HIV and tuberculosis co-infection in Uganda: clinical management, immune reconstitution and health service delivery

Background In HIV-infected patients, tuberculosis (TB) occurs 20 to 30 times more often and is a leading cause of death. Triple combination antiretroviral therapy (cART) reduces mortality and risk of TB in HIV-infected patients. Uganda is a high-burden country of both HIV and TB; more than half of TB patients are also HIV infected. The objectives of this thesis were 1) to evaluate the current state of HIV and TB management and its effects on mortality and TB in an urban HIV care setting in Uganda, and 2) to implement and evaluate ways to optimise care of co-infected patients. Methods Routinely collected data from the HIV clinic at the Infectious Diseases Institute (IDI) in Kampala, Uganda, were used to assess cART provision, mortality and the risk of TB, as well as to investigate the impact of TB on subsequent immune recovery after cART initiation and to evaluate the implementation and impact of an integrated TB-HIV care model and intensified TB case finding. Results The median CD4+ T cell (CD4) counts at cART initiation increased from 82 cells/mm3 in 2005 to 148 cells/mm3 in 2009 at the IDI. At the same time, mortality rates decreased by almost 50% and TB case finding improved. A later year of cART initiation was associated with reduced mortality independent of the higher baseline CD4 count. An unexpected higher risk of TB after initiation of cART containing efavirenz (EFV) compared to nevirapine in patients with CD4 counts