1
|
Gupta M, Srikrishna G, Klein SL, Bishai WR. Genetic and hormonal mechanisms underlying sex-specific immune responses in tuberculosis. Trends Immunol 2022; 43:640-656. [PMID: 35842266 PMCID: PMC9344469 DOI: 10.1016/j.it.2022.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
Abstract
Tuberculosis (TB), the world's deadliest bacterial infection, afflicts more human males than females, with a male/female (M/F) ratio of 1.7. Sex disparities in TB prevalence, pathophysiology, and clinical manifestations are widely reported, but the underlying biological mechanisms remain largely undefined. This review assesses epidemiological data on sex disparity in TB, as well as possible underlying hormonal and genetic mechanisms that might differentially modulate innate and adaptive immune responses in males and females, leading to sex differences in disease susceptibility. We consider whether this sex disparity can be extended to the efficacy of vaccines and discuss novel animal models which may offer mechanistic insights. A better understanding of the biological factors underpinning sex-related immune responses in TB may enable sex-specific personalized therapies for TB.
Collapse
|
2
|
Burke RM, Nyirenda S, Twabi HH, Nliwasa M, Joekes E, Walker N, Nyirenda R, Gupta-Wright A, Fielding K, MacPherson P, Corbett EL. Design and protocol for a cluster randomised trial of enhanced diagnostics for tuberculosis screening among people living with HIV in hospital in Malawi (CASTLE study). PLoS One 2022; 17:e0261877. [PMID: 35007306 PMCID: PMC8746787 DOI: 10.1371/journal.pone.0261877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND People living with HIV (PLHIV) have a high risk of death if hospitalised in low-income countries. Tuberculosis has long been the leading cause of admission and death, in part due to suboptimal diagnostics. Two promising new diagnostic tools are digital chest Xray with computer-aided diagnosis (DCXR-CAD) and urine testing with Fujifilm SILVAMP LAM (FujiLAM). Neither test has been rigorously evaluated among inpatients. Test characteristics may be complementary, with FujiLAM especially sensitive for disseminated tuberculosis and DCXR-CAD especially sensitive for pulmonary tuberculosis, making combined interventions of interest. DESIGN AND METHODS An exploratory unblinded, single site, two-arm cluster randomised controlled trial, with day of admission as the unit of randomisation. A third, smaller, integrated cohort arm (4:4:1 random allocation) contributes to understanding case-mix, but not trial outcomes. Participants are adults living with HIV not currently on TB treatment. The intervention (DCXR-CAD plus urine FujiLAM plus usual care) is compared to usual care alone. The primary outcome is proportion of participants started on tuberculosis treatment by day 56, with secondary outcomes of mortality (time to event) measured to to 56 days from enrolment, proportions with undiagnosed tuberculosis at death or hospital discharge and comparing proportions with enrolment-day tuberculosis treatment initiation. DISCUSSION Both DCXR-CAD and FujiLAM have potential clinical utility and may have complementary diagnostic performance. To our knowledge, this is the first randomised trial to evaluate these tests among hospitalised PLHIV.
Collapse
Affiliation(s)
- Rachael M. Burke
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| | - Saulos Nyirenda
- Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Hussein H. Twabi
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Marriott Nliwasa
- Helse Nord TB Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Naomi Walker
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rose Nyirenda
- Department of HIV AIDS, Malawi Ministry of Health, Lilongwe, Malawi
| | - Ankur Gupta-Wright
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Institute for Global Health, University College London, London, England
| | - Katherine Fielding
- Faculty of Epidemiology and Population Health, Infectious Disease Epidemiology Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter MacPherson
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth L. Corbett
- Faculty of Infectious and Tropical Disease, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|