Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection

SETTING: Five primary health care clinics in Kinshasa, Democratic Republic of Congo. OBJECTIVE: To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment. DESIGN: Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm³ or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100- 350 cells/mm³, or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤350 cells/mm³ or patient has WHO Clinical Stage 4. RESULTS : Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm³), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and nondisclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation. CONCLUSION: Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.