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Kebede Bizuneh F, Tsegaye D, Negese Gemeda B, Kebede Bizuneh T. Proportion of active tuberculosis among HIV-infected children after antiretroviral therapy in Ethiopia: A systematic review and meta-analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003528. [PMID: 39093892 PMCID: PMC11296650 DOI: 10.1371/journal.pgph.0003528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
Despite effectiveness of antiretroviral therapy in reducing mortality of opportunistic infections among HIV infected children, however tuberculosis (TB) remains a significant cause for morbidity and attributed for one in every three deaths. HIV-infected children face disproportionate death risk during co-infection of TB due to their young age and miniatures immunity makes them more vulnerable. In Ethiopia, there is lack of aggregated data TB and HIV mortality in HIV infected children. We conducted an extensive systematic review of literature using Preferred Reporting of Systematic Review and Meta-Analysis (PRISMA) guideline. Five electronic databases were used mainly Scopus, PubMed, Medline, Web of Science, and Google scholar for articles searching. The pooled proportion of TB was estimated using a weighted inverse variance random-effects meta-regression using STATA version-17. Heterogeneity of the articles was evaluated using Cochran's Q test and I2 statistic. Subgroup analysis, sensitivity test, and Egger's regression were conducted for publication bias. This met-analysis is registered in Prospero-CRD42024502038. In the final met-analysis report, 13 out of 1221 articles were included and presented. During screening of 6668 HIV-infected children for active TB occurrence, 834 cases were reported after ART was initiated. The pooled proportion of active TB among HIV infected children was found 12.07% (95% CI: 10.71-13.41). In subgroup analysis, the Oromia region had 15.6% (95%CI: 10.2-20.6) TB burden, followed by southern Ethiopia 12.8% (95%CI: 10.03-15.67). During meta-regression, missed isoniazid Preventive therapy (IPT) (OR: 2.28), missed contrimoxazole preventive therapy (OR: 4.26), WHO stage III&IV (OR: 2.27), and level of Hgb ≤ 10gm/dl (OR = 3.11.7) were predictors for active TB. The systematic review found a higher proportion of active TB in HIV-infected children in Ethiopia compared to estimated rates in end TB strategy. To prevent premature death during co-infection, implement effective TB screening and cases tracing strategies in each follow up is needed.
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Affiliation(s)
| | - Dejen Tsegaye
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Hailu S, Hurst C, Cyphers G, Thottunkal S, Harley D, Viney K, Irwin A, Dean J, Nourse C. Prevalence of extra-pulmonary tuberculosis in Africa: A systematic review and meta-analysis. Trop Med Int Health 2024; 29:257-265. [PMID: 38263374 DOI: 10.1111/tmi.13970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
OBJECTIVE The burden of extra-pulmonary tuberculosis (EPTB) is not well quantified in TB endemic countries such as those in sub-Saharan Africa. This study aimed to quantify that burden via a systematic review of the prevalence of EPTB in African countries. METHODS Studies were retrieved by searching five databases; 105 studies published between 1990 and 2023 were included. The studies described the prevalence of EPTB among the general population (4 studies), TB patients (68) and patients with other conditions, including HIV (15), meningitis (3), renal failure (3) and other comorbidities, some of which are cancer (12). Due to the low number of studies reporting EPTB in patients with conditions other than TB, the meta-analysis was performed on studies reporting on EPTB among TB patients (68 studies). Meta-analysis was performed on the 68 studies (271,073 participants) using a random-effects model to estimate the pooled prevalence of EPTB. Meta-regression was used to explore possible explanations for heterogeneity according to regions and time periods. RESULTS The pooled prevalence of EPTB among TB patients was 26% (95% CI 23-29%). There was substantial heterogeneity of prevalence for the five African regions. The Eastern region had the highest prevalence of 32% (95% CI 28-37%) and the lowest in Western Africa, 16% (95% CI 10-24%). There was no significant difference in the prevalence of EPTB between the 3 eleven-year time periods. CONCLUSIONS Our systematic review and meta-analysis give insight into the burden of EPTB in Africa. This review could inform clinical and programmatic practices-a higher suspicion index for clinicians and more effort for better services. This could contribute to efforts aiming to end TB, which have historically been focused on PTB.Coordinated efforts that target both EPTB and PTB are needed.
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Affiliation(s)
- Semira Hailu
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Cameron Hurst
- Molly Wardaguga Research Centre, Charles Darwin University, Brisbane, Australia
| | - Griffin Cyphers
- Faculty of Medicine, School of Public Health, The University of Queensland, Brisbane, Australia
| | - Stefan Thottunkal
- ANU College of Health and Medicine, Australian National University, Canberra, Australia
| | - David Harley
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Kerri Viney
- ANU College of Health and Medicine, Australian National University, Canberra, Australia
- School of Public Health, University of Sydney, Camperdown, Australia
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Adam Irwin
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Australia
| | - Judith Dean
- Faculty of Medicine, School of Public Health, The University of Queensland, Brisbane, Australia
- UQ Poche Centre for Indigenous Health, The University of Queensland, Brisbane, Australia
| | - Clare Nourse
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Australia
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Enane LA, Duda SN, Chanyachukul T, Bolton-Moore C, Navuluri N, Messou E, Mbonze N, McDade LR, Figueiredo MC, Ross J, Evans D, Diero L, Akpata R, Zotova N, Freeman A, Pierre MF, Rupasinghe D, Ballif M, Byakwaga H, de Castro N, Tabala M, Sterling TR, Sohn AH, Fenner L, Wools-Kaloustian K, Poda A, Yotebieng M, Huebner R, Marcy O. The Tuberculosis Sentinel Research Network (TB-SRN) of the International epidemiology Databases to Evaluate AIDS (IeDEA): protocol for a prospective cohort study in Africa, Southeast Asia and Latin America. BMJ Open 2024; 14:e079138. [PMID: 38195167 PMCID: PMC10806577 DOI: 10.1136/bmjopen-2023-079138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/23/2023] [Indexed: 01/11/2024] Open
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious cause of death globally. It is the most common opportunistic infection in people living with HIV, and the most common cause of their morbidity and mortality. Following TB treatment, surviving individuals may be at risk for post-TB lung disease. The TB Sentinel Research Network (TB-SRN) provides a platform for coordinated observational TB research within the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS AND ANALYSIS This prospective, observational cohort study will assess treatment and post-treatment outcomes of pulmonary TB (microbiologically confirmed or clinically diagnosed) among 2600 people aged ≥15 years, with and without HIV coinfection, consecutively enrolled at 16 sites in 11 countries, across 6 of IeDEA's global regions. Data regarding clinical and sociodemographic factors, mental health, health-related quality of life, pulmonary function, and laboratory and radiographic findings will be collected using standardised questionnaires and data collection tools, beginning from the initiation of TB treatment and through 12 months after the end of treatment. Data will be aggregated for proposed analyses. ETHICS AND DISSEMINATION Ethics approval was obtained at all implementing study sites, including the Vanderbilt University Medical Center Human Research Protections Programme. Participants will provide informed consent; for minors, this includes both adolescent assent and the consent of their parent or primary caregiver. Protections for vulnerable groups are included, in alignment with local standards and considerations at sites. Procedures for requesting use and analysis of TB-SRN data are publicly available. Findings from TB-SRN analyses will be shared with national TB programmes to inform TB programming and policy, and disseminated at regional and global conferences and other venues.
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Affiliation(s)
- Leslie A Enane
- The Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Global Health Equity, Indianapolis, Indiana, USA
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | - Neelima Navuluri
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Eugène Messou
- Centre de Prise en Charge de Recherche et de Formation (Aconda-CePReF), Abidjan, Côte d'Ivoire
| | - Nana Mbonze
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - LaQuita R McDade
- Vanderbilt Institute of Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marina Cruvinel Figueiredo
- Vanderbilt Tuberculosis Center, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jeremy Ross
- TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lameck Diero
- Department of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | | | - Natalia Zotova
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Aimee Freeman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marie Flore Pierre
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Marie Ballif
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Helen Byakwaga
- Mbarara University of Science and Technology Faculty of Medicine, Mbarara, Uganda
| | | | - Martine Tabala
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Timothy R Sterling
- Vanderbilt Tuberculosis Center, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Annette H Sohn
- TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | - Lukas Fenner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Kara Wools-Kaloustian
- Indiana University Center for Global Health Equity, Indianapolis, Indiana, USA
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Armel Poda
- Centre Hospitalier Universitaire Sourô Sanou, Bobo Dioulasso, Burkina Faso
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robin Huebner
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Bohlbro AS, Mendes AM, Sifna A, Patsche CB, Soelberg MES, Gomes V, Wejse C, Rudolf F. BCG is protective against death in male but not female patients with pulmonary tuberculosis in Guinea-Bissau. Trans R Soc Trop Med Hyg 2023; 117:365-374. [PMID: 36575997 DOI: 10.1093/trstmh/trac120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/26/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Growing evidence supports the existence of a sex difference in immunity to tuberculosis (TB). This is most often to the detriment of males. This study aimed to assess the association between scar size from bacillus Calmette-Guérin (BCG) and mortality risk stratified by sex. METHODS Kaplan-Meier survivor functions and Cox proportional hazard models were used to assess mortality risk by sex and scar size. Groups were further compared by clinical and epidemiological characteristics. RESULTS Between 2003 and 2019, 2944 eligible patients were identified, of whom 1003 were included in the final analysis. Males with BCG scars, particularly large scars, were less likely to die within 1 y of diagnosis than males with no scar (adjusted hazard ratio 0.36 [95% confidence interval 0.15 to 0.88]). In contrast, females with small scars trended towards higher mortality than females with no scars or females with large scars. CONCLUSIONS BCG protects against death in male but not female patients with TB. More research is needed to determine the mechanisms underpinning these sex differences and whether they are generalizable beyond this setting.
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Affiliation(s)
- Anders Solitander Bohlbro
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Armando Sifna
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau
| | - Cecilie Blenstrup Patsche
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau
- GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Victor Gomes
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau
| | - Christian Wejse
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Frauke Rudolf
- Bandim Health Project, INDEPTH Network, Apartado 861, Bissau, Guinea-Bissau
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
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Burke RM, Twabi HH, Johnston C, Nliwasa M, Gupta-Wright A, Fielding K, Ford N, MacPherson P, Corbett EL. Interventions to reduce deaths in people living with HIV admitted to hospital in low- and middle-income countries: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001557. [PMID: 36963024 PMCID: PMC10022356 DOI: 10.1371/journal.pgph.0001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
People living with HIV (PLHIV) admitted to hospital have a high risk of death. We systematically appraised evidence for interventions to reduce mortality among hospitalised PLHIV in low- and middle-income countries (LMICs). Using a broad search strategy with terms for HIV, hospitals, and clinical trials, we searched for reports published between 1 Jan 2003 and 23 August 2021. Studies of interventions among adult HIV positive inpatients in LMICs were included if there was a comparator group and death was an outcome. We excluded studies restricted only to inpatients with a specific diagnosis (e.g. cryptococcal meningitis). Of 19,970 unique studies identified in search, ten were eligible for inclusion with 7,531 participants in total: nine randomised trials, and one before-after study. Three trials investigated systematic screening for tuberculosis; two showed survival benefit for urine TB screening vs. no urine screening, and one which compared Xpert MTB/RIF versus smear microscopy showed no difference in survival. One before-after study implemented 2007 WHO guidelines to improve management of smear negative tuberculosis in severely ill PLHIV, and showed survival benefit but with high risk of bias. Two trials evaluated complex interventions aimed at overcoming barriers to ART initiation in newly diagnosed PLHIV, one of which showed survival benefit and the other no difference. Two small trials evaluated early inpatient ART start, with no difference in survival. Two trials investigated protocol-driven fluid resuscitation for emergency-room attendees meeting case-definitions for sepsis, and showed increased mortality with use of a protocol for fluid administration. In conclusion, ten studies published since 2003 investigated interventions that aimed to reduce mortality in hospitalised adults with HIV, and weren't restricted to people with a defined disease diagnosis. Inpatient trials of diagnostics, therapeutics or a package of interventions to reduce mortality should be a research priority. Trial registration: PROSPERO Number: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019150341.
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Affiliation(s)
- Rachael M. Burke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
| | - Hussein H. Twabi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Cheryl Johnston
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nathan Ford
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Peter MacPherson
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elizabeth L. Corbett
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
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Zhang L, Meng X, Dong P, Qi T, Liu L, Wang B. Effects of rifampicin, CYP2B6 and ABCB1 polymorphisms on efavirenz plasma concentration in Chinese patients living with HIV and tuberculosis. Int J STD AIDS 2023; 34:37-47. [PMID: 36356965 DOI: 10.1177/09564624221134137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Tuberculosis (TB) is the leading opportunistic infection of people living with human immunodeficiency virus (HIV; PLWH). Cytochrome P450 (CYP) 2B6 and ATP-binding cassette sub-family B member 1 (ABCB1) are involved in the metabolism and transportation of efavirenz. The study was aimed to investigate the effects of rifampicin, CYP2B6 and ABCB1 polymorphisms on efavirenz exposure in Chinese PLWH co-infected with TB. METHOD PLWH were screened according to inclusion and exclusion criteria and divided into HIV group and HIV/TB group. Efavirenz plasma concentration (C0) was determined, dose-adjusted concentration (C0/D) was calculated, and genotypes of CYP2B6 516G>T, 785A>G, and ABCB1 2677G>T, 3435C>T were analyzed. RESULTS 252 PLWH were enrolled, including 75 co-infected with TB and concomitant with rifampicin. Efavirenz C0 and C0/D were both higher in HIV group (1.94 μg/mL, 0.2007 (μg/ml)/(mg/kg/d)) compared with HIV/TB group (1.52 μg/mL, 0.1557 (μg/ml)/(mg/kg/d)) (p = .001). Efavirenz C0/D was significantly higher in patients with variant genotypes of CYP2B6 516G>T and 785A>G (p<.001), and was significantly lower in HIV/TB group compared with HIV group among patients with CYP2B6 516 GG, TT, and 785 AA, AG genotypes (p < .05). CONCLUSION Efavirenz exposure is reduced by co-administration with rifampicin, and related to genetic polymorphisms of CYP2B6.
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Affiliation(s)
- Li Zhang
- Department of Pharmacy, 159397Huashan Hospital Fudan University, Shanghai, People's Republic of China.,Department of Pharmacy, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Xianmin Meng
- Department of Pharmacy, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Ping Dong
- Department of Pharmacy, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Tangkai Qi
- Department of Infectious Disease, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Li Liu
- Department of Infectious Disease, 34748Shanghai Public Health Clinical Center, Shanghai, People's Republic of China
| | - Bin Wang
- Department of Pharmacy, 159397Huashan Hospital Fudan University, Shanghai, People's Republic of China
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Drug resistance characteristics of Mycobacterium tuberculosis isolates obtained between 2018 and 2020 in Sichuan, China. Epidemiol Infect 2022; 150:e27. [PMID: 35086596 PMCID: PMC8888273 DOI: 10.1017/s0950268822000127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We investigated the drug resistance of Mycobacterium tuberculosis isolates from patients with tuberculosis (TB) and HIV, and those diagnosed with only TB in Sichuan, China. TB isolates were obtained from January 2018 to December 2020 and subjected to drug susceptibility testing (DST) to 11 anti-TB drugs and to GeneXpert MTB/RIF testing. The overall proportion of drug-resistant TB (DR-TB) isolates was 32.1% (n = 10 946). HIV testing was not universally available for outpatient TB cases, only 29.5% (3227/10 946) cases had HIV testing results. The observed proportion of multidrug-resistant TB (MDR-TB) isolates was almost double than that of the national level, with approximately 1.5% and 0.1% of the isolates being extensively drug resistant and universally drug resistant, respectively. The proportions of resistant isolates were generally higher in 2018 and 2019 than in 2020. Furthermore, the sensitivities of GeneXpert during 2018–2020 demonstrated a downward trend (80.9, 95% confidence intervals (CI) 76.8–85.0; 80.2, 95% CI 76.4–84.1 and 75.4, 95% CI 70.7–80.2, respectively). Approximately 69.0% (7557/10 946) of the TB cases with DST results were subjected to GeneXpert detection. Overall, the DR-TB status and the use of GeneXpert in Sichuan have improved, but DR-TB challenges remain. HIV testing for all TB cases is recommended.
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Sullivan A, Nathavitharana RR. Addressing TB-related mortality in adults living with HIV: a review of the challenges and potential solutions. Ther Adv Infect Dis 2022; 9:20499361221084163. [PMID: 35321342 PMCID: PMC8935406 DOI: 10.1177/20499361221084163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/12/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) is the leading cause of death in people living with HIV (PLHIV) globally, causing 208,000 deaths in PLHIV in 2019. PLHIV have an 18-fold higher risk of TB, and HIV/TB mortality is highest in inpatient facilities, compared with primary care and community settings. Here we discuss challenges and potential mitigating solutions to address TB-related mortality in adults with HIV. Key factors that affect healthcare engagement are stigma, knowledge, and socioeconomic constraints, which are compounded in people with HIV/TB co-infection. Innovative approaches to improve healthcare engagement include optimizing HIV/TB care integration and interventions to reduce stigma. While early diagnosis of both HIV and TB can reduce mortality, barriers to early diagnosis of TB in PLHIV include difficulty producing sputum specimens, lower sensitivity of TB diagnostic tests in PLHIV, and higher rates of extra pulmonary TB. There is an urgent need to develop higher sensitivity biomarker-based tests that can be used for point-of-care diagnosis. Nonetheless, the implementation and scale-up of existing tests including molecular World Health Organization (WHO)-recommended diagnostic tests and urine lipoarabinomannan (LAM) should be optimized along with expanded TB screening with tools such as C-reactive protein and digital chest radiography. Decreased survival of PLHIV with TB disease is more likely with late HIV diagnosis and delayed start of antiretroviral (ART) treatment. The WHO now recommends starting ART within 2 weeks of initiating TB treatment in the majority of PLHIV, aside from those with TB meningitis. Dedicated TB treatment trials focused on PLHIV are needed, including interventions to improve TB meningitis outcomes given its high mortality, such as the use of intensified regimens using high-dose rifampin, new and repurposed drugs such as linezolid, and immunomodulatory therapy. Ultimately holistic, high-quality, person-centered care is needed for PLHIV with TB throughout the cascade of care, which should address biomedical, socioeconomic, and psychological barriers.
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Affiliation(s)
- Amanda Sullivan
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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Moucheraud C, Hoffman RM, Balakasi K, Wong V, Sanena M, Gupta S, Dovel K. Screening Adults for HIV Testing in the Outpatient Department: An Assessment of Tool Performance in Malawi. AIDS Behav 2022; 26:478-486. [PMID: 34379273 PMCID: PMC8813838 DOI: 10.1007/s10461-021-03404-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 02/03/2023]
Abstract
Little is known about screening tools for adults in high HIV burden contexts. We use exit survey data collected at outpatient departments in Malawi (n = 1038) to estimate the sensitivity, specificity, negative and positive predictive values of screening tools that include questions about sexual behavior and use of health services. We compare a full tool (seven relevant questions) to a reduced tool (five questions, excluding sexual behavior measures) and to standard of care (two questions, never tested for HIV or tested > 12 months ago, or seeking care for suspected STI). Suspect STI and ≥ 3 sexual partners were associated with HIV positivity, but had weak sensitivity and specificity. The full tool (using the optimal cutoff score of ≥ 3) would achieve 55.6% sensitivity and 84.9% specificity for HIV positivity; the reduced tool (optimal cutoff score ≥ 2) would achieve 59.3% sensitivity and 68.5% specificity; and standard of care 77.8% sensitivity and 47.8% specificity. Screening tools for HIV testing in outpatient departments do not offer clear advantages over standard of care.
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Affiliation(s)
- Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, 650 Charles E. Young Dr. S., 31-235A, Los Angeles, CA 90095 USA
| | - Risa M. Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | | | | | | | - Sundeep Gupta
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | - Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA USA ,Partners in Hope, Lilongwe, Malawi
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Nathavitharana RR, Lederer P, Chaplin M, Bjerrum S, Steingart KR, Shah M. Impact of diagnostic strategies for tuberculosis using lateral flow urine lipoarabinomannan assay in people living with HIV. Cochrane Database Syst Rev 2021; 8:CD014641. [PMID: 34416013 PMCID: PMC8407503 DOI: 10.1002/14651858.cd014641] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Tuberculosis is the primary cause of hospital admission in people living with HIV, and the likelihood of death in the hospital is unacceptably high. The Alere Determine TB LAM Ag test (AlereLAM) is a point-of-care test and the only lateral flow lipoarabinomannan assay (LF-LAM) assay currently commercially available and recommended by the World Health Organization (WHO). A 2019 Cochrane Review summarised the diagnostic accuracy of LF-LAM for tuberculosis in people living with HIV. This systematic review assesses the impact of the use of LF-LAM (AlereLAM) on mortality and other patient-important outcomes. OBJECTIVES To assess the impact of the use of LF-LAM (AlereLAM) on mortality in adults living with HIV in inpatient and outpatient settings. To assess the impact of the use of LF-LAM (AlereLAM) on other patient-important outcomes in adults living with HIV, including time to diagnosis of tuberculosis, and time to initiation of tuberculosis treatment. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (Ovid); Science Citation Index Expanded (Web of Science), BIOSIS Previews, Scopus, LILACS; ProQuest Dissertations and Theses; ClinicalTrials.gov; and the WHO ICTRP up to 12 March 2021. SELECTION CRITERIA Randomized controlled trials that compared a diagnostic intervention including LF-LAM with diagnostic strategies that used smear microscopy, mycobacterial culture, a nucleic acid amplification test such as Xpert MTB/RIF, or a combination of these tests. We included adults (≥ 15 years) living with HIV. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility, extracted data, and analysed risk of bias using the Cochrane tool for assessing risk of bias in randomized studies. We contacted study authors for clarification as needed. We used risk ratio (RR) with 95% confidence intervals (CI). We used a fixed-effect model except in the presence of clinical or statistical heterogeneity, in which case we used a random-effects model. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included three trials, two in inpatient settings and one in outpatient settings. All trials were conducted in sub-Saharan Africa and assessed the impact of diagnostic strategies that included LF-LAM on mortality when the test was used in conjunction with other tuberculosis diagnostic tests or clinical assessment for clinical decision-making in adults living with HIV. Inpatient settings In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy likely reduces mortality in people living with HIV at eight weeks compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 0.85, 95% CI 0.76 to 0.94; 5102 participants, 2 trials; moderate-certainty evidence). That is, people living with HIV who received LF-LAM had 15% lower risk of mortality. The absolute effect was 34 fewer deaths per 1000 (from 14 fewer to 55 fewer). In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy probably results in a slight increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 1.26, 95% CI 0.94 to 1.69; 5102 participants, 2 trials; moderate-certainty evidence). Outpatient settings In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality in people living with HIV at six months compared to routine tuberculosis diagnostic testing without LF-LAM (RR 0.89, 95% CI 0.71 to 1.11; 2972 participants, 1 trial; low-certainty evidence). Although this trial did not detect a difference in mortality, the direction of effect was towards a mortality reduction, and the effect size was similar to that in inpatient settings. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may result in a large increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (RR 5.44, 95% CI 4.70 to 6.29, 3022 participants, 1 trial; low-certainty evidence). Other patient-important outcomes Assessment of other patient-important and implementation outcomes in the trials varied. The included trials demonstrated that a higher proportion of people living with HIV were able to produce urine compared to sputum for tuberculosis diagnostic testing; a higher proportion of people living with HIV were diagnosed with tuberculosis in the group that received LF-LAM; and the incremental diagnostic yield was higher for LF-LAM than for urine or sputum Xpert MTB/RIF. AUTHORS' CONCLUSIONS In inpatient settings, the use of LF-LAM as part of a tuberculosis diagnostic testing strategy likely reduces mortality and probably results in a slight increase in tuberculosis treatment initiation in people living with HIV. The reduction in mortality may be due to earlier diagnosis, which facilitates prompt treatment initiation. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality and may result in a large increase in tuberculosis treatment initiation in people living with HIV. Our results support the implementation of LF-LAM to be used in conjunction with other WHO-recommended tuberculosis diagnostic tests to assist in the rapid diagnosis of tuberculosis in people living with HIV.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Philip Lederer
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Marty Chaplin
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Bjerrum
- Department of Clinical Research, Research Unit of Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maunank Shah
- Department of Medicine, Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, USA
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11
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Haraka F, Kakolwa M, Schumacher SG, Nathavitharana RR, Denkinger CM, Gagneux S, Reither K, Ross A. Impact of the diagnostic test Xpert MTB/RIF on patient outcomes for tuberculosis. Cochrane Database Syst Rev 2021; 5:CD012972. [PMID: 34097769 PMCID: PMC8208889 DOI: 10.1002/14651858.cd012972.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends Xpert MTB/RIF in place of smear microscopy to diagnose tuberculosis (TB), and many countries have adopted it into their diagnostic algorithms. However, it is not clear whether the greater accuracy of the test translates into improved health outcomes. OBJECTIVES To assess the impact of Xpert MTB/RIF on patient outcomes in people being investigated for tuberculosis. SEARCH METHODS We searched the following databases, without language restriction, from 2007 to 24 July 2020: Cochrane Infectious Disease Group (CIDG) Specialized Register; CENTRAL; MEDLINE OVID; Embase OVID; CINAHL EBSCO; LILACS BIREME; Science Citation Index Expanded (Web of Science), Social Sciences citation index (Web of Science), and Conference Proceedings Citation Index - Social Science & Humanities (Web of Science). We also searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the Pan African Clinical Trials Registry for ongoing trials. SELECTION CRITERIA We included individual- and cluster-randomized trials, and before-after studies, in participants being investigated for tuberculosis. We analysed the randomized and non-randomized studies separately. DATA COLLECTION AND ANALYSIS: For each study, two review authors independently extracted data, using a piloted data extraction tool. We assessed the risk of bias using Cochrane and Effective Practice and Organisation of Care (EPOC) tools. We used random effects meta-analysis to allow for heterogeneity between studies in setting and design. The certainty of the evidence in the randomized trials was assessed by GRADE. MAIN RESULTS We included 12 studies: eight were randomized controlled trials (RCTs), and four were before-and-after studies. Most included RCTs had a low risk of bias in most domains of the Cochrane 'Risk of bias' tool. There was inconclusive evidence of an effect of Xpert MTB/RIF on all-cause mortality, both overall (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.75 to 1.05; 5 RCTs, 9932 participants, moderate-certainty evidence), and restricted to studies with six-month follow-up (RR 0.98, 95% CI 0.78 to 1.22; 3 RCTs, 8143 participants; moderate-certainty evidence). There was probably a reduction in mortality in participants known to be infected with HIV (odds ratio (OR) 0.80, 95% CI 0.67 to 0.96; 5 RCTs, 5855 participants; moderate-certainty evidence). It is uncertain whether Xpert MTB/RIF has no or a modest effect on the proportion of participants starting tuberculosis treatment who had a successful treatment outcome (OR) 1.10, 95% CI 0.96 to 1.26; 3RCTs, 4802 participants; moderate-certainty evidence). There was also inconclusive evidence of an effect on the proportion of participants who were treated for tuberculosis (RR 1.10, 95% CI 0.98 to 1.23; 5 RCTs, 8793 participants; moderate-certainty evidence). The proportion of participants treated for tuberculosis who had bacteriological confirmation was probably higher in the Xpert MTB/RIF group (RR 1.44, 95% CI 1.29 to 1.61; 6 RCTs, 2068 participants; moderate-certainty evidence). The proportion of participants with bacteriological confirmation who were lost to follow-up pre-treatment was probably reduced (RR 0.59, 95% CI 0.41 to 0.85; 3 RCTs, 1217 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We were unable to confidently rule in or rule out the effect on all-cause mortality of using Xpert MTB/RIF rather than smear microscopy. Xpert MTB/RIF probably reduces mortality among participants known to be infected with HIV. We are uncertain whether Xpert MTB/RIF has a modest effect or not on the proportion treated or, among those treated, on the proportion with a successful outcome. It probably does not have a substantial effect on these outcomes. Xpert MTB/RIF probably increases both the proportion of treated participants who had bacteriological confirmation, and the proportion with a laboratory-confirmed diagnosis who were treated. These findings may inform decisions about uptake alongside evidence on cost-effectiveness and implementation.
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Affiliation(s)
- Frederick Haraka
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Claudia M Denkinger
- FIND, Geneva, Switzerland
- Division of Tropical Medicine, Centre for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastien Gagneux
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Klaus Reither
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Amanda Ross
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
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12
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Zhang P, Xiong J, Zeng J, Zhan S, Chen T, Wang Y, Deng G. Clinical Evaluation of Active Tuberculosis-Related Deaths in Shenzhen, China: A Descriptive Study. Int J Gen Med 2021; 14:237-242. [PMID: 33519230 PMCID: PMC7837593 DOI: 10.2147/ijgm.s291146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/07/2021] [Indexed: 12/27/2022] Open
Abstract
Objective The aim of this study was to assess active tuberculosis-related deaths in Shenzhen city of China to identify major causes of mortality in different age groups. Patients and Methods Medical records of mortality cases of patients with active TB diagnosed during 2013-2018 were reviewed. All TB deaths were classified into two broad age groups (the young group: 18-65 years old and the elderly group: >65 years old). Causes of death were analyzed based on medical records. Results A total of 279 mortality cases of active TB were reviewed during the study period. Among them, mean age was 54.0±20.5 years old; 80.6% (225/279) were male. There were 5.7% and 4.6% MDR/XDRTB patients in the young and elderly group. Newly treated TB accounted for 89.6% in the young group and 85.1% in the elderly group. Pulmonary TB was a major infection type in both groups (65.1% vs 77.0%). Advanced TB (23.4%) and HIV co-infection (20.8%) were the leading causes of deaths in the young group, but deaths in the elderly group were mostly associated with underlying diseases, including cardiovascular disease (52.9%), diabetes (33.3%), COPD (16.1%) and cancer (11.5%). Malnutrition was a significant condition in both groups (43.2% vs 35.6%). In terms of respiratory complications, bacterial infection was the leading comorbidity in both groups (27.1% vs 18.4%), followed by septic shock (18.2% vs 12.6%) and respiratory failure (12.0% vs 11.5%). There were no significant statistical differences between the two groups. Conclusion Our findings suggest that screening for HIV co-infection and early diagnosis of TB is vital in lowering TB-related deaths in young patients. Most deaths in elderly TB patients were caused by underlying health conditions or complications other than TB.
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Affiliation(s)
- Peize Zhang
- Department of Pulmonary Medicine and Tuberculosis, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
| | - Juan Xiong
- School of Public Health, Health Science Center, Shenzhen University, Shenzhen, Guangdong, People's Republic of China
| | - Jianfeng Zeng
- Department of Pulmonary Medicine and Tuberculosis, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
| | - Senlin Zhan
- Department of Pulmonary Medicine and Tuberculosis, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
| | - Tao Chen
- Department of Pulmonary Medicine and Tuberculosis, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
| | - Yuxiang Wang
- Department of Pulmonary Medicine and Tuberculosis, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
| | - Guofang Deng
- Department of Pulmonary Medicine and Tuberculosis, The Third People's Hospital of Shenzhen, Shenzhen, Guangdong, People's Republic of China
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Gupta-Wright A, Fielding K, Wilson D, van Oosterhout JJ, Grint D, Mwandumba HC, Alufandika-Moyo M, Peters JA, Chiume L, Lawn SD, Corbett EL. Tuberculosis in Hospitalized Patients With Human Immunodeficiency Virus: Clinical Characteristics, Mortality, and Implications From the Rapid Urine-based Screening for Tuberculosis to Reduce AIDS Related Mortality in Hospitalized Patients in Africa. Clin Infect Dis 2020; 71:2618-2626. [PMID: 31781758 PMCID: PMC7744971 DOI: 10.1093/cid/ciz1133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/15/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is the major killer of people living with human immunodeficiency virus (HIV) globally, with suboptimal diagnostics and management contributing to high case-fatality rates. METHODS A prospective cohort of patients with confirmed TB (Xpert MTB/RIF and/or Determine TB-LAM Ag positive) identified through screening HIV-positive inpatients with sputum and urine diagnostics in Malawi and South Africa (Rapid urine-based Screening for Tuberculosis to reduce AIDS Related Mortality in hospitalized Patients in Africa [STAMP] trial). Urine was tested prospectively (intervention) or retrospectively (standard of care arm). We defined baseline clinical phenotypes using hierarchical cluster analysis, and also used Cox regression analysis to identify associations with early mortality (≤56 days). RESULTS Of 322 patients with TB confirmed between October 2015 and September 2018, 78.0% had ≥1 positive urine test. Antiretroviral therapy (ART) coverage was 80.2% among those not newly diagnosed, but with median CD4 count 75 cells/µL and high HIV viral loads. Early mortality was 30.7% (99/322), despite near-universal prompt TB treatment. Older age, male sex, ART before admission, poor nutritional status, lower hemoglobin, and positive urine tests (TB-LAM and/or Xpert MTB/RIF) were associated with increased mortality in multivariate analyses. Cluster analysis (on baseline variables) defined 4 patient subgroups with early mortality ranging from 9.8% to 52.5%. Although unadjusted mortality was 9.3% lower in South Africa than Malawi, in adjusted models mortality was similar in both countries (hazard ratio, 0.9; P = .729). CONCLUSIONS Mortality following prompt inpatient diagnosis of HIV-associated TB remained unacceptably high, even in South Africa. Intensified management strategies are urgently needed, for which prognostic indicators could potentially guide both development and subsequent use.
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Affiliation(s)
- Ankur Gupta-Wright
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Katherine Fielding
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of the Witwatersrand, Johannesburg, South Africa
| | - Douglas Wilson
- Department of Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Daniel Grint
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Jurgens A Peters
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Stephen D Lawn
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth L Corbett
- Tuberculosis Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
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14
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García JI, Mambuque E, Nguenha D, Vilanculo F, Sacoor C, Sequera VG, Fernández-Quevedo M, Pierre MLL, Chiconela H, Faife LA, Respeito D, Saavedra B, Nhampossa T, López-Varela E, Garcia-Basteiro AL. Mortality and risk of tuberculosis among people living with HIV in whom TB was initially ruled out. Sci Rep 2020; 10:15442. [PMID: 32963296 PMCID: PMC7509810 DOI: 10.1038/s41598-020-71784-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) misdiagnosis remains a public health concern, especially among people living with HIV (PLHIV), given the high mortality associated with missed TB diagnoses. The main objective of this study was to describe the all-cause mortality, TB incidence rates and their associated risk factors in a cohort of PLHIV with presumptive TB in whom TB was initially ruled out. We retrospectively followed a cohort of PLHIV with presumptive TB over a 2 year-period in a rural district in Southern Mozambique. During the study period 382 PLHIV were followed-up. Mortality rate was 6.8/100 person-years (PYs) (95% CI 5.2-9.2) and TB incidence rate was 5.4/100 PYs (95% CI 3.9-7.5). Thirty-six percent of deaths and 43% of TB incident cases occurred in the first 12 months of the follow up. Mortality and TB incidence rates in the 2-year period after TB was initially ruled out was very high. The TB diagnostic work-up and linkage to HIV care should be strengthened to decrease TB burden and all-cause mortality among PLHIV with presumptive TB.
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Affiliation(s)
- Juan Ignacio García
- TB Group, Population Health Program, Texas Biomedical Research Institute, San Antonio, TX, USA
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Edson Mambuque
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Dinis Nguenha
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | | | - Charfudin Sacoor
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | | | | | | | - Helio Chiconela
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Luis A Faife
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Durval Respeito
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Belén Saavedra
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Tacilta Nhampossa
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Elisa López-Varela
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Desmond Tutu TB center, Stellenbosch University, Cape Town, South Africa
| | - Alberto L Garcia-Basteiro
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique.
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
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Divala TH, Fielding KL, Kandulu C, Nliwasa M, Sloan DJ, Gupta-Wright A, Corbett EL. Utility of broad-spectrum antibiotics for diagnosing pulmonary tuberculosis in adults: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2020; 20:1089-1098. [PMID: 32437700 PMCID: PMC7456780 DOI: 10.1016/s1473-3099(20)30143-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 01/15/2020] [Accepted: 02/18/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Suboptimal diagnostics for pulmonary tuberculosis drive the use of the so-called trial of antibiotics, a course of broad-spectrum antibiotics without activity against Mycobacterium tuberculosis that is given to patients who are mycobacteriology negative but symptomatic, with the aim of distinguishing pulmonary tuberculosis from bacterial lower respiratory tract infection. The underlying assumption-that patients with lower respiratory tract infection will improve, whereas those with pulmonary tuberculosis will not-has an unclear evidence base for such a widely used intervention (at least 26·5 million courses are prescribed per year). We aimed to collate available evidence on the diagnostic performance of the trial of antibiotics. METHODS In this systematic review and meta-analysis we searched the MEDLINE, Embase, and Global Health databases for studies published up to March 15, 2019, that investigated the sensitivity and specificity of the trial of antibiotics against mycobacteriology tests in adults (≥15 years) with tuberculosis symptoms. We used the QUADAS-2 tool to assess the risk of bias. We estimated pooled values for sensitivity and specificity of trial of antibiotics (as the index text) versus mycobacteriology tests (as the reference standard) using random-effects bivariate modelling, and we used the I2 statistic to assess heterogeneity between studies contributing to these estimates. This study is registered with PROSPERO, number CRD42017083915. FINDINGS Of the 9410 articles identified by our search, eight studies were eligible for inclusion. The studies were from seven countries in Africa, South America, and Asia, and involved 2786 participants. Six studies used mycobacterial culture as the reference standard, and six used penicillins for the trial of antibiotics. The treatment duration, number of antimicrobial courses, and definition of what constituted response to treatment varied substantially between studies. The pooled sensitivity (67%, 95% CI 42-85) and specificity (73%, 58-85) of the trial of antibiotics versus mycobacteriology tests were below internationally defined minimum performance profiles for tuberculosis diagnostics and had substantial heterogeneity (I2 was 96% for sensitivity and 99% for specificity). Each included study failed on one or more domain of the QUADAS-2 tool. INTERPRETATION Current policy and practice regarding the trial of antibiotics appear inappropriate, given the weak evidence base, poor diagnostic performance, potential contribution to the global antimicrobial resistance crisis, and adverse individual and public health consequences from the misclassification of tuberculosis status. Antibiotic strategies during tuberculosis investigations should instead optimise clinical outcomes, ideally guided by clinical trials in both inpatient and outpatient groups. FUNDING Helse Nord RHF, Wellcome Trust, and the UK Commonwealth Scholarship Commission.
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Affiliation(s)
- Titus H Divala
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Chikondi Kandulu
- Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marriott Nliwasa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Ankur Gupta-Wright
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Elizabeth L Corbett
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi; Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
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Mair L, Corbett EL, Feasey HRA, Kamchedzera W, Khundi M, Lalloo DG, Maheswaran H, Nliwasa M, Squire SB, Webb EL, MacPherson P. Provider-initiated HIV testing and TB screening in the era of universal coverage: Are the right people being reached? A cohort study in Blantyre, Malawi. PLoS One 2020; 15:e0236407. [PMID: 32790669 PMCID: PMC7425889 DOI: 10.1371/journal.pone.0236407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 07/06/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Patients with tuberculosis (TB) symptoms have high prevalence of HIV, and should be prioritised for HIV testing. METHODS In a prospective cohort study in Bangwe primary care clinic, Blantyre, Malawi, all adults (18 years or older) presenting with an acute illness were screened for TB symptoms (cough, fever, night sweats, weight loss). Demographic characteristics were linked to exit interview by fingerprint bioidentification. Multivariable logistic regression models were constructed to estimate the proportion completing same-visit HIV testing, comparing between those with and without TB symptoms. RESULTS There were 5427 adult attendees between 21/5/2018 and 6/9/2018. Exit interviews were performed for 2402 (44%). 276 patients were excluded from the analysis, being already on antiretroviral therapy (ART). Presentation with any TB symptom was common for men (54.6%) and women (57.4%). Overall 27.6% (585/ 2121) attenders reported being offered testing and 21.5% (455/2121) completed provider-initiated HIV testing and counselling (PITC) and received results. The proportions offered testing were similar among participants with and without TB symptoms (any TB symptom: 29.0% vs. 25.7%). This was consistent for each individual symptom; cough, weight loss, fever and night sweats. Multivariable regression models indicated men, younger adults and participants who had previously tested were more likely to complete PITC than women, older adults and those who had never previously tested. CONCLUSIONS Same-visit completion of HIV testing was suboptimal, especially among groups known to have high prevalence of undiagnosed HIV. As countries approach universal coverage of ART, identifying and prioritising currently underserved groups for HIV testing will be essential.
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Affiliation(s)
- Luke Mair
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingom
- Tropical and Infectious Diseases Unit, Royal Liverpool University and Broadgreen Hospitals NHS Trust, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Helena R. A. Feasey
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Wala Kamchedzera
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - McEwen Khundi
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingom
| | | | - Marriott Nliwasa
- Helse-Nord TB Programme, College of Medicine, University of Malawi, Malawi
| | - S. Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingom
| | - Emily L. Webb
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
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17
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Nathavitharana RR, Yoon C, Macpherson P, Dowdy DW, Cattamanchi A, Somoskovi A, Broger T, Ottenhoff THM, Arinaminpathy N, Lonnroth K, Reither K, Cobelens F, Gilpin C, Denkinger CM, Schumacher SG. Guidance for Studies Evaluating the Accuracy of Tuberculosis Triage Tests. J Infect Dis 2019; 220:S116-S125. [PMID: 31593600 PMCID: PMC6782021 DOI: 10.1093/infdis/jiz243] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Approximately 3.6 million cases of active tuberculosis (TB) go potentially undiagnosed annually, partly due to limited access to confirmatory diagnostic tests, such as molecular assays or mycobacterial culture, in community and primary healthcare settings. This article provides guidance for TB triage test evaluations. A TB triage test is designed for use in people with TB symptoms and/or significant risk factors for TB. Triage tests are simple and low-cost tests aiming to improve ease of access and implementation (compared with confirmatory tests) and decrease the proportion of patients requiring more expensive confirmatory testing. Evaluation of triage tests should occur in settings of intended use, such as community and primary healthcare centers. Important considerations for triage test evaluation include study design, population, sample type, test throughput, use of thresholds, reference standard (ideally culture), and specimen flow. The impact of a triage test will depend heavily on issues beyond accuracy, primarily centered on implementation.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Department of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston,Correspondence: R. Nathavitharana, MBBS, MPH, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Lowry Building, Suite GB, 110 Francis Street, Boston MA 02215
| | - Christina Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco
| | - Peter Macpherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, United Kingdom,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malawi
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco,Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, University of California San Francisco
| | - Akos Somoskovi
- Intellectual Ventures Laboratory, Global Good Fund, Bellevue, Washington
| | - Tobias Broger
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, The Netherlands
| | - Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, Stockholm, Sweden
| | - Knut Lonnroth
- Department of Public Health Sciences, Karolinska Instituet, Stockholm, Sweden
| | - Klaus Reither
- University of Basel, Switzerland,Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Frank Cobelens
- Department of Global Health, Amsterdam UMC, University of Amsterdam, The Netherlands
| | | | - Claudia M Denkinger
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland,University Hospital Heidelberg, Division of Tropical Medicine, Centre of Infectious Diseases, Germany
| | - Samuel G Schumacher
- University Hospital Heidelberg, Division of Tropical Medicine, Centre of Infectious Diseases, Germany
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18
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Gelaw YA, Williams G, Soares Magalhães RJ, Gilks CF, Assefa Y. HIV Prevalence Among Tuberculosis Patients in Sub-Saharan Africa: A Systematic Review and Meta-analysis. AIDS Behav 2019; 23:1561-1575. [PMID: 30607755 DOI: 10.1007/s10461-018-02386-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
HIV associated tuberculosis (TB) morbidity and mortality is a major concern in sub-Saharan Africa. Understanding the level of HIV infection among TB patients is vital for adequate response. We conducted a systematic review and meta-analysis to estimate the prevalence of HIV in TB patients in sub-Saharan Africa. We searched PubMed, EMBASE, Web of Science and CINAHL databases. A meta-analysis with a random-effects model was performed. Potential sources of heterogeneity in the prevalence estimates were explored using meta-regression analysis. We identified 68 studies that collectively included 62,969 TB patients between 1990 and 2017. The overall estimate of HIV prevalence in TB patients was 31.8% (95% CI 27.8-36.1). There was substantial heterogeneity in the prevalence estimates in Southern, Central, Eastern, and Western sub-Saharan Africa regions (43.7, 41.3, 31.1 and 25.5%, respectively). We noted an apparent reduction in the estimate from 33.7% (95% CI 27.6-40.4) in the period before 2000 to 25.7% (95% CI 17.6-336.6) in the period after 2010. The Eastern and Southern sub-Saharan Africa region had higher prevalence [34.4% (95% CI 29.3-34.4)] than the Western and Central region [27.3% (95% CI 21.6-33.8)]. The prevalence of HIV in TB patients has declined over time in sub-Saharan Africa. We argue that this is due to strengthened HIV prevention and control response and enhanced TB/HIV collaborative activities. Countries and regions with high burdens of HIV and TB should strengthen and sustain efforts in order to achieve the goal of ending both HIV and TB epidemics in line with the Sustainable Development Goals.
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Affiliation(s)
- Yalemzewod Assefa Gelaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia.
- Institute of Public Health, College of Medicine and Health Science, University of Gondar, 196, Gondar, Ethiopia.
| | - Gail Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
| | - Ricardo J Soares Magalhães
- UQ Spatial Epidemiology Laboratory, Faculty of Science, School of Veterinary Science, The University of Queensland, Gatton, QLD, 4343, Australia
- Children's Health and Environment Program, Faculty of Medicine, Child Health Research Centre, The University of Queensland, Brisbane, QLD, 4101, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
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