WHO/HIV/2013.83 © World Health Organization 2013

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WHO/HIV/2013.83 © World Health Organization 2013

31 Oct 2012 PICO b - This work was commissioned by the World Health Organization and carried out by The University of California, San Francisco (UCSF), Cochrane Review Group on HIV/AIDS

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GRADE tables: PICO b – Does TB diagnosis and/or TB treatment at specialized HIV clinics result in better outcomes than referring people living with HIV to TB clinics for TB diagnosis and/or TB treatment?

Author(s): Sarah Royce, Andrew Anglemyer, Erin McCarthy Date: 2012-08-17

Question: Does TB diagnosis and/or TB treatment at specialized HIV clinics result in better outcomes than referring people living with HIV to TB clinics for TB diagnosis and/or TB treatment?

Settings: Brazil

Bibliography: Bento 2010

Quality assessment No. of patients Effect

QualityImportance No. of

studies Design Risk of

bias Inconsistency IndirectnessImprecision Other considerations

Home visit by team delivers TB and

ART medicine

Patients pick up TB and ART medicine from outpatient department

Relative

(95% CI) Absolute Mortality-matched

1 observational studies

serious⁴ no serious inconsistency

serious³ very serious¹

strong association²

10/48 (20.8%)

3/48 (6.3%)

RR 3.33 (0.98 to 11.37)

146 more per 1000 (from 1 fewer to

648 more)

⊕OOO VERY LOW

CRITICAL

TB treatment success 1 observational

studies

none 36/48

(75%)

35/48 (72.9%)

RR 1.03 (0.81 to 1.30)

219 more)

⊕OOO VERY LOW

CRITICAL Abandonment of treatment one year after discharge

11/48 (22.9%)

26/48 (54.2%)

RR 0.42 (0.24 to 0.76)

314 fewer per 1000 (from 130 fewer to

412 fewer)

⊕OOO VERY LOW

CRITICAL

1 Very few cases (less than 150).

2 Large effect (>2.0 or <0.50).

3 Care not occurring in the clinic in the intervention group; the model of care in the comparator is not specified.

4 The effect estimate could be a result of home visits rather than the provision of TB treatment by an HIV team. Also, in the comparator, patients attending the outpatient department self-administered medicines, whereas those in the intervention group (home care) received directly observed TB treatment and ART.

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WHO/HIV/2013.83 © World Health Organization 2013

31 Oct 2012 PICO b - This work was commissioned by the World Health Organization and carried out by The University of California, San Francisco (UCSF), Cochrane Review Group on HIV/AIDS

2

Settings: Peru

Bibliography: Cerda 2011

Quality Importance No. of

bias Inconsistency IndirectnessImprecision Other considerations

Cerda: CASA providing TB treatment supervised

ART

Referral to DOT for TB (with ART not directly observed)

Relative

(95% CI) Absolute Mortality or loss to follow-up

no serious risk of bias

no serious inconsistency

serious⁴ very serious¹

4/33 (12.1%)³

11/33 (33.3%)³

HR 0.34 (0.12 to 0.98)

205 fewer per 1000 (from 5 fewer to 286

fewer)

⊕OOO VERY LOW

CRITICAL

TB cure

none 27/33

(81.8%)³

18/33 (54.5%)³

RR 1.28 (0.9 to 1.83)

447 more)

⊕OOO VERY LOW

CRITICAL

Hospital days per person per year 1 observational

studies

5.43⁵ 14.82⁵ IRR 0.37

(0.14 to 0.99)

-- ⊕OOO

VERY LOW

IMPORTANT

3 The numbers are count data from the text. The numbers were not used to calculate the relative estimate of effect. They were used to calculate the absolute effect.

4 Care not occurring in the clinic in the intervention group.

5 The numbers are average days per hospitalization from each group; data from text. The numbers were not used to calculate the relative estimate of effect. They were used to calculate the absolute effect.

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WHO/HIV/2013.83 © World Health Organization 2013

31 Oct 2012 PICO b - This work was commissioned by the World Health Organization and carried out by The University of California, San Francisco (UCSF), Cochrane Review Group on HIV/AIDS

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Settings: Uganda

Bibliography: Hermans 2012

Quality Importance No. of

bias Inconsistency Indirectness Imprecision Other considerations

TB treatment in TB/HIV unit in

HIV clinic

TB treatment by TB clinic within

HIV clinic

Relative

(95% CI) Absolute Death or lost among patients not receiving ART

serious¹ no serious inconsistency

serious² very serious³ none 41/99

(41.4%)

52/82 (63.4%)

RR 0.65 (0.49 to 0.87)

323 fewer)

⊕OOO VERY LOW

CRITICAL

Death or lost among patients receiving ART 1 observational

studies

(15.4%)

30/161 (18.6%)

RR 0.83 (0.49 to 1.38)

more)

⊕OOO VERY LOW

CRITICAL

TB treatment success among patients not receiving ART 1 observational

studies

(46.5%)

24/82 (29.3%)

RR 1.59 (1.07 to 2.36)

173 more per 1000 (from 20 more to 398

more)

⊕OOO VERY LOW

CRITICAL

TB treatment success among patients receiving ART 1 observational

studies

serious² serious⁵ none 104/130

(80%)

124/161 (77%)

RR 1.04 (0.92 to 1.17)

131 more)

⊕OOO VERY LOW

CRITICAL

ART initiation among ART-naive patients 1 observational

studies

serious² no serious imprecision

none 130/228

(57%)

161/243 (66.3%)

RR 0.86 (0.75 to 0.99)

fewer)

⊕OOO VERY LOW

CRITICAL ART initiation among ART-naive patients during the intensive phase of TB treatment

serious² very serious³ strong association⁴

78/130 (60%)

37/161 (23%)

RR 2.61 (1.90 to 3.58)

370 more per 1000 (from 207 more to

593 more)

⊕OOO VERY LOW

CRITICAL

ART initiation among ART-naive patients during the continuation phase of TB treatment 1 observational

studies

(33.8%)

88/161 (54.7%)

RR 0.62 (0.47 to 0.82)

290 fewer)

⊕OOO VERY LOW

CRITICAL

ART initiation among ART-naive patients after TB treatment completion

1 observational serious¹ no serious serious² very serious³ strong 8/130 36/161 RR 0.28 161 fewer per 1000 ⊕OOO CRITICAL

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31 Oct 2012 PICO b - This work was commissioned by the World Health Organization and carried out by The University of California, San Francisco (UCSF), Cochrane Review Group on HIV/AIDS

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studies inconsistency association⁴ (6.2%) (22.4%) (0.13 to

0.57)

(from 96 fewer to 195 fewer)

VERY LOW ART initiation among <100 cells/mm³ CD4 ART-naive patients

1 observational

studies serious¹ no serious

inconsistency serious² very serious³ none 65/79

(82.3%) 55/75

(73.3%) RR 1.12 (0.95 to 1.33)

242 more)

⊕OOO VERY LOW

CRITICAL

ART initiation among 100–249 cells/mm³ CD4 ART-naive patients 1 observational

studies serious¹ no serious

inconsistency serious² very serious³ none 34/51

(66.7%) 53/67

(79.1%) RR 0.84 (0.67 to 1.06)

47 more)

⊕OOO VERY LOW

CRITICAL

ART initiation among ≥250 cells/mm³ CD4 ART-naive patients 1 observational

studies

serious² very serious³ strong association⁴

10/53 (18.9%)

19/40 (47.5%)

RR 0.40 (0.21 to 0.76)

375 fewer)

⊕OOO VERY LOW

CRITICAL

1 Possible confounding by many other interventions during the study period that accompanied the reorganization of services.

2 TB services provided within the HIV service in both time periods.

5 Few cases (<300).

Settings: Six African countries Bibliography: Howard 2009

QualityImportance No. of

bias Inconsistency Indirectness Imprecision Other considerations

HIV programmes with TB treatment

on-site

Referral for TB treatment off-

site

Relative

(95% CI) Absolute Adjusted mean proportion screened for TB

serious risk of bias¹

no serious indirectness

no serious imprecision

back-calculated

proportions¹ 14418/18971 (76%)

2265/4044 (56%)

RR 1.36 (95% CI 1.32-1.40)

202 more cases per 1000 (from 179 to 224 more)

⊕OOO VERY LOW

CRITICAL

1 The weighted proportions were used to calculate proportion screened for TB.