AIDS Research and Treatment resourced to address these medical and logistical issues, not the case in resource-constrained health care systems. Innova- tion will be critical in solving these challenges. Hospitalization, while theoretically practical for pro- foundly immunosuppressed patients who are initiating both TB treatment and ART, may often not be possible or ideal. The lack of strong infection control programs within hos- pitals in sub-Saharan Africa resulting in nosocomial TB transmission raises a cautionary note [32]. The risk of hospitalization with poor infection control is particularly problematic in areas such as Kenya where TB drug suscep- tibility data is lacking. Congregation of the most vulnerable (i.e., those with CD4+ T-cell count <50 cells/mm3) with those with unknown rates of multidrug or extensively drug resistant TB has led to devastating consequences in South African settings [32]. Hospitalization to overcome challenges and logistical issues of TB/HIV treatments must therefore be initiated with programmatic interventions that can reduce risk. “Know your status” campaigns combined with aggressive community-based TB case ﬁnding campaigns will oﬀer long- term solutions [4, 5]. The former will avoid discovery of the HIV patient presenting late into care with a low CD4+ T-cell count. The later will reduce transmission risk for all. Until those public health interventions can be broadly implemented, the integrated TB/HIV clinical service must look for solutions to translate clinical trials ﬁndings and recommendations into best practice scenarios. Perhaps the most notable strength of the Kericho inte- grated TB/HIV clinic was the very early recognition of the need for integrating services (one patient, one clinic) and the institution of an integrated clinic into routine practice at a Ministry of Health facility. The most important limitation to recognize is the retrospective, uncontrolled nature of our analyses and those limitations (e.g., missing data) and biases (e.g., selection, referral, and report biases) inherent in all such secondary analyses. To that end, analyses were identiﬁed as exploratory and results are best considered hypotheses supporting or generating. While particular caution should be given to interpretations of pediatric data alone due to the low proportion of pediatric patients, we feel that a strength of the integrated TB/HIV clinic is the inclusion of pediatric patients. 5. Conclusions TB/HIV patients with advanced HIV disease can be suc- cessfully managed in integrated TB/HIV MoH clinics in rural Kenya. Treatment outcomes improve with time, likely reﬂecting a variety of factors certainly including additional expertise that follows experience. Baseline CD4+ T-cell count is a driving force in predicting outcomes. Loss to followup remains a critical challenge in care delivery that demands attention and innovation. With high loss to followup occur- ring early in care and likely representing further deaths, the beneﬁts and challenges of early ART initiation in TB treatment in nonclinical trial, resource-limited, rural set- tings are underscored. This “TB/HIV timeline” conundrum underscores the need for increased eﬀorts for early detection 7 of TB/HIV coinfected patients combined with innovative case holding interventions. An integrated TB/HIV clinic (one patient, one clinic) is a feasible goal in resource-constrained settings. Disclaimer The content of this publication is the sole responsibility of the authors and does not necessarily reﬂect the views or policies of the Kenya Medical Research Institute, the Kenya Ministry of Health, the US Military HIV Research Program or Department of Defense, or Brown University. Acknowledgments The authors wish to acknowledge the support of Dr. Betty Langat (Kericho District Hospital Medical Superintendent) for her vision and commitment to strive to provide the best care possible to all patients as well as the staﬀ in the TB/HIV clinic and patients for whom they care. The authors also wish to recognize the roles of the Division of Leprosy, Tuberculosis, and Lung Diseases (DLTLD), formally the National Leprosy & Tuberculosis control Program (NLTP), and National AIDS and STI Control Programme (NASCOP) in their oversight and support of both TB and HIV as well as integrated TB/HIV programs. References [1] WHO, “TB/HIV Facts 2011,” May 2011, http://www.who.int/ tb/challenges/hiv/factsheet hivtb 2011.pdf. [2] WHO, “Recommendations of the Interim Policy on Collabo- rative TB/HIV activities,” The Weekly Epidemiological Record, vol. 79, no. 1-2, pp. 6–11, 2004. 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