title: Time to ART Initiation among Patients Treated for Rifampicin-Resistant Tuberculosis in Khayelitsha, South Africa: Impact on Mortality and Treatment Success.
abstract: METHODS
  Khayelitsha, South Africa, with high burdens of rifampicin-resistant tuberculosis (RR-TB) and HIV co-infection.
  
  
  OBJECTIVE
  To describe time to antiretroviral treatment (ART) initiation among HIV-infected RR-TB patients initiating RR-TB treatment and to assess the association between time to ART initiation and treatment outcomes.
  
  
  METHODS
  A retrospective cohort study of patients with RR-TB and HIV co-infection not on ART at RR-TB treatment initiation.
  
  
  RESULTS
  Of the 696 RR-TB and HIV-infected patients initiated on RR-TB treatment between 2009 and 2013, 303 (44%) were not on ART when RR-TB treatment was initiated. The median CD4 cell count was 126 cells/mm3. Overall 257 (85%) patients started ART during RR-TB treatment, 33 (11%) within 2 weeks, 152 (50%) between 2-8 weeks and 72 (24%) after 8 weeks. Of the 46 (15%) who never started ART, 10 (21%) died or stopped RR-TB treatment within 4 weeks and 16 (37%) had at least 4 months of RR-TB treatment. Treatment success and mortality during treatment did not vary by time to ART initiation: treatment success was 41%, 43%, and 50% among patients who started ART within 2 weeks, between 2-8 weeks, and after 8 weeks (p = 0.62), while mortality was 21%, 13% and 15% respectively (p = 0.57). Mortality was associated with never receiving ART (adjusted hazard ratio (aHR) 6.0, CI 2.1-18.1), CD4 count ≤100 (aHR 2.1, CI 1.0-4.5), and multidrug-resistant tuberculosis (MDR-TB) with second-line resistance (aHR 2.5, CI 1.1-5.4).
  
  
  CONCLUSIONS
  Despite wide variation in time to ART initiation among RR-TB patients, no differences in mortality or treatment success were observed. However, a significant proportion of patients did not initiate ART despite receiving >4 months of RR-TB treatment. Programmatic priorities should focus on ensuring all patients with RR-TB/HIV co-infection initiate ART regardless of CD4 count, with special attention for patients with CD4 counts ≤ 100 to initiate ART as soon as possible after RR-TB treatment initiation.
authors.affiliation: Médecins sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: Johnny Flippie
authors.initials: JF
authors.lastname: Daniels
authors.affiliation: Médecins sans Frontières, Luxembourg, Luxembourg.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Khogali
authors.affiliation: Médecins sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: Erika
authors.initials: E
authors.lastname: Mohr
authors.affiliation: Médecins sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: Vivian
authors.initials: V
authors.lastname: Cox
authors.affiliation: Médecins sans Frontières, Khayelitsha, Cape Town, South Africa.|Human Sciences Research Council, HIV/AIDS, STIs and TB programme, Cape Town, South Africa.
authors.forename: Sizulu
authors.initials: S
authors.lastname: Moyo
authors.affiliation: International Union against TB and Lung Disease, Paris, France.|School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Mary
authors.initials: M
authors.lastname: Edginton
authors.affiliation: University of Bergen, Bergen, Norway.
authors.forename: Sven Gudmund
authors.initials: SG
authors.lastname: Hinderaker
authors.affiliation: Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Graeme
authors.initials: G
authors.lastname: Meintjes
authors.affiliation: Médecins sans Frontières, Khayelitsha, Cape Town, South Africa.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hughes
authors.affiliation: City of Cape Town Department of Health, Cape Town, South Africa.
authors.forename: Virginia
authors.initials: V
authors.lastname: De Azevedo
authors.affiliation: Médecins sans Frontières, Khayelitsha, Cape Town, South Africa.|Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
authors.forename: Gilles
authors.initials: G
authors.lastname: van Cutsem
authors.affiliation: Division of Medical Microbiology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Helen Suzanne
authors.initials: HS
authors.lastname: Cox
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D000995:Antitubercular Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D012293:Rifampin / Q000627:therapeutic use*; D013019:South Africa; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents; D012293:Rifampin