2 changes in treatment success over time, evaluate TB treat- ment outcomes given baseline CD4+ T-cell counts and timing of ART, and explore the relationship between baseline characteristics and treatment success. 2. Materials and Methods 2.1. Study Design. We conducted a retrospective, secondary analysis of KDH clinic electronic medical records. 2.2. Study Setting. KDH is located in Kericho among the tea ﬁelds and plantations of Kenya’s southern Rift Valley Province 260 kilometers northwest of Nairobi. As a Ministry of Health (MoH) facility under the Ministry of Medical Services, KDH provides services to a rural, largely uninsured population, representative of the national statistic indicating that 46% of the population lives below the poverty line [17]. In 2010, approximately 12,000 patients received inpatient and approximately 160,000 patients received outpatient ser- vices [18]. Both HIV and TB services are provided by funding from the Government of Kenya/MoH [19, 20] and through donor programs, principally the President’s Emergency Plan for AIDS Relief (PEPFAR) [21]. TB and HIV care services including HIV Counseling and Testing and Prevention of Mother- to- Child Transmission (PMTCT) operate in part- nership with the Kenya Medical Research Institute/Walter Reed Project (KEMRI/WRP) HIV Program. The KEMRI/ WRP partnership is part of the US Military HIV Research Program (MHRP), an international HIV vaccine research program under the Walter Reed Army Institute of Research (WRAIR) [22, 23]. The MoH in collaboration with KEMRI/WRP under the PEPFAR program supports HIV care, prevention, and treat- ment services in the southern Rift Valley Province of Kenya (population of approximately 2.5 million). Beginning with 4 initial treatment sites (including KDH) in 2004, program coverage now includes 11 district level, primary treat- ment facilities, 10 subdistrict hospitals, 75 dispensaries/rural health centers, and 403 PMTCT sites. Expansion has been based upon a network model focusing upon decentralization in an eﬀort to bring services closer to communities and decongest primary treatment centers. After the initial KDH TB/HIV clinic opened in 2005, expansion of integrated TB/ HIV services began in 2007 and currently includes 8 TB/HIV integrated clinics (Figure 1). In late 2005, KDH opened the integrated TB/HIV clinic using current MoH TB and HIV guidelines as well as expert consultation (EJC). Operational components of the integrated TB/HIV clinic included (1) HIV Diagnostic Testing and Counseling (DTC) for patients and family members presenting to the TB clinic where >90% annual patient acceptance rate was achieved [18]; (2) use of “cough monitors” (trained lay individuals) to maximize sputum collection in an eﬀort to improve case ﬁnding and categoriza- tion of TB disease, (3) referral to the TB clinic of all patients diagnosed with TB in the HIV clinic at KDH as well as local subdistrict hospitals and dispensaries/rural health centers; and, (4) treatment for HIV including ART in the TB clinic AIDS Research and Treatment with patient referral for continued care to the HIV clinic on completion of TB therapy. Trimethoprim/sulfamethoxazole prophylaxis is routinely provided to all HIV-infected patients. Patients receive multivitamins for nutritional supplementation as well as pyridoxine while on isoniazid for prevention of peripheral neuropathy. TB, HIV, and TB/HIV coinfection preven- tion, diagnoses, and treatments evolve based upon current national guidelines and are conducted with support from and under the auspices of Division of Leprosy, Tuberculosis, and Lung Diseases (DLTLD) and National AIDS and STI Control Programme (NASCOP) [3, 24–29]. The TB/HIV clinic is staﬀed primarily by clinical oﬃcers and nurses and is supplemented by DTC staﬀ, cough monitors, and a nutri- tionist. Medical oﬃcers and consultants (mostly Internists) see patients 1-2 days a week or as needed. TB intensive phase treatment consists of isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months in a ﬁxed dose combination with followup weekly. TB continuation phase treatment initially consisted of isoniazid and ethambutol for 6 months in a ﬁxed dose combination until 2009 when country guidelines changed the regimen to isoniazid and rifampin for 4 months in a ﬁxed dose combi- nation. Continuation phase visits were scheduled monthly. First-line ART prescribed in the TB clinic was in accordance with national guidelines and consisted initially of stavudine or zidovudine, lamivudine, and efavirenz until 2010 when tenofovir became available and stavudine was removed from ﬁrst-line recommendations. TB and ART medications were dispensed on the same schedule. No drug stockouts of TB medications or ART were experienced during the study period. However, postelection violence occurred in Kenya beginning December 29, 2007 and resulted in the displacement of up to 600,000 individuals and over 1,000 deaths. The region of violence included Kericho and resulted in displacement of both patients and staﬀ during the study period. 2.3. Data Collection and Variables. Data were collected from the KDH TB/HIV and HIV clinic electronic medical records systems. These KDH MS Access databases include clinical information from both clinic encounter forms and laboratory results. Data were extracted from both the TB/HIV and HIV clinic databases and merged by patient clinic number to allow evaluation of KDH HIV clinic followup. A ﬁnal password protected, anonymous database was created for all retrospective, secondary analyses and stored in the KEMRI/WRP Clinical Research Center secured, double-locked Information Department. Basic demographic and medical information extracted included age, gender, baseline CD4+ T-cell count, TB type, treatment and referral categories, and TB treatment outcomes. 2.4. Statistical Analysis. Descriptive analyses including paired t-tests and chi-square or Fisher’s exact tests where appropriate were used for baseline characteristics and follow- up outcomes. Unadjusted and adjusted multivariable logistic regression analyses were used to examine the relationship between baseline characteristics, clinic year, and outcomes.