Assessment of the integration of TB and HIV services at different levels of selected health facilities in Ilala District, Dar-es-Salaam

Abstract

Background: In 2015, there were an estimated 10.4 million new cases of Tuberculosis (TB) worldwide of which 1.2 million (11%) were associated with HIV. In Tanzania, the prevalence for TB is estimated at 164 per 100,000 population and about 50% of all TB patients are HIV positive. TB and HIV are overlapping epidemics where HIV is known for being the strongest risk factor for developing TB disease. TB disease is also more common in people living with HIV and accelerates progression of HIV infection. Several studies have shown early antiretroviral therapy (ART) reduces both morbidity and mortality in TB patients co-infected with HIV, hence improving the quality of life. Tanzania started offering HIV services in TB clinics in 2008 as per the World Health Organization recommendations; however no systematic assessment on the extent of integration of HIV services in TB clinics has been done to date. Objective: To determine the level of integration of HIV services in TB clinics in different levels of selected health facilities and associated factors in Ilala district, Dar-es-Salaam. Methodology: A retrospective cohort was established with all adult TB infected patients registered in selected TB clinics from January to December 2016. Data was extracted from facility records using a data compilation sheet and qualitative interviews were held with TB focal persons. Cumulative proportion of TB registered clients provided with HIV counselling and testing and/or initiated on ART was calculated. Survival analysis to determine time to integration was run. Cox regression models were used to identify independent predictors of overall integration of HIV services. Significance level was set at alpha = 5%. Results: A total of 1138 patients, ≥18 years who initiated on TB treatment between January and December 2016 were included in the study after excluding 12 patients with incomplete data. The median age (IQR) of study participants was 35 (28-45) years and 31% were females. Prevalence of TB/HIV co-infection among adult TB patients in our study was 33.7%. Of the 228 co-infected ART naïve patients, 6.6% were not initiated on ART during the TB treatment period. The level of CD4 cell count at the start of TB treatment was strongly associated with timely initiation of ART. Fifty percent (50%) of those with CD4 cell count<100 cells/mm3 were started on ART within 2 weeks after commencing TB treatment as compared to 17.2% of those with CD4 cell counts >300 cells/mm3 (HR = 5.09, 95%CI: 1.82-14.18, p = <0.001).There was no significant association between age, sex or type of TB and timely ART initiation. All TB/HIV patients already on ART were linked to HIV clinics within the recommended time. Conclusion and recommendations: The overall integration of TB/HIV services in TB clinics was at 100%, 98% and 93.4% for HIV screening, CPT coverage and ART coverage respectively. Delays in starting ART were substantial with more than half of ART naive TB/HIV co-infected patients initiated on ART more than 2 weeks post TB diagnosis contrary to the WHO and National guidelines of within 2 weeks and some did not start ART at all during TB treatment. More collaborative and coordinative efforts at district level is needed to ensure all newly diagnosed TB patients are timely started on ART and other HIV care and management services as per WHO and National guidelines.