Linkage to Care and Treatment for TB and HIV among People Newly Diagnosed with TB or HIV-Associated TB at a Large, Inner City South African Hospital

Objective: To assess the outcomes of linkage to TB and HIV care and identify risk factors for poor referral outcomes. Design: Cohort study of TB patients diagnosed at an urban hospital. Methods: Linkage to care was determined by review of clinic files, national death register, and telephone contact, and classified as linked to care, delayed linkage to care (>7 days for TB treatment, >30 days for HIV care), or failed linkage to care. We performed log-binomial regression to identify patient and referral characteristics associated with poor referral outcomes. Results: Among 593 TB patients, 23% failed linkage to TB treatment and 30.3% of the 77.0% who linked to care arrived late. Among 486 (86.9%) HIV-infected TB patients, 38.3% failed linkage to HIV care, and 32% of the 61.7% who linked to care presented late. One in six HIV-infected patients failed linkage to both TB and HIV care. Only 20.2% of HIV-infected patients were referred to a single clinic for integrated care. A referral letter was present in 90.3%, but only 23.7% included HIV status and 18.8% CD4 cell count. Lack of education (RR 1.85) and low CD4 count (CD4 <= 50 vs. >250cells/mm(3); RR 1.66) were associated with failed linkage to TB care. Risk factors for failed linkage to HIV care were antiretroviral-naive status (RR 1.29), and absence of referral letter with HIV or CD4 cell count (RR1.23). Conclusions: Linkage to TB/HIV care should be strengthened by communication of HIV and CD4 results, ART initiation during hospitalization and TB/HIV integration at primary care.