Study: Does practice follow evolving TB-HIV guidelines, evidence?

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How long is the lag before the new becomes the norm? In the midst of evolving guidelines based on evidence surrounding the treatment of HIV and TB co-infection, the answer can be a matter of life and preventable death. And in resource poor settings, where changes to treatment can face more challenges, and where physicians have less access to professional conferences where data is presented that points to the need to change practices, adjusting treatment to evidence and guidelines has been assumed to take longer, noted authors of a recently released study in Clinical Infectious Diseases. The study, Changes in the timing of antiretroviral therapy initiation in HIV-infected patients with tuberculosis in Uganda: a study of the diffusion of evidence into practice in the global response to HIV/AIDS found that putting guidelines into practice in resource poor settings doesn’t have to take longer in resource-poor settings than in resource-rich settings.

The researchers looked at data over the course of six years from two HIV clinics in Uganda to track the impact of shifting guidelines for starting antiretroviral treatment among patients starting treatment for tuberculosis. The period covered began in 2006, when the World Health Organization recommended TB patients with HIV start antiretroviral treatment within periods ranging from two to 24 weeks of beginning treatment for TB, depending on the level of damage to patients’ immune systems (their immune cell, or CD4 counts). By 2010 the WHO recommended that all co-infected individuals begin antiretroviral treatment within eight weeks of starting treatment for TB, regardless of their immune cell count. But by October 2011 three studies had indicated that for tuberculosis patients with low immune cell counts (less than 50 per cubic millimeter of blood) starting treatment for HIV within two weeks was life-saving, and this led to new guidelines from WHO. Uganda national treatment guidelines followed WHO guidelines.

Researchers found the clinics responded to both WHO and national guidelines with significant changes in antiretroviral treatment initiation. Still, the numbers of patients with low immune cell counts getting antiretroviral treatment within two weeks was still, researchers said, “suboptimal.” Additional studies, they recommended, should delve into provider, patient and structural barriers standing between antiretroviral treatment for people with HIV-associated TB.

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