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The Impact of Implementation Fidelity on Mortality Under a CD4-Stratified Timing Strategy for Antiretroviral Therapy in Patients With Tuberculosis.
- Source :
-
American journal of epidemiology [Am J Epidemiol] 2015 May 01; Vol. 181 (9), pp. 714-22. Date of Electronic Publication: 2015 Mar 18. - Publication Year :
- 2015
-
Abstract
- Among patients with tuberculosis and human immunodeficiency virus type 1, CD4-stratified initiation of antiretroviral therapy (ART) is recommended, with earlier ART in those with low CD4 counts. However, the impact of implementation fidelity to this recommendation is unknown. We examined a prospective cohort study of 395 adult patients diagnosed with tuberculosis and human immunodeficiency virus between August 2007 and November 2009 in Kinshasa, Democratic Republic of the Congo. ART was to be initiated after 1 month of tuberculosis treatment at a CD4 count of <100 cells/mm(3) or World Health Organization stage 4 (other than extrapulmonary tuberculosis) and after 2 months of tuberculosis treatment at a CD4 count of 100-350 cells/mm(3). We used the parametric g-formula to estimate the impact of implementation fidelity on 6-month mortality. Observed implementation fidelity was low (46%); 54% of patients either experienced delays in ART initiation or did not initiate ART, which could be avoided under perfect implementation fidelity. The observed mortality risk was 12.0% (95% confidence interval (CI): 8.2, 15.7); under complete (counterfactual) implementation fidelity, the mortality risk was 7.8% (95% CI: 2.4, 12.3), corresponding to a risk reduction of 4.2% (95% CI: 0.3, 8.1) and a preventable fraction of 35.1% (95% CI: 2.9, 67.9). Strategies to achieve high implementation fidelity to CD4-stratified ART timing are needed to maximize survival benefit.<br /> (© The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)
- Subjects :
- Adult
CD4 Lymphocyte Count
Democratic Republic of the Congo epidemiology
Female
HIV Infections complications
HIV Infections immunology
HIV Infections mortality
Humans
Male
Middle Aged
Prospective Studies
Anti-Retroviral Agents administration & dosage
Guideline Adherence statistics & numerical data
HIV Infections drug therapy
Primary Health Care statistics & numerical data
Tuberculosis complications
Subjects
Details
- Language :
- English
- ISSN :
- 1476-6256
- Volume :
- 181
- Issue :
- 9
- Database :
- MEDLINE
- Journal :
- American journal of epidemiology
- Publication Type :
- Academic Journal
- Accession number :
- 25787266
- Full Text :
- https://doi.org/10.1093/aje/kwu338