patients possessed characteristics indicative of more severe disease. In total, 540(82.2%) patients experienced treatment success, 69(10.5%) died, and 46(7.0%) defaulted. Down-referred patients experienced higher treatment success, and lower mortality, but were more likely to default, primarily at the time of transfer to PHC.
  
  
  CONCLUSIONS
  Decentralization of TB treatment to the primary care level is feasible in rural South Africa. Treatment outcomes are favorable when patients are carefully chosen for down-referral. Higher mortality in retained patients reflects increased baseline disease severity while higher default among down-referred patients reflects failed linkage of care. Better linkage mechanisms are needed including improved identification of potential defaulters, increased patient education, active communication between hospitals and PHCs, and tracing of patients lost to follow up. Decentralized and integrated care is successful for carefully selected TB/HIV coinfected patients and should be expanded.
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York, United States of America.
authors.forename: Karen B
authors.initials: KB
authors.lastname: Jacobson
authors.affiliation: Church of Scotland Hospital, Tugela Ferry, KwaZulu-Natal, South Africa.
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Moll
authors.affiliation: Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America.
authors.forename: Gerald H
authors.initials: GH
authors.lastname: Friedland
authors.affiliation: Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, United States of America.
authors.forename: Sheela V
authors.initials: SV
authors.lastname: Shenoi
mesh_terms: D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006767:Hospitals, District; D006801:Humans; D008297:Male; D011320:Primary Health Care; D012017:Referral and Consultation; D012424:Rural Population; D013019:South Africa; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy*
chemical_list: D000995:Antitubercular Agents