Background: Ukraine is one of the 10 countries with the highest incidence of multi-drug resistant TB; about a quarter of all TB patients are also infected with HIV. The USAID-funded Strengthening Tuberculosis Control in Ukraine project aims to improve the integration of TB and HIV services to reduce mortality through early diagnosis and treatment of TB- and HIV-coinfected clients. This study examined changes in the integration of TB and HIV services, and factors that facilitate or impede timely access to testing and treatment services for TB- and HIV-coinfected clients in project intervention regions.
Methods: We conducted 53 in-depth interviews with three stakeholder groups: 30 TB- and HIV-coinfected clients; 17 infectious disease and TB providers; and six coinfection specialists. We also conducted six focus group discussions with providers. All discussions were digitally recorded, translated, and transcribed. Using ATLAS.ti, we synthesized data based on key themes that were identified using deductive and inductive coding, and then presented results using direct quotes to support themes.
Results: The HIV-TB integration program affected several positive changes in the integration of services, especially around availability of diagnostic tests across facilities, training of providers, and improved communication and collaboration across services. However, client databases are not consistently shared across all TB and HIV services, which makes coordination challenging and further increases travel costs for patients, as they have to travel between TB and HIV clinics. Providers spoke of clients'' inability to accept their HIV diagnosis and follow treatment instructions, short-staffed facilities, and infrastructure issues such as buildings that needed repair as key barriers. From the clients'' perspective, barriers to accessing care included: dealing with HIV-related stigma; long lines at facilities; high out-of-pocket costs associated with travel, inpatient stay, laboratory work, and medications; confusion about where to go to receive treatment; and confusion about medication regimens and their debilitating side effects.
Conclusions: The study suggests that while improvements in diagnostic testing and coordination across TB and HIV facilities is well underway, factors such as stigma, emotional burden, adequate education to deal with the side effects of the medication, and high patient out-of-pocket costs still need to be addressed.

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