Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa.

BACKGROUND: Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV) infected individuals in South Africa. Despite the implementation of HIV/TB integration services at primary healthcare facility level, the effect of HIV on TB treatment outcomes has not been well investigated. To provide evidence base for TB treatment outcome improvement to meet End TB Strategy goal, we assessed the effect of HIV status on treatment outcomes of TB patients at a rural clinic in the Ugu Health District, South Africa.
METHODS: We reviewed medical records involving a cohort of 508 TB patients registered for treatment between 1 January 2013 and 31 December 2015 at rural public sector clinic in KwaZulu-Natal province, South Africa. Data were extracted from National TB Programme clinic cards and the TB case registers routinely maintained at study sites. The effect of HIV status on TB treatment outcomes was determined by using multinomial logistic regression. Estimates used were relative risk ratio (RRR) at 95% confidence intervals (95%CI).
RESULTS: A total of 506 patients were included in the analysis. Majority of the patients (88%) were new TB cases, 70% had pulmonary TB and 59% were co-infected with HIV. Most of HIV positive patients were on antiretroviral therapy (ART) (90% (n = 268)). About 82% had successful treatment outcome (cured 39.1% (n = 198) and completed treatment (42.9% (n = 217)), 7% (n = 39) died 0.6% (n = 3) failed treatment, 3.9% (n = 20) defaulted treatment and the rest (6.6% (n = 33)) were transferred out of the facility. Furthermore, HIV positive patients had a higher mortality rate (9.67%) than HIV negative patients (2.91%)". Using completed treatment as reference, HIV positive patients not on ART relative to negative patients were more likely to have unsuccessful outcomes [RRR, 5.41; 95%CI, 2.11-13.86].
CONCLUSIONS: When compared between HIV status, HIV positive TB patients were more likely to have unsuccessful treatment outcome in rural primary care. Antiretroviral treatment seems to have had no effect on the likelihood of TB treatment success in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients emphasizing the need for enhanced integrated management of HIV/TB in rural South Africa through active screening of TB among HIV positive individuals and early access to ART among HIV positive TB cases.

1. Background

Tuberculosis (TB) is one of the major global infectious diseases with a high morbidity and mortality rate. Globally, an estimated 10.0 million (range 8.9–11.0 million) people fell ill with TB in 2019 [1]. There were 1.2 million (range, 1.1–1.3 million) TB deaths among human immunodeficiency virus (HIV)—negative people and an additional 208 000 (range, 177 000–242 000) TB deaths among HIV-positive people [1]. Ninety percent (90%) of all TB cases occur in adults, with a high prevalence in males compared to females [2]. The increase in incidence is also attributed to the development of multidrug resistant (MDR) and extremely drug resistant (XDR) strains of Mycobacterium tuberculosis [3]. Both MDR and XDR-TB are the causes of high TB mortality [4]. HIV prevalence in sub-Saharan Africa has significantly contributed to an increase in the incidence of TB [5]. An estimated 10 million people have been living with TB and 1.5 million have died in 2018 and the global burden of TB falls on 20 low-and middle-income (LMIC) countries, including sub-Saharan Africa [6]. The burden is attributed to the high rate of HIV/AIDS pandemics in those countries. Africa accounted for 84% of all TB/HIV deaths [6].

TB is the most common opportunistic infection and cause of death among PLWHIV in resource-limited countries [7, 8]. In the post-mortem period, the overall prevalence of TB was enormous and accounted for almost 40% of HIV-related facility-based deaths in resource-limited countries such as South Africa [9-11], Botswana [11, 12], Zimbabwe [11, 13, 14], Mozambique [11, 15], Uganda [11, 16] and Kenya [11, 17]. In contrast, the WHO reported 16% of HIV/TB related death in Africa [1].

South Africa (SA) ranked fifth among the highest TB incidences worldwide and first among TB/HIV co-infection cases with more than 65 percent of patients co-infected with TB/HIV [5]. TB accounted for the third highest number of deaths in 2018 (6%; n = 454,014), and combined TB and HIV accounted for 35.6% of all-cause mortality in SA [18-20]. The total number of people living with HIV in SA increased from an estimated 4.64 million in 2002 to 7.97 million by 2019 [21]. There are significant geographical variations in the rate of TB notification in SA which are not clearly correlated with the prevalence of HIV at the district level [21-23]. KwaZulu-Natal (KZN) carries the largest burden of HIV and related infections in SA, with HIV–TB co-infection estimated at approximately 70% [5, 24], and Ugu district reported 60.5% of TB/HIV co-infection rate [25].

According to recent data, 90% of people are aware of their HIV status of which 68% are on antiretroviral therapy (ART) and of which 87% are virally suppressed in SA [26]. ART may be associated with a reduced risk of HIV-associated TB disease in HIV-positive individuals due to a decrease in their viral load and an improvement in their immune system function [27]. On the one hand, while ART reduces new HIV infections, on the other hand, the marked decline in HIV-associated mortality has led to an increase in HIV prevalence and an increase in the number of life-years at TB risk. It is also plausible that HIV-positive people with TB infection may increase with CD4+ T-cell ART recovery, although the available data do not support this [27-29]. In addition, early initiation of ART during TB treatment (within 2–4 weeks) increased AIDS-free survival by 34–68% among patients with advanced HIV disease [11, 30–32]. Despite the inclusion of TB-HIV in the international and SA guidelines, the 2018 mortality rate for co-infected TB-HIV patients in SA was 73 (51–99) per 100,000 populations, which is more than three times higher than that for HIV-negative TB patients with a mortality rate of 37 (35–39) per 100,000 population [33]. TB incidence and mortality are declining in SA [7]. Data from a well-characterized rural SA population with high HIV prevalence and TB incidence demonstrated considerable spatial heterogeneity in people with recently diagnosed TB, and has shown that every percentage increase in ART coverage was associated with a 2% decrease in the odds of recently diagnosed TB [23].

The End TB Strategy aims to reduce TB deaths by 90% and TB incidence rates by 80% in 2030 compared to 2015 [34]. Examining the various challenges that may impact on TB outcomes in rural primary health care in SA, the TB elimination target set for 2050 could be compromised if this dual burden of TB and HIV diseases is not controlled [5, 35]. The rate of TB incident stabilizes at a rate higher than that of the general population. These data highlight the need for more research into strategies for finding active cases in rural settings and the need to focus on strengthening primary health care [36]. Therefore, this retrospective study has been undertaken to determine TB outcomes in HIV positive patients in rural primary healthcare in Ugu Health District, KwaZulu-Natal, SA.

2. Methods

2.1. Study design

This retrospective cohort study of TB patients initiated on TB treatment was conducted from 1 January 2013 to 31 December 2015.

2.2. Study population

We included all patients diagnosed with TB irrespective of their age and HIV status in the study. Further, we included individuals that were registered as TB patients in 2012 and completed treatment or died in 2013. We also included as well as those that died or survived during the treatment period. Patients with unknown outcome or those with incomplete record were excluded Basic demographic information including the age, gender, co-morbidities, tobacco Use, alcohol Use, substance use and duration on treatment were collected.

2.3. Study setting

The Ugu Health District is in the rural aspects of the KwaZulu-Natal (KZN) province (Figs 1 & 2). Ugu district has a population of 733 228 people [37]. During the study period, Ugu district had the highest HIV prevalence and TB incidence of any district in KZN, 41.7% and 1096 per 100,000 people, respectively [37]. In terms of infectious TB (pulmonary smear-positive), Ugu ranks 12th, with 325 cases per 100,000 people, which is higher than the country’s average of 208 cases per 100,000 people [37]. Elim clinic, a primary health care facility was selected based on convenience, the study goal, and the availability of information on HIV and TB infections”.

Fig 1

TB treatment success rate in South African districts.

Fig 2

TB treatment success rate in Ugu district/South Africa.

2.4. Sample size

A total of 478 cases were estimated to be adequate sample that would have the power to detect a significant difference in mortality between HIV positive and negative TB patients on anti-tuberculosis treatment. We used a 95% precision of estimate with power of 80% and estimated risk difference of 6% in outcome between exposed and unexposed.

2.5. Participant selection and definitions

All TB patients of all ages recorded in the TB treatment register, with HIV positive status and started on treatment were included in this study. These were all TB patients on treatment attending care at Elim Clinic, in Ugu District, KZN province within the stipulated time. At admission, patients were screened for other comorbidities including HIV infection. After following the treatment, the outcomes of treatment were recorded in seven mutually exclusive categories. Patients were classified as cured, completed treatment, interrupted treatment, moved, transferred out, failed, and died. The main interest of this study was to compare the likelihood of observing two main outcomes. These included being cured versus all other outcomes including death and the likelihood of dying versus staying alive regardless of the outcome of treatment. The World Health Organization (WHO) defines “cured” as follows: a pulmonary TB patient with bacteriologically confirmed TB at the start of treatment who was smear or culture negative in the last month of treatment and on at least one previous occasion, and "treatment completed": A TB patient who completed treatment without evidence of failure but with no record to show that sputum smear or culture results in the last month of treatment and on at least one previous occasion were negative either because tests were not done or because results are unavailable [38]. Treatment success includes the sum of cured and treatment completed [38].

2.6. Outcome and exposures

The first outcome of interest was “treatment success” defined as 1 if the patient was declared “treatment success” by the healthcare team or 0 if otherwise. The second outcome was “death” coded 1 if the patient was declared dead and 0 if otherwise. Given the small number of deaths which were 35 in total, we created a nominal outcome, which captured all outcomes and combined them into 3 categories: treatment success, dead and other outcomes.

2.7. Data collection

Data were extracted from the TB register using structured data collection form from all the TB patients initiated on treatment at this rural public health clinic from 1 January 2013 and 31 December 2015. The data consists of collecting socio-demographic factors (age and gender), TB related factors (categories, pre-treatment smear, type, site, outcome duration, regimen at the baseline) and other factors such as ART initiation and co-trimoxazole prophylaxis, comorbidities, tobacco, and alcohol use. A data dictionary was formulated to guide data cleaning and analysis. No personal identifiers were extracted from the manual medical records.

2.8. Data management

Data were entered on excel spread sheet and imported into Stata software. This step was followed by thorough checking to assess missing values. Data were coded into numerical values and continuous data categorised; clean data were imported into Stata version 15 for analysis.

2.9. Data analysis

The main interest of this study was to compare the likelihood of observing two main outcomes. These included being cured versus all other outcomes including death and the likelihood of dying versus staying alive regardless of the outcome of treatment. Data were summarized and presented in tables. As part of the descriptive statistics for the population under study, summary tables were constructed to describe variables in terms of their frequency distribution. Pearson Chi-square and Fisher Exact tests were used to test association between independent variables and TB outcomes (cured, completed treatment, interrupted treatment, moved, transferred out, failed, and died). Given the fact that cured was a common outcome (39%), we fitted a log-binomial regression model to estimate the relative risk of being declared cured versus not being cured (Table 2). Finally, we fitted a multinomial logistic regression model predicting the likelihood of cured and death versus other outcomes. This allowed us to make some predictions on death, as a function of the selected socio-demographic covariates. Odds ratios were computed to assess the association between HIV status and TB mortality. Precision of estimate of the odds ratio was set at 5% significance level. All factors with p ≤ 0.1 on univariate analysis were further analysed in multiple logistic regression model.

Table 2

Factors associated with treatment success among TB patients presenting for care at Elim Clinic.

Factors	Univariate Analysis RR (95% C.I.)	Adjusted Analysis RR (95% C.I.)	p-value
Duration on treatment	1.02 (1.01–1.05)	1.03(1.01–1.06)	0.039
HIV Status
Negative	Ref	Ref
Positive	0.95 (0.76–1.19)	0.88(0.69–1.11)	0.124
Age-group
<20	Ref	Ref
20–29	1.85(1.19–2.88)	1.82(1.15–2.91)	0.014
30–39	1.97(1.27–3.06)	2.00(1.26–3.17)	0.008
40–49	1.81(1.13–2.92)	1.79(1.10–2.91)	0.033
50+	1.82(1.13–2.93)	1.77(1.09–2.85)	0.036
Sex
Female	Ref	-
Male	1.03(0.83–1.29)	-
Comorbidity
No	Ref	-
Yes	1.04(0.69–1.56)	-
Tobacco Use
No	Ref	Ref
Yes	1.60(1.22–2.12)	1.54(0.95–2.48)	0.117
Alcohol Use
No	Ref	Ref
Yes	1.5(1.07–2.11)	0.93(0.51–1.69)	0.909

2.10. Ethical considerations

Ethical approval was granted by the Monash University Human Research Ethics Committee and permission to conduct the study and access the medical records at Elim Primary Health Care Clinic was obtained from the District Manager of Ugu Health District, KwaZulu Natal province. Waiver of consent was applied for and obtained since the data were retrieved from older clinic records. Data entry and analysis were done anonymously, and no attempt was made to link data to the individual identifier.

3. Results

Overall, the study included 508 patients. Of this total, 2 patients were dropped from further analysis because one was transferred to another facility the same day of admission to the hospital and the other one was on prophylaxis TMP-SMX and was HIV negative. Hence, our final analytical sample included 506 patients for whom we had valid data on the TB treatment outcomes. Among them, only 13% (66/506) were children.

Table 1 reported the demographic characteristics and TB outcomes. The findings revealed that 39.13% (n = 198) were reported as being treatment success at the end of treatment. The remaining 60.87% patients were classified as dead or alive, but not treatment success. Some patients were transferred to other facilities, whereas other were classified as treatment interrupted, transferred to another district, treatment outcome unknown, treatment completed and moved to another facility in the same district. Table 1 shows significant differences with regards to TB treatment success in terms of age, tobacco, and alcohol uses. For instance, younger patients had lower proportion of TB treatment success (22.62% of those less than 20 years of age) compared to older patients. Among tobacco users, we found that about 60% had TB treatment success, whereas among non-tobacco users only 37% had TB treatment success. Likewise, the findings estimated that alcohol users, had higher proportion of being TB treatment success (57.14% of all alcohol users) while non-alcohol users’ patients only (38.08%) were TB treatment success.

Table 1

Characteristics of TB patients presenting to Elim Clinic on the basis of TB cured outcomes.

Factors	Not Cured n (%)	Cured n (%)	P-value	Alive) n (%)	Dead n (%)	p-value
	308 (60.87)	198 (39.13)		471 (93.08)	35 (6.92)
Duration on treatment 1	5.55 (0.16)	6.15 (0.13)	0.009*	6.01 (0.11)	2.74 (0.44)	0.001*
HIV Status
Negative	123 (59.71)	83 (40.29)	0.658	200 (97.09)	6 (2.91)	0.004*
Positive	185 (61.67)	115 (38.33)		271 (90.33)	29 (9.67)
Age-group
<20	65 (77.38)	19 (22.62)	0.018*	82 (97.62)	2 (2.38)	0.101F
20–29	78 (58.21)	56 (41.79)		124 (92.54)	10 (7.46)
30–39	72 (55.38)	58 (44.62)		120 (92.31)	10 (7.69)
40–49	46 (58.97)	32 (41.03)		75 (96.15)	3 (3.85)
50+	47 (58.75)	33 (41.25)		70 (87.50)	10 (12.50)
Sex
Female	138 (61.61)	86 (38.39)	0.762	205 (91.52)	19 (8.48)	0.216
Male	170 (60.28)	112 (39.72)		266 (94.33)	16 (5.67)
Comorbidity
No	286 (60.98)	183 (39.02)	0.855	438 (93.39)	31 (6.61)	0.311F
Yes	22 (59.46)	15 (40.54)		33 (89.19)	4 (10.81)
Tobacco Use
No	292 (62.66)	174 (37.34)	0.005*	432 (92.70)	34 (7.30)	0.345F
Yes	16 (40.00)	24 (60.00)		39 (97.50)	1 (2.50)
Alcohol Use
No	296 (61.92)	182 (38.08)	0.045*	443 (92.68)	35 (7.32)	0.246F
Yes	12 (42.86)	16 (57.14)		28 (100.00)	0 (0.00)
Substance Use
No	292 (60.08)	194 (39.92)	0.101	452 (93.00)	34 (7.00)	1.00F
Yes	16 (80.00)	4 (20.00)		19 (95.00)	1 (5.00)

Note:

1 Duration of treatment in months

All p-value from Pearson Chi-square test, unless otherwise determined.

* p-value < 0.05;

Findicates results from Fisher Exact test

The overall TB related mortality rate was 6.92% (n = 35 patients). The mortality rate was significantly associated with HIV status. For instance, the mortality rate was higher among HIV positive patients (9.67%, i.e., 29 patients out of 300 patients) compared to HIV negative patients among whom only for 2.91% was reported (6 patients out of 206 HIV negative patients). Given the small sample size for the mortality rate, this was impractical to perform further analysis and obtain reliable estimates.

Table 2 below presented the results from the univariate and multivariate log-binomial model, which sought to identify covariates associated with cure event. These factors included ‘duration of treatment, age, comorbidity, tobacco, alcohol use, and HIV positive status’ which was our main exposure of interest.

We found that HIV positive status showed to affect the likelihood of TB cure among patients on TB treatment. The results seem to suggest that HIV positive patients were 12% less likely to be cured from TB compared to the HIV negative patients, however this finding was not statistically significant (RR: 0.88; 95% C.I.: 0.69–1.11). The length of TB treatment was associated with TB cure. The results show that for each additional month on TB treatment there was a 3% significantly increased likelihood of TB cure (RR: 1.03; 95% C.I.: 1.01–1.06). Alcohol use and Tobacco smoking were not significantly associated with increased risk of treatment success.

Table 3 below present’s results from the multinomial logistic regression model with two levels of outcomes ‘dead and other’. We found that HIV status and age were associated with increased mortality among TB patients on treatment. The results show that HIV positive TB patients were nearly 4 times likely to die of TB compared to the HIV negative patients, and this finding was statistically significant (RRR: 3.73; 95% C.I.: 1.24–11.19). Furthermore, older age was associated with 5 times increased risk of dying among TB patients aged 50 years and above, however this was not statistically significant (RR: 4.99; 95% C.I. 0.88–28.50). In addition, duration of TB treatment was associated with reduced risk of dying. We found that for each additional month on TB treatment there was a 44% significant reduction in the risk of TB mortality (RR: 0.56; 95% C.I.: 0.47–0.66).

Table 3

Risk factors associated with death among TB patients presenting for care at Elim Clinic.

Factors	Univariate Analysis RRR (95% C.I.)	Adjusted Analysis RRR (95% C.I.)
Duration on treatment	0.54 (0.46–1.13)	0.56 (0.47–0.66)
HIV Status
Negative	Ref	Ref
Positive	3.63 (1.46–9.02)	3.73 (1.24–11.19)
Age group
<20	Ref	Ref
20–29	4.63 (0.98–21.97)	2.40 (0.45–12.78)
30–39	5.08 (1.07–24.13)	2.18 (0.39–12.29)
40–49	2.20 (0.35–13.71)	1.46 (0.20–10.83)
50+	8.51 (1.77–40.98)	4.99 (0.88–28.50)
Sex
Female	Ref	Ref
Male	0.65 (0.32–1.32)	0.61 (0.26–1.46)
Co-morbidity
No	Ref	Ref
Yes	1.83 (0.58–5.75)	1.30 (0.29–5.80)
Tobacco Use
No	Ref	Ref
Yes	0.51 (0.06–3.95)	0.56 (0.06–4.96)

*Other outcomes include…. Alive, transferred, defaulted etc

4. Discussion

This study determined the effect of HIV status and antiretroviral treatment on the treatment outcome of TB patients in a primary healthcare facility in rural South Africa. The study comprised of 282 males (55.7) and 224 females (44.3) with a median age of 32 (IQR: 23–43) years. The main outcomes of the study were categorized as cured or dead or other. This study found that 39.13% (198/506) of the patients were cured of Tuberculosis, of which 115 were HIV positive. Even though the patient’s records did not clarify that TB patients completed a full course of treatment, our findings show that the treatment success rate may be estimated as below the WHO target of 90% [39]. The overall TB related mortality rate was 6.92% (n = 35 patients) and the study showed that the risk of mortality rate was significantly associated with HIV positive status. For instance, the mortality rate was higher among HIV positive patients (9.67%, i.e., 29 patients out of 300 patients) compared to HIV negative patients (2.91%, 6 patients out of 206 HIV negative patients). Longer treatment period was associated with a lowered risk of death; however, HIV positive status of a TB patient had no effect on the likelihood of TB cure when compared to HIV negative status of a TB patient.

In reviewing other studies conducted in rural Africa, HIV infection did not appear to have any effect on successful treatment of TB, and this could be due to lack of sufficient data in a study conducted in Ghana [40], however, the same study showed that HIV-positive status was associated with death [40]. Our study found a close association between HIV-positive status and increased risk of dying of TB like the Ghana study that showed a higher mortality rate among HIV/TB co-infected individuals [40]. Another study in Tanzania found an EPTB prevalence of 5.6% with a high mortality rate of 14.3% and a combined death/LTFU rate of 46.8% among people living with HIV [41]. Patients with EPTB not receiving ART and >45 years of age were at a higher risk for poor outcomes [41]. There were no differences in treatment success rates for HIV-positive TB patients on ART and HIV-negative in Kenya [42]. The similarities and differences between studies could be explained by the levels of ART uptake and TB diagnosis. Following a review several of these studies, our study finding is consistent with the study conducted in Kenya, owing to the ongoing increasing scale-up and uptake of ART among HIV positive individuals in both South Africa and Kenya. In Table 4 we show an ART uptake rate of 89.9%, compared to 61% in Kenya [42]. In contrast, 3.7% of ART uptake was recorded in Ghana [40] and 16% patients with extrapulmonary TB did not receive ART in Tanzania [41]. Aside from that, our study found 70.0% of patients to have pulmonary TB, compared to 36.9% in a Tanzanian study [41]. In fact, pulmonary TB is easier to diagnose than other types of TB. Previous data shows that Extrapulmonary TB is associated with poor TB outcome in HIV-infected people [43]. In our study low number of people were on ART at that time as the scaling up program was still in its infancy stage, hence difficult to make a meaningful analysis to assess its impact on TB outcome.

Table 4

Characteristics of TB patients presenting to Elim Clinic on the basis of HIV status.

Characteristics	HIV Negative n(%)	HIV Positive n(%)	P-value
	178 (37.2)	300 (62.8)
Categories of TB
New	161 (91.0)	259 (86.3)	0.395¶
RAC	8 (4.5)	25 (8.3)
RF	5 (2.8)	8 (2.7)
RI	3 (1.7)	8 (2.7)
Pre-treatment sputum smear status
Negative	27 (29.7)	41 (30.4)	0.910‡
Positive	64 (70.3)	94 (69.6)
Type of Tuberculosis
Pulmonary	124 (69.7)	210 (70.0)	0.938‡
Extra-Pulmonary	54 (30.3)	90 (30.0)
Site of Tuberculosis
Bones/Joints	1 (2.0)	0 (0.0)	0.047*¶
Lymph Nodes	0 (0.0)	4 (4.5)
Miliary	4 (7.8)	6 (6.7)
Meningitis	2 (3.9)	17 (19.1)
Primary	12 (23.5)	17 (19.1)
Pleura	12 (23.5)	22 (24.7)
Other organs	20 (39.2)	23 (25.8)
Receiving ART
No	172 (100.0)	30 (10.1)	<0.001*¶
Yes	0 (0.0)	267 (89.9)
Co-trimoxazole Prophylaxis
No	173 (100.0)	22 (7.3)	<0.001*¶
Yes	0 (0.0)	278 (92.7)
Outcome duration(days)	184 (176–203)**	184 (173–209)*	0.7547†
Comorbidity
No	155 (87.1)	286 (95.3)	0.001*
Yes	23 (12.9)	14 (4.7)
Regimen type at baseline
HRZE	157 (88.7)	280 (93.4)	0.005*¶
HR	15 (8.5)	10 (3.3)
RHZ	5 (2.8)	3 (1.0)
HRZES	0 (0.0)	7 (2.3)

N- Total number in each group; %—row percentages; Numbers may not add-up because of missing variables.

*Significant p-value;

**Median and Inter-quartile ranges (IQR); Test statistic based on ¶Fisher’s Exact, ‡Chi-square and Wilcoxson †Rank-sum test.

HIV–Human Immunodeficiency Virus; ART–Antiretroviral therapy; Categories of TB treatment: RAC–retreatment after completion of a previous course without microscopic result; RF–Treatment failure: a patient who, while on treatment, remained or became again smear positive five months or later after commencing treatment; RI–Treatment after interruption: a patient whose treatment is interrupted for two or more months and who returned to the health service.

HRZE–Isoniazid, Rifampicin, Pyrazinamide and Ethambutol for New adult patients; HRZ–Isoniazid, Rifampicin and Pyrazinamide for New Paediatric patients; HRZES–Isoniazid, Rifampicin, Pyrazinamide, Ethambutol and Streptomycin for Retreatment patients.

Age was reported as significantly associated with being treatment success. In our study, older patients were less likely to be treatment success and more likely to die of TB compared to younger patients. These results are in line with the study conducted in Zimbabwe where elderly patients had a higher risk of not being cured and high risk of dying [44]. Another study reported that older age patients are more likely to develop extra-pulmonary and atypical forms of TB disease that are often harder to diagnose than sputum smear-positive pulmonary tuberculosis [45]. Extra pulmonary and smear negative PTB have all previously shown to be associated with high TB mortality [43, 46, 47].

Existing evidence from previous meta-analysis of high-quality studies has shown that smoking tobacco was noted to influence the outcome of TB treatment as smokers had a likelihood of being cured compared with non-smokers (OR of 2.6 (95%CI 2.1–3.4) [48]. Further, the associations between smoking and TB mortality showed a pooled OR of 1.3 (95%CI 1.1–1.6) [48]. Another large systematic review showed that cigarette smoking was significantly linked with poor TB treatment outcomes [49]. This shows that evidence on the effect of smoking on TB outcomes remains inconclusive. The findings of our study however confirm what has been previously reported showing an association between smoking tobacco and TB cure. Smoking tobacco affects both innate and adaptive immunity, weakening the immunological defensive system in humans [50]. This appears to be the reason why smokers are at a higher risk of developing extra-pulmonary tuberculosis [51]. Apart from this, smoking tobacco increases the risk of mycobacterium TB infection as well as the development of tuberculosis in infected individuals [52]. However, it does not have a negative effect on cure among those on TB treatment.

A study done in in the KZN revealed that staff rotation challenges across different services have been contributed to skills insufficiency (80%); staff shortage (50%); high staff turnover, absenteeism, and staff personal preferences (30%) in the KZN [5]. Despite a substantial investment in the clinical expansion program in SA, sparsely populated rural areas are still constrained in geographic distribution and access to health services (seen at a lower PHC utilization rate) and this is a major challenge in provision HIV and TB services in rural areas [33]. In this context, integrated services could enhance and promote equity as they maximize the potential benefit for each facility visit for health care access [33]. Besides this, a large TB cohort in Western Cape, South Africa showed that concomitant diseases were not associated with TB mortality [53]. This has been clearly shown in our study. However, in the same study, factors such as ‘treatment category’ and ‘comorbidity’ were significantly associated with unsuccessful TB treatment [53].

Coronavirus disease 2019 (COVID-19) has a significant impact on TB services in addition to the previous TB challenges faced in rural areas in SA. A study conducted in a rural area in SA discovered a significant drop in total TB treatment enrolment from April to December 2020 when compared to April to December 2019, with the largest drop occurring in July 2020 (–26%) [54]. Data shows a decrease across all TB indicators in April, the month of the first COVID-19 lockdown, with positive TB tests experiencing the greatest decrease (–33%) [54]. TB testing and diagnosis decreased by 50% and 33%, respectively, during the COVID-19 lockdown in SA [55, 56]. Furthermore, the National Health Laboratory Service (NHLS) reported that the number of GeneXpert tests performed decreased by 26% between 2019 and 2020, and the proportion of positive tests decreased by 18% in SA [57]. Given that the GeneXpert is a key diagnostic test for TB in HIV-positive people, the TB mortality rate in HIV-positive patients may be higher in rural areas during the COVID-19 pandemic. In addition to the findings of this study, COVID-19 may jeopardize the End TB strategy in rural area in SA.

The strength of our study is our sample size and its representativeness of the rural population, thereby minimizing selection bias. It was sufficient to estimate HIV/TB outcomes in rural primary care settings. Our study had several limitations that could lead to underestimation of HIV/TB outcomes. Retrospective cohort design uses records that have already been collected. This is an inherent weakness of the nature of use of existing medical records as data used is dependent on data documented in the records. We did not obtain the information on treatment completed outcome, HIV viral load and CD4 cells as this information was not available in the patients’ medical records. As such, we were unable to accurately link all our patients’ outcomes to these specific exposures. It is also possible that some of the patients included in our study were misclassified based on exposure or outcome status during analysis. Other study limitations included the fact that no patients were diagnosed nor treated for MDR-TB, which may limit the study’s generalizability. “Additionally, 5.5% of the HIV status was missing, which might have hampered our understanding of the effect on HIV on mortality among people with TB. To overcome missing data challenges, we used complete case (or available case) analysis or listwise deletion approach, hence included in the final analysis only cases with complete data available.

5. Conclusion

In conclusion, HIV positive status, and length of treatment were significantly associated with TB treatment outcomes in this rural primary care facility. The risk of dying was higher among the HIV positive TB patients while duration on treatment was associated with increased likelihood of treatment success and reduced risk of mortality. Despite a higher ART coverage in general, HIV status was a strong predictor of the TB mortality in rural SA. However, the TB treatment success rate in rural SA was lower than the WHO target. This study could have a significant impact on the reinforcement of HIV/TB program integration in rural SA. To achieve the End TB strategy in rural SA, HIV/TB integration services needs to be reviewed to identify potential challenges in its implementation. Furthermore, various HIV/TB indicators should be reviewed to allow for strengthening of TB/HIV integration monitoring approach by the TB program.

Data analysis commands.

(XLS)

Click here for additional data file.

5 Aug 2021

PONE-D-21-05746

Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa

PLOS ONE

Dear Dr. Nyasulu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The reviewers have made a number of helpful suggestions that we hope will assist you in revision to meet PLOS ONE's publication criteria.

Please submit your revised manuscript by Sep 18 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Janet E Rosenbaum, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. In the ethics statement in the manuscript and in the online submission form, please provide additional information about the patient records used in your retrospective study, including: a) whether all data were fully anonymized before you accessed them; b) the date range (month and year) during which patients' medical records were accessed; c) the date range (month and year) during which patients whose medical records were selected for this study sought treatment. If the ethics committee waived the need for informed consent, or patients provided informed written consent to have data from their medical records used in research, please include this information.

3. Thank you for stating the following financial disclosure:

N/A

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

5. We note that Figure 1 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 1 to publish the content specifically under the CC BY 4.0 license.

We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text:

“I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.”

Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

The following resources for replacing copyrighted map figures may be helpful:

USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/

The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/

Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html

NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/

Landsat: http://landsat.visibleearth.nasa.gov/

USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/#

Natural Earth (public domain): http://www.naturalearthdata.com/

6. Please upload a copy of Supporting Information S1 Dataset which you refer to in your text on page 18.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I wish to record my sincere appreciation to the authors for addressing this important topic. There is good insight to be gained from the research. However, my opinion is that the presentation style needs to be improved in order to allow a reader to gain proper insight into the presentation. I have raised a number of comments on the PDF that are required to be addressed

Reviewer #2: The abstract is well written. It contains the main findings and the conclusion of the study.

The background is comprehensive and well written. Although, it does not reflect on the decreasing TB cases that South Africa is experiencing.

The methodology is clear, well defined. The paper does not clearly define treatment cure, treatment completed. The researcher used the outcome allocated by the facility. I am not sure whether these outcomes were checked. Sometimes patients who fulfill the cure criteria are captured as completed. It is also important to highlight that the outcomes are allocated mainly on the basis of negative TB smear microscopy. TB microscopy has a low sensitivity. TB culture is not done routinely in susceptible TB patients.

My other issue is the choice of comparing cure or death. TB programme targets are based on treatment success rate (Cure and Completion). I agree that it is better to have a higher cure rate although for several reasons I have noted over the years the final sputum is often not collected hence the outcome will be "treatment completed". Also Table 1 indicates that 30 % of the cohort had a negative smear microscopy. Such patients may not have a "cure" outcome. Favorable outcomes include cure and completion rate. I am not sure what is the motivation for having cure, death and other outcomes. It would have been useful to briefly explain why are there more treatment completion than treatment cure in this facility. Data analysis is very clear except the issue of separating cure and completion. On page 11 of the manuscript, the Authors stated that among tobacco users the cure rate was for TB was 60 % and it was only 37 % among the non-tobacco users. In the conclusion, it is stated that the use of tobacco appeared to decrease the TB cure. It is also said that the cure rate was below district and provincial targets. To the best of my knowledge, there are no separate targets between cure and completion. Targets are based on Treatment Success Rate.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ozayr Mahomed

Reviewer #2: Yes: Dr Norbert NDJEKA, Director DR-TB, TB & HIV, National Department of Health, Republic of South Africa.

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-21-05746_reviewer.pdf

Click here for additional data file.

24 Jan 2022

Reviewers’ responses to reviewers

Title: Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa

Journal Requirements:

Comment 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: Thanks, we have revised the manuscript in accordance with the PLOS One formatting sample.

Comment 2. In the ethics statement in the manuscript and in the online submission form, please provide additional information about the patient records used in your retrospective study, including a) whether all data were fully anonymized before you accessed them; b) the date range (month and year) during which patients' medical records were accessed; c) the date range (month and year) during which patients whose medical records were selected for this study sought treatment. If the ethics committee waived the need for informed consent, or patients provided informed written consent to have data from their medical records used in research, please include this information.

Response: Thanks for the comments and suggestions. Data collection for this study commenced from the 1st of September 2016 and ended on 31st of October 2016. The data clerk was contracted for a 2-month period to enter as well as do quality control of the data entered. Data were abstracted directly from registers of TB patients who were initiated on TB treatment from 1 January 2013 to 31 December 2015. Furthermore, TB patients registered in the TB register in 2012 and died in 2013 were also included in the data extraction. (Line 147 to 152 Page 8). The data entry clerk was under strict instruction to enter data anonymously from the TB registers onto the database. No identifiers were extracted from the TB registers. It should be noted that this data were extracted in 2016 of patients who received service for TB treatment almost 3 years previously. As a result it was not possible to get patient consent as these were historical records and patients had been out of the system for 3 years already by the time the study was being conducted, so we had to seek waiver of consent to use the data as we believed that we could generate informative data that would shape policy and treatment guidelines in the management of TB at a time when expanding access to TB/HIV collaborative treatment was actively being rolled out by the department of health as a successful model of clinical care to minimise poor outcomes. Ethical approval was granted by the Monash University Human Research Ethics Committee (approval number: CF16/2803- 2014001548). Permission to conduct the study at Elim Primary Health Care Clinic was obtained from the Director of in Ugu Health District, KwaZulu Natal.

Comment 3. Thank you for stating the following financial disclosure:

Response: N/A

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution. N/A

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” N/A

c) If any authors received a salary from any of your funders, please state which authors and which funders. N/A

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Response: In track change document on page 26, Line 492. Thanks, we state this: “Financial Disclosure: The author(s) received no specific funding for this work”.

Comment 4. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Response: In track change document on page 23, lines 423-424. Thanks, Dataset is available upon request by submitting the request form to the corresponding author (email: pnyasulu@sun.ac.za).

Comment 5. We note that Figure 1 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 1 to publish the content specifically under the CC BY 4.0 license.

We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text:

“I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.”

Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

The following resources for replacing copyrighted map figures may be helpful:

USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/

The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/

Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html

NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/

Landsat: http://landsat.visibleearth.nasa.gov/

USGS EROS (Earth Resources Observatory and Science (EROS) Centre) (public domain): http://eros.usgs.gov/#

Natural Earth (public domain): http://www.naturalearthdata.com/

Response: Thanks for this comment. The map was created using a shapefile from the Africa map library software, which was then imported into the Quantum Geographic information system (QGIS) software for georeferencing of the Ugu district. Figure 1 is licensed under a CC BY 4.0

Comment 6. Please upload a copy of Supporting Information S1 Dataset which you refer to in your text on page 18.

Response: In track change document on page 21 and lines 399. Thanks, we have uploaded the raw data for the study.

Reviewer #1

Comment 1: although this statement maybe correct, it cannot be a conclusion at the level of the abstract as the reader has no comparator.

Response: In track change document on page 3 and lines 46 to 49. The conclusion is now: “when compared HIV positive and HIV negative status, antiretroviral treatment had no effect on the likelihood of TB cure in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients”.

Comment 2: based on this what is your recommendation.

Response: In track change document on page 3 and lines 49 to 50. We recommend this: “Various HIV/TB indicators should be reviewed, and gaps filled in order to achieve the “End TB strategy” in rural South Africa”.

Comment 3: comma

Response: In track change document on page 4 and line 64, the comma has been inserted.

Comment 4: I suggest that paragraph 2 is integrated at this point to improve the flow and readability of the manuscript.

Response: In track change document on page 4 and lines 65-71. Thanks, paragraph 2 has been integrated as suggested.

Comment 5: I think that this sentence is redundant information.

Response: In track change document on page 4 and lines 75-77. Thanks, this sentence has been written more clearly in the background.

Comment 6: There are two concepts being discussed in this sentence- decrease in mortality and increased incidence. however, the sentence needs multiple readings to make sense. therefore, I suggest that the sentence is separated.

Response: In track change document on page 4 and lines 63-66. We have separated the two concepts. It now reads: “The increase in incidence is also attributed to the development of multidrug resistant (MDR) and extremely drug resistant (XDR) strains of Mycobacterium tuberculosis [34]. Both MDR/XDR-TB are the causes of high TB mortality [4]”.

Comment 7: This sentence appears out of sync as the previous discussion only relate to mortality and this sentence intends on providing reason for increased risk for TB.

Response: The sentence has been deleted and removed.

Comment 8: Which countries as the authors quoting facility based postmortem findings.

Response: In track change document on pages 4-5 and lines 75-77. Thanks, we have listed the countries reporting post-mortem TB rate. It now reads: “such as South Africa [9-11], Botswana [11, 12], Zimbabwe [11, 13, 14], Mozambique [11, 15], Uganda [11, 16] and Kenya [11, 17]”.

Comment 9: I am sure that the WHO global report on TB provides data in resource limited countries.

Response: In track change document on page 5 and lines 77. Thanks, we have provided TB data in Africa. “In contrast, the WHO reported 16% of HIV/TB related death in Africa [1]”.

Comment 10: please update this data as later information is available.

Response: In track change document on pages 5 and lines 80-81. Thanks, this data has been updated. “TB accounted for the third highest number of deaths in 2018 (6 %; n = 454 014)”

Comment 11: specific data for Ugu district

Response: In track change document on page 5 and lines 87-88. “Ugu district reported 60.5% of TB/HIV co-infection rate [25]”.

Comment 12: provide information on South Africa antiretroviral treatment programme in terms of number of patients on treatment and accessibility to treatment.

Response: In track change document on pages 6 and lines 89-90. Thanks, we have reported this: “According to recent data, 90% of people are aware of their HIV status of these 68% are on antiretroviral therapy (ART) of which 87% are virally suppressed in SA [26]”.

Comment 13: this paragraph is out of sync in building the case. it may be more suited to a discussion

Response: In track change document on pages 19-20, lines 360-367. Thanks, this paragraph has been moved to the discussion section.

Comment 14: with a view to?

Response: In track change document on page 7 and lines 141. Thanks, we state as follows: “with a view to Ugu district”.

Comment 15: the author needs to separate study design, population and study setting

Response: In track change document on pages 8-9 and lines 122-142.Thanks, we have separated the study design, population and study setting. It is now reads:

“Study design

This retrospective cohort study of TB patients initiated on TB treatment was conducted from 1 January 2013 to 31 December 2015.

Study population

We included all patients diagnosed with TB irrespective of their age and HIV status in the study. Further, we registered patients that were in the TB register in 2012 and died in 2013. We also included as well as those that died or survived during the treatment period. Patients with unknown outcome were from the study or those with incomplete record were excluded. Basic demographic information including the age, gender, co-morbidities, tobacco Use, alcohol Use, substance use and duration on treatment were collected.

Study setting

The Ugu district is located in the rural KwaZulu-Natal province (Figure 1). Ugu district has a population of 733 228 people [37]. During the study period, Ugu district had the highest HIV prevalence and TB incidence of any district in KZN, 41.7% and 1096 per 100,000 people, respectively [37]. In terms of infectious TB (pulmonary smear-positive), Ugu ranks 12th, with 325 cases per 100,000 people, which is higher than the country's average of 208 cases per 100,000 people [37]. Elim clinic, a primary health care facility was selected based on convenience, the study goal and the availability of information on HIV and TB infections”.

Comment 16: this is about uGu- what about the specific area of your study- what is catchment population, what is outpatient headcount? what proportion or incidence of TB per year over the study period?

Response: In track change document on pages 7 and lines 136-142. Thanks, we have stated the following: “Ugu district has a population of 733 228 people [37]. During the study period, Ugu district had the highest HIV prevalence and TB incidence of any district in KZN, 41.7% and 1096 per 100,000 people, respectively [37]. In terms of infectious TB (pulmonary smear-positive), Ugu ranks 12th, with 325 cases per 100,000 people, which is higher than the country's average of 208 cases per 100,000 people [37]. Elim clinic, a primary health care facility was selected based on convenience, the study goal and the availability of information on HIV and TB infections”.

Comment 17: was provincial authorization obtained? I am confused by the term Director of Health as no such position exists in the organogram.

Response: Thanks for this comment. Authorisation to access clinic records was granted by the Ugu Health District Manager. Apologies for the incorrect use of word ‘Director’.

Comment 18: it would be good to also provide the socio-demographic profile of patients first before the HIV status of patients.

Response: In track change document on page 12and line 240. Thanks, before the HIV status table (Table 2), we have provided a socio-demographic table (Table 1).

Comment 19: p values determination- and if any of the information is statistically significant

Response: In track change document on page 15, table 3, line 277. Thanks, p-values have been provided. Duration on treatment and age-group were significant predictors of cure.

Comment 20: were the values statistically significant?

Response: In track change document on page 15, line 277. “The 95% CI shows that the values obtained were statistically significant”.

Comment 21: to evaluate TB outcomes in HIV positive patients in rural primary healthcare in South Africa

Response: In track change document on page 17, lines 300. Thanks, it now reads: “This study evaluated the effect of HIV status and antiretroviral treatment on the treatment outcome of TB patients in a primary healthcare facility in rural South Africa”.

Comment 22: what about findings from your analytical study?

Response: In track change document on page 17, lines 312-317. We have reported the findings from the analytical study as follows: “Longer treatment periods were associated with a lower risk of death in both the bivariate and covariate log-binomial regression models. Furthermore, in bivariate and covariate analysis, younger ages had a lower likelihood of being cured than older ages. However, HIV positive status of a TB patient had no effect on the likelihood of TB cure when compared to HIV negative status of a TB patient”.

Comment 23: please clarify this- is this initiation of treatment or treatment duration

Response: In track change document on page 17, lines 315-317. It now reads “However, HIV positive status of a TB patient had no effect on the likelihood of TB cure when compared to HIV negative status of a TB patient”.

Comment 24: how does this study relate to your findings. what is the plausible explanation for the similarities and differences?

Response: In track change document on page 18, lines 329-340. Thanks, the plausible explanation for the similarities and differences is stated as follows: “The similarities and differences between studies could be explained by ART uptake percentage and TB diagnosis. Following a review of these studies, the findings of our study was consistent with the study conducted in Kenya, owing to the ongoing scale-up and uptake of ART programs in both South Africa and Kenya. Table 2 of our study revealed an ART uptake rate of 89.9%, compared to 61% in Kenya [42]. In contrast, 3.7% of ART uptake was recorded in Ghana [40] and 16% patients with extrapulmonary TB did not receive ART in Tanzania [41]. Aside from that, our study found 70.0% of patients to have pulmonary TB, compared to 36.9% in a Tanzanian study [41]. In fact, pulmonary TB is easier to diagnose than other types of TB. Previous data shows that “Extrapulmonary TB is associated with poor TB outcome in HIV-infected people [43]”.

Comment 25: is better adherence to treatment the only plausible explanation? if you review the data. It is noticed that age > 50 years also had a very high likelihood of mortality and therefore, i question your statement provided.

Response: In track change document on page 19, lines 349-353. Thanks, we have provided the following statement:” Another study has shown that older ages are more likely to develop extra-pulmonary and atypical forms of TB disease that are often harder to diagnose than conventional sputum smear-positive pulmonary tuberculosis [45]. Extra pulmonary and smear negative PTB were associated with high TB mortality [43, 46, 47].”

Comment 26: what is the plausible explanation for tobacco and TB treatment outcomes?

Response: In track change document on page 19, lines 362-366. The discussion part is improved as follows: “Smoking tobacco affects both innate and adaptive immunity, weakening the immunological defensive system in humans [50]. This appears to be the reason why smokers are at a higher risk of developing extra-pulmonary tuberculosis [51]. Apart from this, smoking tobacco increases the risk of mycobacterium TB infection as well as the development of tuberculosis in infected individuals [52]”.

Comment 27: please discuss the study limitations

Response: In track change document on page 20, lines 381-388. We have included the study strengths and limitations. It now read: “The strength of our study is our sample size which was representative of the study population thereby minimizing selection bias. This is substantial to estimate HIV/TB outcomes in rural settings. Our study has several limitations that could lead to underestimation HIV/TB outcomes. Retrospective cohort design uses records that have already been collected and we did not obtain the information on treatment completed outcome, HIV viral load and CD4 cells. As the fact, we were unable to accurately link all our patients to the various outcomes. It is also possible that some of the patients included in our study misclassified in the current analysis”.

Comment 28: this is a repetition of results without adequate considering for the overall aim and why the study was done?

Response: In track change document on page 21, lines 392-395, 400-404. Thanks, we have improved the conclusion as follows: “In conclusion, HIV positive status and antiretroviral treatment had no effect on the likelihood of TB cure in rural primary care when compared to HIV negative patients. However, the TB mortality rate in HIV positive patients was higher than in HIV negative patients”. And further recommendation: “TB mortality in rural SA. Furthermore, the TB success rate in rural SA may be lower than the WHO target. This study could have a significant impact on the HIV/TB program in rural SA. To achieve the End TB strategy in rural SA, various HIV/TB indicators should be reviewed, and gaps filled”.

Reviewer #2:

Comment 1: The abstract is well written. It contains the main findings and the conclusion of the study. The background is comprehensive and well written. Although, it does not reflect on the decreasing TB cases that South Africa is experiencing.

Response: In track change document on page 5-6, lines 103-108. Thanks, we have improved the background as follows:” TB incidence and mortality are declining in SA [7]. Data from a well-characterized rural SA population with high HIV prevalence and TB incidence demonstrated considerable spatial heterogeneity in people with recently-diagnosed TB and has shown that every percentage increase in ART coverage was associated with a 2% decrease in the odds of recently-diagnosed TB [23]”.

Comment 2: The methodology is clear, well defined. The paper does not clearly define treatment cure, treatment completed.

Response: In track change document on pages 8, lines 160-167. We have referred to the WHO definitions. Cured: A pulmonary TB patient with bacteriologically confirmed TB at the beginning of treatment who was smear or culture negative in the last month of treatment and on at least one previous occasion. Treatment completed: A TB patient who completed treatment without evidence of failure but with no record to show that sputum smear or culture results in the last month of treatment and on at least one previous occasion were negative either because tests were not done or because results are unavailable [37].

Comment 3: The researcher used the outcome allocated by the facility. I am not sure whether these outcomes were checked. Sometimes patients who fulfil the cure criteria are captured as completed. It is also important to highlight that the outcomes are allocated mainly on the basis of negative TB smear microscopy. TB microscopy has a low sensitivity. TB culture is not done routinely in susceptible TB patients.

Response: In track change document on page 20, lines 384-388. Thanks, we have addressed this issue in the study weaknesses. As a retrospective cohort study, we conducted the records review of the patients. As a matter of fact, we were unable to accurately link all of our patients to the various outcomes due to missing data. It is also possible that some of the patients included in our study might have been misclassified in the current analysis.

Comment 5: My other issue is the choice of comparing cure or death. TB programme targets are based on treatment success rate (Cure and Completion). I agree that it is better to have a higher cure rate although for several reasons I have noted over the years the final sputum is often not collected hence the outcome will be "treatment completed".

Response: Thanks for the observation, as previously stated, retrospective cohort design used records that have already been collected and we did not obtain the information on treatment completed from the records.

Comment 6: Also, Table 1 indicates that 30 % of the cohort had a negative smear microscopy. Such patients may not have a "cure" outcome. Favorable outcomes include cure and completion rate. I am not sure what is the motivation for having cure, death, and other outcomes. It would have been useful to briefly explain why are there more treatment completion than treatment cure in this facility.

Response: In track change document on page 9, lines 160-163. Thanks, “cured” is defined as a pulmonary TB patient with bacteriologically confirmed TB at the beginning of treatment in an individual who was smear or culture negative in the last month of treatment and on at least one previous occasion. So, people may complete TB treatment without necessarily being cured. In this study we used these outcomes because they are key TB Program indicators as defined by the National TB Control Program. The focus of our study was to assess the effect of HIV status and antiretroviral treatment on TB treatment outcomes including cure. Our data has shown that HIV status and antiretroviral treatment did not have effect on TB cure but on TB mortality. We suggest that further studies are warranted to help explain low TB cure in this setting.

Comment 7: Data analysis is very clear except the issue of separating cure and completion. On page 11 of the manuscript, the Authors stated that among tobacco users the cure rate was for TB was 60 % and it was only 37 % among the non-tobacco users. In the conclusion, it is stated that the use of tobacco appeared to decrease the TB cure. It is also said that the cure rate was below district and provincial targets. To the best of my knowledge, there are no separate targets between cure and completion. Targets are based on Treatment Success Rate.

Response: Thanks for the observations, In track change document on page 19-20, Table 4. We separated cure and completion because they are two separate National TB Control Program treatment outcomes. The overall cure rate was 39.13% which falls below district and provincial targets based on South African District Health Barometer. Treatment Success Rate is the sum of cured and treatment completion rates.

Submitted filename: Reviewers_responses_December 2, 2021.docx

Click here for additional data file.

30 May 2022

Submitted filename: PONE-D-21-05746_R1.pdf

Click here for additional data file.

20 Jul 2022

Reviewers’ responses to reviewers

Title: Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa

Journal Requirements:

Comment 1: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and include a citation and full reference for the retraction notice.

Response 1: Thank you for this guidance. In the tracking manuscript, the reference 10, 12, 14, 16, 17, 30, and 31 have been revised according to PLOS One submission guideline.

Reviewer #1:

Comment 1: The authors have addressed most of the substantive points of the previous review. I have highlighted certain areas on the re-submission that need to be looked at again. However, the authors have data from more than 5 years ago and do not provide a critical discussion of how this old data still stands currently with the growth and changes in the program. Is it not likely that a greater saturation in terms of ART has improved TB outcomes or there is a worsening due to COVID-19.

Response 1: Thanks for this valuable comment. In the tracking document lines 382-396, the following has been highlighted: “Coronavirus disease 2019 (COVID-19) has a significant impact on TB services in addition to the previous TB challenges faced in rural areas in SA. A study conducted in a rural area in SA discovered a significant drop in total TB treatment enrolment from April to December 2020 when compared to April to December 2019, with the largest drop occurring in July 2020 (–26%) [54]. Data shows a decrease across all TB indicators in April 2020, the month of the first COVID-19 lockdown, with positive TB tests experiencing the greatest decrease (–33%) [54]. TB testing and diagnosis decreased by 50% and 33%, respectively, during the COVID-19 lockdown in SA [55, 56]. Furthermore, the National Health Laboratory Service (NHLS) reported that the number of GeneXpert tests performed decreased by 26% between 2019 and 2020, and the proportion of positive tests decreased by 18% in SA [57]. Given that the GeneXpert is a key diagnostic test for TB in HIV-positive people, the TB mortality rate in HIV-positive patients may be higher in rural areas during the COVID-19 pandemic. In addition to the findings of this study, COVID-19 may jeopardize the End TB strategy in rural area in SA.”.

Reviewer #2:

Comment 1: on what premise is this conclusion derived to be presented in the abstract

Response 1: Thanks for the observation. In tracking manuscript line 46-49, we have changed the conclusion as follows: “When compared between HIV status, HIV positive TB patients were more likely to have unsuccessful treatment outcome in rural primary care”. Antiretroviral treatment seems to have had no effect on the likelihood of TB treatment success in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients emphasizing the need for enhanced integrated management of HIV/TB in rural South Africa through active screening of TB among HIV positive individuals and early access to ART among HIV positive TB cases.

Comment 2: these results have not been presented in abstract

Response 2: Thanks for highlighting this. In the tracking manuscript line 42-43, “Furthermore, HIV positive patients had a higher mortality rate (9.67%) than HIV negative patients (2.91%)”.

Comment 3: at this point this has no bearing with the results in abstract or link to introduction

Response 3: Thanks for this comment, the conclusion has been revised based on above comment 1 and 2.

Comment 4: the term evaluate has a deeper meaning than just an epidemiological study as conducted by the authors

Response 4: Thanks. In the tracking manuscript line 118, It reads: “Therefore, this retrospective study has been undertaken to determine….”

Comment 5: geo spatial map of Ugu and the key TB indicators in comparison to other districts in the Province will be beneficial for external readers to picture the burden in Ugu

Response 5: Thanks for the guidance. Figure 1 has been designed according to this recommendation.

Comment 6: out of sync

Response 6: Thanks for this observation. In the tracking manuscript, line 145, the title has been aligned.

Comment 7: based on what you have provided you have not evaluated you have only determined factors associated with

Response 7: Thanks for the observation. In the tracking manuscript, line 308, we have replaced “evaluated” to “determined”.

Comment 8: please clarify what HIV status is

Response 8: Thanks for this advice. Line 326, we have specified as follows: “HIV positive status”.

Comment 9: what is recent

Response 9: Thanks for this point seeking clarity. Line 371, “recent” has been removed from this sentence with appropriate edit.

Reviewer #3:

Comment 1: Line 126: would it have been helpful to distinguish pediatric from adult participants given likely baseline differences in HIV and TB risk?

Response 1: Thanks for this observation. In the tracking document line 223-224: “Among them, only 13% (66/506) were children”. We do not believe that removing it will change the outcome.

Comment 2: Line 182: what proportion of data were missing and how were missing data accounted for?

Response 2: Thanks for this question. In the tracking document line 409-415: “Additionally, 5.5% of the HIV status was missing, which might have hampered our understanding of the effect on HIV on mortality among people with TB. To overcome missing data challenges, we used complete case (or available case) analysis or listwise deletion approach, hence include in the final analysis only cases with complete data available.

Comment 3: Was HIV status confirmed based on seropositivity using chart abstraction? If based on self-report, may result in measurement bias, possibly underestimating true HIV prevalence.

Response 3: Thanks for this comment. As part of a retrospective study design, HIV status was confirmed using medical records available to ascertain objectiveness.

Comment 4: Use of TB cure definition using smear negativity may miss cases that are smear negative and go on to become culture positive. Use of completed TB definition may include persons who were cured following treatment.

Response 4: Thanks for this comment. Given that the study outcome includes “cured” and “treatment completion”, we have added the following definition: “Treatment success includes the sum of cured and treatment completed [38]” (Line 168-169). “Cured” has been replaced by “treatment success” in the following line 49, 168, 172, 173, 226, 228, 231, 233, 232, 233, 235-238, 280, 286, 347, 348, and 422.

Comment 5: Based on baseline TB regimens, it appears none of the patients were being treated for multidrug resistant TB (which is prevalent in South Africa); this may limit generalizability/external validity.

Response 5: Thank for this valuable comment. Line 409-411. We have added the following: “Other study limitations included the fact that no patients were diagnosed nor treated for MDR-TB at this clinic, which may limit the study's generalizability”.

Comment 6: Was matching on covariates between HIV positive and HIV negative participants considered?

Response 6: Thanks for this question. Since HIV status was an important covariate in the statistical modelling, we did not perform matching of variables.

Submitted filename: PONE_Reviewers responses_July 16_2022.docx

Click here for additional data file.

31 Aug 2022

Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa

PONE-D-21-05746R2

Dear Dr. Nyasulu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Janet E Rosenbaum, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: All points addressed and quality of manuscript is enhanced. I am of teh opinion it is suitable for publication

Reviewer #3: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ozayr Mahomed

Reviewer #3: No

**********

12 Sep 2022

PONE-D-21-05746R2

Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa

Dear Dr. Nyasulu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Janet E Rosenbaum

Academic Editor

PLOS ONE