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Objective To determine if implementation of 2010 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) initiation reduced delay from tuberculosis diagnosis to initiation of ART in a Cambodian urban hospital. Methods A retrospective cohort study was conducted in a nongovernmental hospital in Phnom Penh that followed new WHO guidelines in patients with human immunodeficiency virus (HIV) and tuberculosis. All ART-naive, HIV-positive patients initiated on antituberculosis treatment over the 18 months before and after guideline implementation were included. A competing risk regression model was used. Findings After implementation of the 2010 WHO guidelines, 190 HIV-positive patients with tuberculosis were identified: 53% males; median age, 38 years; median baseline CD4+ T-lymphocyte (CD4+ cell) count, 43 cells/µL. Before implementation, 262 patients were identified; 56% males; median age, 36 years; median baseline CD4+ cell count, 59 cells/µL. With baseline CD4+ cell counts < 50 cells/µL, median delay to ART declined from 5.8 weeks (interquartile range, IQR: 3.7-9.0) before to 3.0 weeks (IQR: 2.1-4.4) after implementation (P < 0.001); with baseline CD4 + cell counts > 50 cells/µL, delay dropped from 7.0 (IQR: 5.3-11.3) to 3.6 (IQR: 2.9-5.3) weeks (P < 0.001). The probability of ART initiation Within 4 and 8 weeks after tuberculosis diagnosis rose from 23% and 65%, respectively, before implementation, to 62% and 90% after implementation. A non-significant increase in 6-month retention and antiretroviral substitution was seen after implementation. Conclusion Implementation of 2010 WHO recommendations in a routine clinical setting shortens delay to ART. Larger studies with longer follow-up are needed to assess impact on patient outcomes. Objectif Determiner si la mise en oeuvre des lignes directrices 2010 de l'Organisation mondiale de la Sante (OMS) relatives a la mise en oeuvre du traitement antiretroviral (TAR) a reduit le delai entre le diagnostic de la tuberculose et la mise en oeuvre du TAR dans un hopital cambodgien urbain. Methodes Une etude de cohorte retrospective a ete effectuee dans un hopital non gouvernemental de Phnom Penh, appliquant les nouvelles lignes directrices de l'OMS, aupres de patients atteints du virus d'immunodeficience humaine (VlH) et de la tuberculose. Ont ete inclus tous les patients VlH-positifs, n'ayant pas beneficie auparavant d'un TAR, ayant entame un traitement antituberculeux au cours des 18 mois avant et apres la mise en oeuvre des lignes directrices. Un modele de regression a risques concurrents a ete utilise. Resultats Apres la mise en oeuvre des lignes directrices 2010 de l'OMS, 190 patients seropositifs atteints de la tuberculose ont ete identifies: 53% d'hommes; age median: 38 ans; nombre median de lymphocytes T CD4+ (cellule CD4+): 43 cellules/pL. Avant la mise en oeuvre, 262 patients ont ete identifies; 56% d'hommes; age median: 36 ans; nombre median de cellules CD4+: 59 cellules/µL. Avec un nombre median de cellules CD4+ ≤ 50 cellules/µL, le delai median avant leTAR est passe de 5,8 semaines (intervalle interquartile, IIQ: 3,7 a 9) avant, a 3.0 semaines (IIQ: 2,1 a 4,4) apres la mise en oeuvre (P 50 cellules/µL, le delai est passe de 7.0 (IIQ: 5,3 a 11,3) a 3,6 semaines (IIQ: 2,9 a 5,3) (P Conclusion La mise en oeuvre des lignes directrices 2010 de l'OMS dans un contexte clinique de routine raccourcit le delai avant la mise en oeuvre du TAR. Des etudes plus importantes, avec un suivi plus long, seront necessaires pour evaluer l'impact sur les patients. Objetivo Determinar si la puesta en practica de las directrices de la Organizacion Mundial de la Salud (OMS) para el ano 2010 acerca de la iniciacion de la terapia antirretroviral (TAR)redujo la demora desde el diagnostico de tuberculosis hasta el inicio de la TAR en un hospital urbano de Camboya. Metodos Se llevo a cabo un estudio de cohorte retrospectivo en un hospital no gubernamental de Phnom Penh que siguio las directrices nuevas de la OMS en pacientes con el virus de la inmunodeficiencia humana (VIH) y tuberculosis. Se incluyeron todos los pacientes seropositivos que no recibieron TAR y que iniciaron un tratamiento contra la tuberculosis durante los 18 meses antes y despues de la puesta en practica de las directrices. Se utilizo un modelo de regresion de riesgos competitivos. Resultados Tras la puesta en practica de las directrices OMS para el ano 2010, se identificaron 190 pacientes seropositivos con tuberculosis: el 53% de ellos, varones, edad media de 38 anos y un recuento de LT CD4+ (celulas CD4+) como punto de partida con una mediana de 43 celulas/L. Antes de la puesta en practica, se identificaron 262 pacientes; el 56% de ellos, varones;, edad media de 36 anos y un recuento de celulas CD4+ como punto de partida con una mediana de 59 celulas/ µL. Con los recuentos de celulas CD4+ de ≤ 50 celulas/µL como punto de partida, la demora media hasta la TAR disminuyo de 5,8 semanas (rango intercuartilico: 3,7-9,0) antes, a 3,0 semanas (rango intercuartilico: 2,1-4,4) tras la implementacion (P < 0,001); con los recuentos de celulas CD4+ inferiores a 50 celulas/µL como punto de partida, la demora bajo de 7,0 (rango intercuartilico: 5,3-11,3) a 3,6 (rango intercuartilico: 2,9-5,3) semanas (p < 0,001). La probabilidad de iniciar TAR entre 4 y 8 semanas tras el diagnostico de tuberculosis aumento del 23% y el 65%, respectivamente, antes de la implementacion, hasta el 62% y el 90% despues de la misma. Tras la implementacion se observo un aumento no significativo de la retencion a 6 meses, asi como de la sustitucion antirretroviral. Conclusion La puesta en practica de las recomendaciones de la OMS para el ano 2010 en un entorno clinico habitual acorta la demora hasta el inicio de laTAR. Son necesarios estudios mas amplios con seguimientos mayores para evaluar el impacto sobre los resultados en los pacientes., Introduction Tuberculosis remains one of the major causes of death in patients infected with the human immunodeficiency virus (HIV) in resource-limited settings. (1) Initiating antiretroviral therapy (ART) during the treatment [...]

Background Given the lack of detailed studies on tuberculosis (TB) in patients on antiretroviral treatment (ART) in South-East Asia, we aimed to determine the incidence and risk factors for early (after ≤6 months of ART) and late (after >6 months of ART) incident TB in Cambodia. Methods We conducted a retrospective analysis of all patients started on ART at a non-governmental hospital in Phnom Penh (March 2003–December 2010). TB diagnosis was performed according to WHO algorithms. Risk factor analysis was performed using multivariate Cox regression modeling. Results Overall, 2984 patients started ART. The median baseline CD4 count was 89 cells µl−1 (IQR 25–209), median age 34 years (IQR 29–40). Fifty-three percent of the patients were female. Median follow-up time on ART was 2.4 years. In addition to 932 (31.2%) patients already on TB treatment at ART initiation, 313 (10.5%) developed TB, with an overall incidence rate of 3.9/100 patient-years. Of those developing TB, 179 (6.0%) patients were diagnosed with early TB and 134 (4.5%) with late TB, corresponding with a rate of 13.5 and 2.0 per 100 patient-years respectively. Risk factors for early TB included low body mass index, low baseline CD4 count and low hemoglobin levels. Low on-treatment CD4 counts and hemoglobin levels, being underweight while on ART and prevalent TB were identified as risk factors for late TB. Conclusion The incidence of early TB was high, and predominantly associated with advanced HIV progression markers. Earlier ART initiation and enhanced TB screening prior to and after ART initiation is warranted. Late TB amounts to almost half of the total TB burden, meriting specific preventive and diagnostic approaches. [ABSTRACT FROM AUTHOR]