Healthcare provision for HIV co-infected tuberculosis patients in rural Zambia: an observational cohort study at primary care centers

Background Linkage of healthcare services for tuberculosis (TB) and human immunodeficiency virus (HIV) remains a major challenge in resource-limited settings. Our operational research aimed to evaluate the linkage between TB and HIV services in a rural area of Zambia, and to explore factors associated with the enrolment of TB/HIV co-infected patients in HIV care services. Methods All TB patients newly diagnosed as HIV-positive in Chongwe district, Zambia between 2009 and 2010 were included. Data from TB registers and medical records were reviewed. Patient referral to HIV services and provision of antiretroviral therapy (ART) were further examined through HIV registers and records. Results Of 621 patients (median age 33.0 years, female 42.4%) who started anti-TB treatment, clinic records indicated that 297 patients were newly diagnosed as HIV-positive, and 176 (59.3%) of these were referred to an ART clinic. Analysis of records at the ART clinic found that only 85 (28.6%) of TB/HIV patients had actually been enrolled in HIV care, of whom only 58 (68.2%) had commenced ART. Logistic regression analyses demonstrated the following factors associated with lower enrolment: “male” sex (aOR, 0.45; 95% CI 0.26-0.78), “previous TB treatment” (aOR, 0.29; 95% CI, 0.11-0.75), “registration at sites that did not provide ART services (non-ART site)” (aOR, 0.10; 95% CI, 0.01-0.77) and “death on TB treatment outcome (aOR, 0.20; 95% CI, 0.06-0.65). However, patient registration at TB clinics in 2010 was associated with markedly higher enrolment in HIV care as compared to registration in 2009 (aOR, 2.80; 95% CI, 1.53-5.12). Conclusions HIV testing for TB patients has been successfully scaled up. However referrals of co-infected patients still remain a challenge due to poor linkage between TB and HIV healthcare services. Committed healthcare workers, a well-organized health services system and patient education are urgently required to ensure a higher rate of referral of TB/HIV co-infected patients for appropriate care.