OR 0.4 0.7 2.0 reference reference reference 3.5 reference 1.9 reference reference 2.0 1.2 reference Univariate model 95% CI 0.1–1.5 0.5–1.1 1.3–3.1 1.4–8.9 1.0–3.5 1.3–3.3 1.0–1.5 P 0.2 0.09 <0.01 <0.01 0.05 <0.01 0.02 OR — — 1.7 reference 2.4 reference 1.3 reference 1.8 reference 1.3 reference AIDS Research and Treatment Multivariate model1 95% CI — — 1.0–2.7 0.9–6.3 0.6–2.7 1.1–3.0 1.1–1.6 P — — 0.04 0.09 0.5 0.03 <0.01 6 Characteristic Age Adult Pediatric Gender Male Female CD4 Category CD4 Category ≥50 cells/mm3 <50 cells/mm3 ≥200 cells/mm3 <200 cells/mm3 Time Until ART ≥2 weeks <2 weeks Time Until ART ≥2 months <2 months Clinic Year Year (2–5, 1 year increment) previous year Notes: OR: odds ratio, CI: conﬁdence interval. 1Adjusted for CD4 categories, time until ART categories, and clinic year. of 85% cure and 90% treatment completion rates regardless of HIV status can only be achieved if loss to followup is aggressively and promptly addressed. Proportions of patients lost to followup improved from 36% in year 1 to 12.5% in year 5. Interventions employed by the TB/HIV clinic felt to have been beneﬁcial in improving loss to followup rates include (1) early and continuous patient education regarding both TB and HIV therapies by both clinic staﬀ as well as persons living with HIV/AIDS; (2) eﬀort to rapidly identify patients who miss appointments with the use of “tracers” who use village maps obtained with patient permission upon clinic enrollment; (3) use of treatment partners and directly observed therapy (DOT). However, additional qualitative research is required to understand why patients disengage with health care, and innovative solutions are urgently required. In parallel with the declining loss to follow-up, treatment success rose and death rates fell over time. One may speculate that these improvements reﬂect an increased experience and competency in managing well-described complications of TB/HIV treatments including immune reconstitution syndrome, drug interactions, and comorbidities in addition to increased attention to adherence and earlier treatment for patients with lower CD4+ T-cell counts as newer guidelines Table 4: Relationship of treatment success in patients starting antiretroviral therapy after TB treatment in the Kericho District Hospital TB/HIV Clinic (n = 684). Odds of treatment success (cure or treatment complete) versus death or loss to followup appeared [4, 5]. Given the Kericho District Hospital served as a regional hospital and was the ﬁrst to provide comprehen- sive HIV services in the region, outcomes observed may also reﬂect a referral bias, which became less pronounced over time as other facilities became available and decentralization of services occurred. We found baseline CD4+ T-cell count highly associated with treatment success. Patients with lower CD4 counts most in need of ART were less likely to achieve treatment success compared to those with higher CD4 counts, although treatment success improved over time. These ﬁndings under- score challenges in implementing early ART in patients with advanced immunosuppression and achieving results seen in recent clinical trials [14–16]. Challenges of introducing ART early during TB intensive phase treatment in patients with advanced immunosuppression in resource-limited areas are profound, and diﬀerences in outcomes observed in clinical trial versus clinical care settings well described in the resource-rich settings are likely magniﬁed in resource- constrained settings [31]. Barriers to early ART are both medical (e.g., pill burden, adherence, toxicities, immune reconstitution syndrome, and comorbidities) and logistical (e.g., frequent appointments requiring travel time and costs, time away from family and work). Clinical trials are better