Tuberculosis, human immunodeficiency viruses and TB/HIV co-infection in pregnant women: A meta-analysis

Discordance of 3rd and 4th generation QuantiFERON-TB Gold assays by pregnancy stages in India

Background

Pregnancy and HIV affect CD4+ T lymphocytes and impact performance of QuantiFERON-TB Gold (QFT). We compared the results of QFT with QuantiFERON-TB Gold Plus (QFT-Plus), which also measures CD8+ responses to TB antigens, during pregnancy and postpartum.

Methods

We screened 516 pregnant women for TB infection (TBI) with IGRA. From 165 IGRA + pregnant women, QFT vs QFT-Plus results were compared at delivery and postpartum. Longitudinal changes in QFT-Plus were assessed in 74 pregnant women who received QFT-Plus testing at pregnancy, delivery, and postpartum.

Results

Through cross-sectional analysis of the IGRA + cohort, QFT-Plus showed higher positivity than QFT (80 % vs 65 %, p = 0.04) at delivery but no difference postpartum. Among 35 women with HIV, QFT-Plus returned more positive results than QFT at delivery and postpartum (76 % vs 47 %, p = 0.08; 90 % vs 80 %, p = 0.54), though not statistically significant. Longitudinally, QFT-Plus positivity by TB1 or TB2 was highest antepartum vs. delivery and postpartum (74 % vs. 58 % vs. 62 %; p = 0.09) and performed better than TB1 alone (100 % vs 90 %, p = 0.04) in women without HIV but not in women with HIV.

Conclusions

Performance of QFT-Plus was consistent across pregnancy, including at delivery when QFT positivity is lower. QFT-Plus may enhance antenatal TBI detection among pregnant women.

Association between tuberculosis and pregnancy outcomes: a retrospective cohort study of women in Cape Town, South Africa

BACKGROUND

Tuberculosis (TB) remains a leading cause of mortality among women of childbearing age and a significant contributor to maternal mortality. Pregnant women with TB are at high risk of adverse pregnancy outcomes. This study aimed to determine risk factors for an adverse pregnancy outcome among pregnant women diagnosed with TB.

METHODS

Using TB programmatic data, this retrospective cohort analysis included all women who were routinely diagnosed with TB in the public sector between October 2018 and March 2020 in two health subdistricts of Cape Town, and who were documented to be pregnant during their TB episode. Adverse pregnancy outcome was defined as either a live birth of an infant weighing <2500 g and/or with a gestation period <37 weeks or as stillbirth, miscarriage, termination of pregnancy, maternal or early neonatal death. Demographics, TB and pregnancy characteristics were described by HIV status. Logistic regression was used to determine risk factors for adverse pregnancy outcome.

RESULTS

Of 248 pregnant women, half (52%) were living with HIV; all were on antiretroviral therapy at the time of their TB diagnosis. Pregnancy outcomes were documented in 215 (87%) women, of whom 74 (34%) had an adverse pregnancy outcome. Being older (35-44 years vs 25-34 years (adjusted OR (aOR): 3.99; 95% CI: 1.37 to 11.57), living with HIV (aOR: 2.72; 95% CI: 0.99 to 4.63), having an unfavourable TB outcome (aOR: 2.29; 95% CI: 1.03 to 5.08) and having presented to antenatal services ≤1 month prior to delivery (aOR: 10.57; 95% CI: 4.01 to 27.89) were associated with higher odds of an adverse pregnancy outcome.

CONCLUSIONS

Pregnancy outcomes among women with TB were poor, irrespective of HIV status. Pregnant women with TB are a complex population who need additional support prior to, during and after TB treatment to improve TB treatment and pregnancy outcomes. Pregnancy status should be considered for inclusion in TB registries.

Tuberculosis and its associated risk factors among HIV-positive pregnant women in northwest Ethiopia: A retrospective follow-up study

Background

People living with the human immunodeficiency virus have a higher risk of developing active tuberculosis disease. Human immunodeficiency virus infected pregnant women are at a much higher risk of getting active tuberculosis infection, partly due to immune modulation. However, very little is known about the epidemiology of tuberculosis among pregnant women infected with the virus, particularly in resource-limited settings where the burdens of these infections are substantial. Hence, this study aimed to estimate tuberculosis incidence and identify its risk factors among human immunodeficiency virus infected pregnant women in northwest Ethiopia.

Methods

An institutional-based retrospective follow-up study was conducted among pregnant women who were enrolled in option B+ prevention of mother to child transmission service between June 2013 and April 2021 in Pawe district. The Kaplan-Meier survival curve and Weibull regression model were used to estimate survival probability and identify risk factors of tuberculosis, respectively. The best model between the Cox and parametric models was chosen using the Akaike and Bayesian information criteria.

Result

Out of 289 human immunodeficiency virus infected pregnant women included in the final analysis, 29 (10.03 %) developed active tuberculosis. The overall incidence of tuberculosis was 17.4 per 1000 person-months of observation (95 % CI: 12.1, 25.1). Lack of isoniazid preventive therapy (AHR: 6.68, 95 % CI: 2.67, 16.7), new enrollment to care (AHR: 2.62, 95 % CI: 1.14, 6.03), under-nutrition (AHR: 5.09, 95 % CI: 2.02, 12.83), low CD4 count (AHR: 2.61, 95 % CI: 1.01, 6.78), and suboptimal antiretroviral therapy adherence (AHR: 3.17, 95 % CI: 1.46, 6.86) were predictors of tuberculosis among HIV-positive pregnant women.

Conclusion

This study found a high incidence of tuberculosis among human immunodeficiency virus infected pregnant women. Thus, strengthening the provision of tuberculosis preventive therapy, reinforcing adherence support, and controlling under-nutrition should be considered to decrease the risk of tuberculosis.

HIV/Tuberculosis Coinfection in Pregnancy and the Postpartum Period

The convergence of Human Immunodeficiency Virus (HIV) and tuberculosis (TB) represents a considerable global public health challenge. The concurrent infection of HIV and TB in pregnant women not only intensifies the transmission of HIV from mother to fetus but also engenders adverse outcomes for maternal health, pregnancy, and infant well-being, necessitating the implementation of integrated strategies to effectively address and manage both diseases. In this article, we review the pathophysiology, clinical presentation, treatment, and management of HIV/TB coinfection during pregnancy, the postpartum period, and lactation and highlight the differences compared to the general population.

Tuberculosis in pregnancy

Due to COVID-19 pandemic, the latest progress of the End Tuberculosis (TB) Strategy was far from optimal and services for TB needs to be quickly restored. Pregnancy is a unique opportunity to screen and manage TB, and it is an essential step in TB eradication. Early diagnosis and treatment for active disease can reduce maternal and neonatal morbidities and mortality. The more widespread utilization of newer rapid molecular assays with drug-susceptibility testing has significantly shortened the diagnostic process for active TB disease. First-line anti-TB drugs are proven to be safe in pregnancy. Management of latent TB infection (LTBI) during pregnancy is controversial, but puerperium is a period of increased susceptibility to progress to active disease. Extrapulmonary TB (EPTB), multidrug-resistant TB (MDR-TB) and HIV co-infection remain significant issues surrounding TB management during pregnancy and often require input from a multidisciplinary team including TB experts.

Nutrition in HIV-Infected Infants and Children: Current Knowledge, Existing Challenges, and New Dietary Management Opportunities

HIV infection and undernutrition remain significant public health concerns for infants and children. In infants and children under these conditions, undernutrition is one of the leading causes of death. Proper management of nutrition and related nutrition complications in these groups with increased nutrition needs are prominent challenges, particularly in HIV-prevalent poor-resource environments. Several studies support the complexity of the relation between HIV infection, nutrition, and the immune system. These elements interact and create a vicious circle of poor health outcomes. Recent studies on the use of probiotics as a novel approach to manage microbiome imbalance and gut-mucosal impairment in HIV infection are gaining attention. This new strategy could help to manage dysbiosis and gut-mucosal impairment by reducing immune activation, thereby potentially forestalling unwanted health outcomes in children with HIV. However, existing trials on HIV-infected children are still insufficient. There are also conflicting reports on the dosage and effectiveness of single or multiple micronutrient supplementation in the survival of HIV-infected children with severe acute malnutrition. The WHO has published guidelines that include time of initiation of antiretroviral therapy for HIV-pregnant mothers and their HIV-exposed or HIV-infected children, micronutrient supplementation, dietary formulations, prevention, and management of HIV therapy. However, such guidelines need to be reviewed owing to recent advances in the field of nutrition. There is a need for new intervention studies, practical strategies, and evidence-based guidelines to reduce the disease burden, improve adherence to treatment regimen, and enhance the nutrition, health, and well-being of HIV-infected infants and children. This review provides up-to-date scientific information on current knowledge and existing challenges for nutrition therapy in HIV-infected infants and children. Moreover, it presents new research findings that could be incorporated into current guidelines.