A systematic review and meta-analysis of the association between integrated tuberculosis and Human Immuno-deficiency Virus therapy and tuberculosis treatment outcomes among adults in sub-Saharan Africa

<title>Abstract</title> <bold>Background: </bold>Despite the scale-up of programmes integrating treatment of tuberculosis (TB) and Human Immuno-deficiency Virus (HIV) in sub-Saharan Africa (SSA), TB treatment outcomes in TB/HIV co-infected patients in the region remain sub-optimal.<bold>Objective: </bold>To summarize the available evidence on the association between integrated TB/HIV treatment and TB treatment outcomes specifically, successful treatment and all-cause mortality in TB/HIV co-infected adults in SSA.<bold>Method: </bold>A systematic review of studies published between March 2004 and 10 July 2019 was performed. Seven electronic databases including Medline, Embase and Cochrane were searched to identify interventional and observational quantitative studies reporting on integrated TB/HIV treatment in SSA. Two investigators independently screened the search output, reviewed the eligible studies, and rated the quality of eligible studies using quality assessment tools of the National Heart Lung and Blood Institute. Pooled odds ratios (ORs) were derived using random-effects meta-analysis. Heterogeneity across studies was assessed using the I² statistic. The confidence in the pooled ORs was rated using the GRADE. The final review was reported using the PRISMA.<bold>Results: </bold>Eleven studies including 4181 participants were retained. The studies were of moderate to good quality, with 10 being quasi-experimental and cohort. Pooling of relevant studies showed that the odds of treatment success with integration was 1.1 times (95% CI: 0.93-1.29; I²=74.5%; p-value for heterogeneity=0.001) the odds of treatment success without integration and the odds of mortality with integration was 1.27 (95% CI 1.02-1.59; I²=87.3%; p-value for heterogeneity&lt;0.0001) times the odds of mortality without integration. On sensitivity analysis, the odds of mortality with integration decreased to 1.06 (95% CI: 0.83-1.34; I²=80.1%; p-value for heterogeneity&lt;0.0001) times the odds of mortality without integration and there was strong evidence of an association between sample size variation and heterogeneity (p=0.01). Good quality studies (4/11) tended to support the effectiveness of integrated treatment in increasing successful outcomes and decreasing mortality. Certainty in the pooled ORs was low.<bold>Conclusion: </bold>Evidence on the effect of integrated TB/HIV treatment services on treatment success and all-cause mortality in TB/HIV co-infected patients in SSA is inconclusive but the few available good quality studies tend to favour the effectiveness of these services. More robust primary studies are warranted.