The results of this study suggest that, after integration, successful TB treatment outcomes may have increased, but this apparent increase is largely due to the notable increase that was observed only at the RS. The increase was also lower than national levels due to factors such as high mortality, particularly among HIV-positive patients [14,15]. TB/HIV integration is primarily about changing the processes of care and multidisciplinary collaboration , and it is anticipated to increase patient-centeredness, enhance coordination and improve continuity . TB treatment outcomes would subsequently improve through better access, better resource utilisation and enhanced efficiency [6,17]. However, other concurrent TB or HIV, specific interventions may lead to improved outcomes as well. Therefore, when TB/HIV integration is introduced as part of a national programme-improvement approach, successful TB treatment outcomes are then a representation of the impact of all the interventions. The specific impact of each individual intervention becomes difficult to assess. This underscores their non-specificity  as TB/HIV indicators. In this study, for example, improvement in TB treatment success was mainly due to decreases in ‘default’ and ‘transferred out’ cases, which may have only improved as a result of other TB-specific control interventions that were in place, such as community-based TB treatment and the use of treatment supporters in all three study sites [19,20]. Consequently, although integration has the potential to improve TB treatment outcomes, the extent of its contribution may be challenging to assess due to the impact of concurrent strategies.
Among the adverse treatment outcomes, death rates were high at all sites and reduced only marginally after integration. Even though TB deaths include deaths from any cause whilst undertaking TB treatment, research has established that HIV-associated TB is related to an increased risk of TB deaths . Elliot et al.  demonstrated that most deaths in cases of HIV-associated TB result from active TB and its complications, or complications of the HIV infection itself. TB case fatality rates in Africa are 16-35% in HIV-positive patients not receiving ART and 4-9% in HIV-negative patients . The study concurs with the study undertaken for this research paper as mortalities in HIV-positive TB patients were 25%, accounting for 59% of all TB deaths, as compared to 10% among HIV-negative cases, accounting for 25% of all deaths. Even though the treatment success of 75% among HIV-positive TB cases receiving ART after integration was comparable to the 72% as was demonstrated by Huerga et al. , death rates were much higher at 23% in HIV-associated cases, as opposed to the 10% in HIV-negative cases.
Based on the high death rates in the HIV-associated TB cases with little or no apparent influence by other TB-control processes, this study therefore suggests that TB/HIV integration may have a more direct impact on TB deaths than on successful treatment outcomes. While HIV-associated TB accounted for 59% of all TB deaths, the other concurrent TB-control interventions seem to have had much less impact on mortality in Ghana as compared to their impact on defaults and transfers out, which significantly contributed to improved TB treatment success. TB deaths may thus be a more sensitive indicator for TB/HIV integration i.e. TB deaths among TB patients, including those with HIV as well, may provide useful information on the impact of TB/HIV integration.
It is recommended that TB deaths be further explored as an indicator to monitor the impact of TB/HIV integration in similar contexts. This is with reference to the propositions of Maher et al.  that TB deaths are crucial for monitoring programme performance, but are limited by incomplete coverage of all incident TB cases, inaccurate routine programme reporting of deaths, and the unknown contribution of deaths from TB and HIV alone. Even though Maher et al’s study focused on countries with high HIV prevalence in addition to heavy TB burden, this study also suggests that TB mortalities can be useful for monitoring TB/HIV integration in low-income countries with relatively higher TB burden but lower HIV prevalence. More research into the causes of death among HIV-positive TB patients is therefore required to identify and understand the causes of death in order to properly assess its real usefulness as a TB/HIV indicator.
Lack of randomisation and controls limit the internal validity of this study as it subjects it to temporal and selection bias. For that reason, the findings of this study are presented not as categorical statements on the impact of integration, but as a piloting of methods. More rigorous studies are needed to assess the exact impact of TB/HIV integration, and to improve TB/HIV monitoring and evaluation. Another limitation is that evaluation was mainly based on TB-related indicators due to the different programme information systems, and the challenges associated with access to HIV-patient data at the time of the study.