WHO/HIV/2013.83
© World Health Organization 2013
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 studies Design Risk of Other Inconsistency Indirectness Imprecision bias considerations serious3 very serious1 strong association2
No. of patients Home visit by team Patients pick up TB and delivers TB and ART medicine from ART medicine outpatient department 10/48 (20.8%) 3/48 (6.3%) Relative (95% CI) RR 3.33 (0.98 to 11.37) RR 1.03 (0.81 to 1.30) RR 0.42 (0.24 to 0.76)
Effect Quality Importance Absolute
Mortality-matched 1 observational serious4 no serious studies inconsistency TB treatment success 1 observational serious4 no serious studies inconsistency
146 more per 1000 ⊕OOO CRITICAL (from 1 fewer to VERY 648 more) LOW 22 more per 1000 ⊕OOO CRITICAL (from 139 fewer to VERY 219 more) LOW 314 fewer per 1000 ⊕OOO CRITICAL (from 130 fewer to VERY 412 fewer) LOW
serious3
very serious1
none
36/48 (75%)
35/48 (72.9%)
Abandonment of treatment one year after discharge 1 observational serious4 no serious serious3 studies inconsistency 1 2
very serious1
strong association2
11/48 (22.9%)
26/48 (54.2%)
Very few cases (less than 150). 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.
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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WHO/HIV/2013.83
© World Health Organization 2013
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: Peru Bibliography: Cerda 2011
Quality assessment No. of studies Risk of bias
No. of patients
Effect Quality Importance Absolute
Design
Cerda: CASA Referral to DOT for Other providing TB Relative Inconsistency Indirectness Imprecision TB (with ART not considerations treatment supervised (95% CI) directly observed) ART serious4 very serious1 strong association2 4/33 (12.1%)3 11/33 (33.3%)3 HR 0.34 (0.12 to 0.98)
Mortality or loss to follow-up 1 observational no serious no serious studies risk of inconsistency bias
205 fewer per 1000 (from 5 fewer to 286 fewer)
⊕OOO VERY LOW
CRITICAL
TB cure 1 observational no serious no serious serious4 very none 27/33 18/33 RR 1.28 153 more per 1000 ⊕OOO CRITICAL studies risk of inconsistency serious1 (81.8%)3 (54.5%)3 (0.9 to 1.83) (from 55 fewer to VERY bias 447 more) LOW Hospital days per person per year strong 5.435 1 observational no serious no serious serious4 very 14.825 IRR 0.37 -⊕OOO IMPORTANT association2 studies risk of inconsistency serious1 (0.14 to VERY bias 0.99) LOW 1 Very few cases (less than 150). 2 Large effect (>2.0 or <0.50). 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.
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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© World Health Organization 2013
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: Uganda Bibliography: Hermans 2012
Quality assessment No. of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations none
No. of patients TB treatment in TB/HIV unit in HIV clinic 41/99 (41.4%) TB treatment by TB clinic within HIV clinic 52/82 (63.4%) Relative (95% CI) RR 0.65 (0.49 to 0.87) RR 0.83 (0.49 to 1.38) RR 1.59 (1.07 to 2.36) RR 1.04 (0.92 to 1.17) RR 0.86 (0.75 to 0.99) RR 2.61 (1.90 to 3.58) RR 0.62 (0.47 to 0.82) RR 0.28
Effect Quality Importance Absolute
Death or lost among patients not receiving ART 1 observational serious1 no serious studies inconsistency Death or lost among patients receiving ART 1 observational serious1 no serious studies inconsistency
serious2
very serious3
222 fewer per 1000 (from 82 fewer to 323 fewer)
⊕OOO CRITICAL VERY LOW
serious2
very serious3
none
20/130 (15.4%)
30/161 (18.6%)
32 fewer per 1000 ⊕OOO CRITICAL (from 95 fewer to 71 VERY more) LOW 173 more per 1000 ⊕OOO CRITICAL (from 20 more to 398 VERY more) LOW 31 more per 1000 (from 62 fewer to 131 more) ⊕OOO CRITICAL VERY LOW
TB treatment success among patients not receiving ART 1 observational serious1 no serious serious2 studies inconsistency TB treatment success among patients receiving ART 1 observational serious1 no serious serious2 studies inconsistency ART initiation among ART-naive patients 1 observational serious1 no serious studies inconsistency
very serious3
none
46/99 (46.5%)
24/82 (29.3%)
serious5
none
104/130 (80%)
124/161 (77%)
serious2
no serious imprecision
none
130/228 (57%)
161/243 (66.3%)
93 fewer per 1000 ⊕OOO CRITICAL (from 7 fewer to 166 VERY fewer) LOW 370 more per 1000 (from 207 more to 593 more) 208 fewer per 1000 (from 98 fewer to 290 fewer) 161 fewer per 1000 ⊕OOO CRITICAL VERY LOW ⊕OOO CRITICAL VERY LOW ⊕OOO CRITICAL
ART initiation among ART-naive patients during the intensive phase of TB treatment 1 observational serious1 no serious serious2 very serious3 strong studies inconsistency association4 ART initiation among ART-naive patients during the continuation phase of TB treatment 1 observational serious1 no serious serious2 very serious3 none studies inconsistency ART initiation among ART-naive patients after TB treatment completion 1 observational serious1 no serious serious2 very serious3
78/130 (60%)
37/161 (23%)
44/130 (33.8%)
88/161 (54.7%)
strong
8/130
36/161
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) RR 1.12 (0.95 to 1.33) RR 0.84 (0.67 to 1.06) RR 0.40 (0.21 to 0.76)
(from 96 fewer to 195 fewer) 88 more per 1000 (from 37 fewer to 242 more) 127 fewer per 1000 (from 261 fewer to 47 more) 285 fewer per 1000 (from 114 fewer to 375 fewer)
VERY LOW ⊕OOO CRITICAL VERY LOW ⊕OOO CRITICAL VERY LOW ⊕OOO CRITICAL VERY LOW
ART initiation among <100 cells/mm3 CD4 ART-naive patients 1 observational serious1 no serious serious2 very serious3 studies inconsistency ART initiation among 100–249 cells/mm3 CD4 ART-naive patients 1 observational serious1 no serious serious2 very serious3 studies inconsistency ART initiation among ≥250 cells/mm3 CD4 ART-naive patients 1 observational serious1 no serious serious2 very serious3 studies inconsistency 1 2
none
65/79 (82.3%)
55/75 (73.3%)
none
34/51 (66.7%)
53/67 (79.1%)
strong association4
10/53 (18.9%)
19/40 (47.5%)
Possible confounding by many other interventions during the study period that accompanied the reorganization of services. TB services provided within the HIV service in both time periods. 3 Very few cases (less than 150). 4 Large effect (>2.0 or <0.50). 5 Few cases (<300).
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: Six African countries Bibliography: Howard 2009
Quality assessment No. of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations back-calculated proportions1
No. of patients HIV programmes Referral for TB with TB treatment treatment offon-site site Relative (95% CI)
Effect Quality Importance Absolute
Adjusted mean proportion screened for TB 1 observational serious no serious no serious no serious studies risk of inconsistency indirectness imprecision bias1 1 The weighted proportions were used to calculate proportion screened for TB.
14418/18971 (76%)
2265/4044 (56%)
RR 1.36 202 more cases per ⊕OOO CRITICAL (95% CI 1000 (from 179 to VERY 1.32-1.40) 224 more) LOW
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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