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Winter JR, Smith CJ, Davidson JA, Lalor MK, Delpech V, Abubakar I, Stagg HR. The impact of HIV infection on tuberculosis transmission in a country with low tuberculosis incidence: a national retrospective study using molecular epidemiology. BMC Med 2020; 18:385. [PMID: 33308204 PMCID: PMC7734856 DOI: 10.1186/s12916-020-01849-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV is known to increase the likelihood of reactivation of latent tuberculosis to active TB disease; however, its impact on tuberculosis infectiousness and consequent transmission is unclear, particularly in low-incidence settings. METHODS National surveillance data from England, Wales and Northern Ireland on tuberculosis cases in adults from 2010 to 2014, strain typed using 24-locus mycobacterial-interspersed-repetitive-units-variable-number-tandem-repeats was used retrospectively to identify clusters of tuberculosis cases, subdivided into 'first' and 'subsequent' cases. Firstly, we used zero-inflated Poisson regression models to examine the association between HIV status and the number of subsequent clustered cases (a surrogate for tuberculosis infectiousness) in a strain type cluster. Secondly, we used logistic regression to examine the association between HIV status and the likelihood of being a subsequent case in a cluster (a surrogate for recent acquisition of tuberculosis infection) compared to the first case or a non-clustered case (a surrogate for reactivation of latent infection). RESULTS We included 18,864 strain-typed cases, 2238 were the first cases of clusters and 8471 were subsequent cases. Seven hundred and fifty-nine (4%) were HIV-positive. Outcome 1: HIV-positive pulmonary tuberculosis cases who were the first in a cluster had fewer subsequent cases associated with them (mean 0.6, multivariable incidence rate ratio [IRR] 0.75 [0.65-0.86]) than those HIV-negative (mean 1.1). Extra-pulmonary tuberculosis (EPTB) cases with HIV were less likely to be the first case in a cluster compared to HIV-negative EPTB cases. EPTB cases who were the first case had a higher mean number of subsequent cases (mean 2.5, IRR (3.62 [3.12-4.19]) than those HIV-negative (mean 0.6). Outcome 2: tuberculosis cases with HIV co-infection were less likely to be a subsequent case in a cluster (odds ratio 0.82 [0.69-0.98]), compared to being the first or a non-clustered case. CONCLUSIONS Outcome 1: pulmonary tuberculosis-HIV patients were less infectious than those without HIV. EPTB patients with HIV who were the first case in a cluster had a higher number of subsequent cases and thus may be markers of other undetected cases, discoverable by contact investigations. Outcome 2: tuberculosis in HIV-positive individuals was more likely due to reactivation than recent infection, compared to those who were HIV-negative.
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Affiliation(s)
- Joanne R Winter
- Institute for Global Health, University College London, London, UK
| | - Colette J Smith
- Institute for Global Health, University College London, London, UK
| | - Jennifer A Davidson
- Tuberculosis Unit, National Infection Service, Public Health England, London, UK
| | - Maeve K Lalor
- Tuberculosis Unit, National Infection Service, Public Health England, London, UK
| | - Valerie Delpech
- HIV Unit, National Infection Service, Public Health England, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK.
| | - Helen R Stagg
- Institute for Global Health, University College London, London, UK.,Usher Institute, University of Edinburgh, Edinburgh, UK
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Winter JR, Stagg HR, Smith CJ, Lalor MK, Davidson JA, Brown AE, Brown J, Zenner D, Lipman M, Pozniak A, Abubakar I, Delpech V. Trends in, and factors associated with, HIV infection amongst tuberculosis patients in the era of anti-retroviral therapy: a retrospective study in England, Wales and Northern Ireland. BMC Med 2018; 16:85. [PMID: 29879977 PMCID: PMC5992696 DOI: 10.1186/s12916-018-1070-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 05/07/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND HIV increases the progression of latent tuberculosis (TB) infection to active disease and contributed to increased TB in the UK until 2004. We describe temporal trends in HIV infection amongst patients with TB and identify factors associated with HIV infection. METHODS We used national surveillance data of all TB cases reported in England, Wales and Northern Ireland from 2000 to 2014 and determined HIV status through record linkage to national HIV surveillance. We used logistic regression to identify associations between HIV and demographic, clinical and social factors. RESULTS There were 106,829 cases of TB in adults (≥ 15 years) reported from 2000 to 2014. The number and proportion of TB patients infected with HIV decreased from 543/6782 (8.0%) in 2004 to 205/6461 (3.2%) in 2014. The proportion of patients diagnosed with HIV > 91 days prior to their TB diagnosis increased from 33.5% in 2000 to 60.2% in 2013. HIV infection was highest in people of black African ethnicity from countries with high HIV prevalence (32.3%), patients who misused drugs (8.1%) and patients with miliary or meningeal TB (17.2%). CONCLUSIONS There has been an overall decrease in TB-HIV co-infection and a decline in the proportion of patients diagnosed simultaneously with both infections. However, high rates of HIV remain in some sub-populations of patients with TB, particularly black Africans born in countries with high HIV prevalence and people with a history of drug misuse. Whilst the current policy of testing all patients diagnosed with TB for HIV infection is important in ensuring appropriate management of TB patients, many of these TB cases would be preventable if HIV could be diagnosed before TB develops. Improving screening for both latent TB and HIV and ensuring early treatment of HIV in these populations could help prevent these TB cases. British HIV Association guidelines on latent TB testing for people with HIV from sub-Saharan Africa remain relevant, and latent TB screening for people with HIV with a history of drug misuse, homelessness or imprisonment should also be considered.
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Affiliation(s)
- Joanne R Winter
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK.
| | - Helen R Stagg
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK
| | - Colette J Smith
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK
| | - Maeve K Lalor
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK.,National Infections Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Jennifer A Davidson
- National Infections Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Alison E Brown
- National Infections Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - James Brown
- Royal Free London National Health Service Foundation Trust, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
| | - Dominik Zenner
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK.,National Infections Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Marc Lipman
- Royal Free London National Health Service Foundation Trust, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.,UCL Respiratory, Division of Medicine, University College London, Royal Free Campus, Pond Street, London, NW3 2PF, UK
| | - Anton Pozniak
- Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK
| | - Valerie Delpech
- National Infections Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
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Injecting drug use predicts active tuberculosis in a national cohort of people living with HIV. AIDS 2017; 31:2403-2413. [PMID: 28857827 DOI: 10.1097/qad.0000000000001635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Tuberculosis (TB) is common in people living with HIV, leading to worse clinical outcomes including increased mortality. We investigated risk factors for developing TB following HIV diagnosis. DESIGN Adults aged at least 15 years first presenting to health services for HIV care in England, Wales or Northern Ireland from 2000 to 2014 were identified from national HIV surveillance data and linked to TB surveillance data. METHODS We calculated incidence rates for TB occurring more than 91 days after HIV diagnosis and investigated risk factors using multivariable Poisson regression. RESULTS A total of 95 003 adults diagnosed with HIV were followed for 635 591 person-years; overall incidence of TB was 344 per 100 000 person-years (95% confidence interval 330-359). TB incidence was high for people who acquired HIV through injecting drugs [PWID; men 876 (696-1104), women 605 (365-945)] and black Africans born in high TB incidence countries [644 (612-677)]. The adjusted incidence rate ratio for TB amongst PWID was 4.79 (3.35-6.85) for men and 6.18 (3.49-10.93) for women, compared with MSM. The adjusted incidence rate ratio for TB in black Africans from high-TB countries was 4.27 (3.42-5.33), compared with white UK-born individuals. Lower time-updated CD4 cell count was associated with increased rates of TB. CONCLUSION PWID had the greatest risk of TB; incidence rates were comparable with those in black Africans from high TB incidence countries. Most TB cases in PWID were UK-born, and likely acquired TB through transmission within the United Kingdom. Earlier HIV diagnosis and quicker initiation of antiretroviral therapy should reduce TB incidence in these populations.
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von Braun A, Sekaggya-Wiltshire C, Scherrer AU, Magambo B, Kambugu A, Fehr J, Castelnuovo B. Early virological failure and HIV drug resistance in Ugandan adults co-infected with tuberculosis. AIDS Res Ther 2017; 14:1. [PMID: 28086929 PMCID: PMC5237283 DOI: 10.1186/s12981-016-0128-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 12/07/2016] [Indexed: 11/30/2022] Open
Abstract
Purpose This cross-sectional study took place in the integrated tuberculosis (TB) clinic of a large outpatient clinic for HIV-infected patients in Kampala, Uganda. The purpose of this study was to describe the proportion of TB/HIV co-infected adults with virological failure, type and frequency of HIV drug resistance-associated mutations, and the proportion of patients with suboptimal efavirenz levels. Methods HIV-1 plasma viral loads, CD4 cell count measurements, and efavirenz serum concentrations were done in TB/HIV co-infected adults. Genotypic resistance testing was performed in case of confirmed virological failure. Results After a median time on ART of 6 months, virological failure was found in 22/152 patients (14.5%). Of 147 participants with available efavirenz serum concentration, 26 (17.6%) had at least one value below the reference range, including 20/21 (95.2%) patients with confirmed virological failure. Genotypic resistance testing was available for 16/22 (72.7%) patients, of which 15 (93.8%) had at least one major mutation, most commonly M184V (81.2%) and K103NS (68.8%). Conclusion We found a high proportion of TB/HIV co-infected patients with virological failure, the majority of which had developed relevant resistance-mutations after a median time on anti-retroviral treatment (ART) of 6 months. Virological monitoring should be prioritized in TB/HIV co-infected patients in resource-limited settings.
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