Background: Tuberculosis (TB) remains the leading cause of morbidity among people living with HIV (PLHIV) in Central Asia. WHO recommends that all TB patients co-infected with HIV (TB/HIV patients) start TB treatment first and then ART within 8 weeks of TB treatment initiation, unless CD4 < 50 cells/µl when ART should be started within 2 weeks, given the demonstrated survival benefit. In 2016, ICAP conducted a study to assess initiation of ART in TB/HIV patients at nine HIV care and treatment sites in Kazakhstan and Kyrgyzstan.
Description: To assess ART initiation rates, we conducted a retrospective review and analysis of 590 records of TB/HIV patients that were enrolled in HIV care and started TB treatment during 2015. Nine sites were selected on the basis of geographical location, strategic role for the country, number of PLHIV enrolled in care, and the number of TB/HIV cases. To determine obstacles to prompt ART initiation, we conducted semi-structured small group interviews with 37 physicians that provide HIV treatment services.
Lessons learned: During 2015, there were 316 new and 180 relapse TB cases in Kazakhstan. Among them, 221 and 123 patients started ART during TB treatment. In Kyrgyzstan, there were 74 new and 20 relapse TB cases with 48 and 15 of them respectively started on ART during TB treatment. Overall, ART coverage of TB/HIV patients during TB treatment was 70% among new and 68% among relapse TB cases in Kazakhstan, and 65% and 75% in Kyrgyzstan respectively. Many physicians were reluctant to initiate ART in patients receiving TB treatment fearing patients'' poor adherence. In the opinion of physicians, patients were also hesitant to start ART while on TB treatment because of concern for high pill burden and complicated regimens.
Conclusions/Next steps: ART coverage among TB/HIV patients is low. Physicians do not initiate ART during TB treatment in sufficient numbers as they fear poor adherence. Additional training to promote early ART initiation among medical staff, as well as introduction of optimized one-pill a day ART regimens may increase ART initiation in TB/HIV patients. In addition, increased integration between TB and HIV services may also help increase ART coverage in TB/HIV patients.