Loss to follow-up and mortality among HIV-infected people co-infected with TB at ART initiation in Durban South Africa.

OBJECTIVE: To quantify the impact of tuberculosis (TB) co-infection on death and loss to follow-up (LTFU) 12 months after entry into an ART program. DESIGN: Prospective intervention study. METHODS: From May 2007 to 2008 patients undergoing pre-ART training in Durban South Africa were screened for pulmonary TB using mycobacterial culture. Subjects missing appointments for >3 months were phoned. Patients who could not be reached were considered LTFU. Deaths were ascertained by report from family members. We used the Kaplan-Meier method to estimate time to LTFU or death for 3 groups at enrollment as follows: (1) newly diagnosed with TB by sputum culture; (2) on TB treatment (ie previously diagnosed); and (3) TB free. We evaluated the role of TB on mortality and LTFU using Cox proportional hazards models. RESULTS: Nine hundred fifty-one HIV-infected subjects were enrolled; 59% were female and median baseline CD4 count was 90 cells per microliter (IQR: 41-148 cells/muL). One hundred forty-four (15%) were newly diagnosed with TB by sputum culture; an additional 199 (21%) were already on TB treatment. By 12 months 26% newly diagnosed with TB at enrollment died or were LTFU compared with 19% already on TB treatment and 14% who were TB free (P = 0.001). Controlling for age sex smoking CD4 and opportunistic infection history subjects newly diagnosed with pulmonary TB were 76% more likely to die or be LTFU (hazard ratio: 1.76 95% confidence interval: 1.20 to 2.60) than those without TB. CONCLUSIONS: HIV/TB co-infected individuals are more likely to die or be LTFU within 12 months of ART clinic entry in South Africa. These patients require intensive follow-up during ART initiation.