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Xiao P, Chen X, Chen Y, Fan W, Dong Z, Huang J, Zhang Y. CD4 + T cell count in HIV/TB co-infection and co-occurrence with HL: Case report and literature review. Open Life Sci 2023; 18:20220744. [PMID: 37744454 PMCID: PMC10512445 DOI: 10.1515/biol-2022-0744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023] Open
Abstract
In the human immunodeficiency virus (HIV)-infected population, especially HIV with concomitant tuberculosis (TB) or Hodgkin's lymphoma (HL), numerous risk factors have been reported in recent years. Among them, the decreased CD4+ T cell count was recognized as the common risk factor. We report a case of a patient with HIV and TB and HL co-occurrence, in which patient's CD4+ T cell count was inconsistent with disease. A 58-year-old male presented with fever and shortness of breath that persisted for 2 months. The patient had a 4-year history of HIV infection and underwent antiretroviral therapy (ART) effectively. After blood test, computed tomography, bone biopsy, and lymphoma biopsy, the patient was diagnosed with skeletal TB and HL, underwent TB treatment and received ART, and underwent four cycles of chemotherapy. CD4+ T cell count was not decreased before diagnosed with TB/HL and increased in this case after the fourth cycle of chemotherapy. We collected and analyzed CD4+ T cell counts in our case and reviewed relevant literature. It is suggested that CD4+ T cell count may be insufficient to predict the risk of HIV-related disease, especially lymphoproliferative disorders.
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Affiliation(s)
- Pingping Xiao
- Department of Hematology and Rheumatology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P. R. China
| | - Xuyan Chen
- Department of Hematology and Rheumatology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P. R. China
| | - Yongquan Chen
- Department of Hematology and Rheumatology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P. R. China
| | - Wei Fan
- Department of Hematology and Rheumatology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P. R. China
| | - Zhigao Dong
- Department of Hematology and Rheumatology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P. R. China
| | - Jinmei Huang
- Department of Hematology and Rheumatology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P. R. China
| | - Yi Zhang
- Department of Hematology and Rheumatology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, P. R. China
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2
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Azeez A, Mutambayi R, Odeyemi A, Ndege J. Survival model analysis of tuberculosis treatment among patients with human immunodeficiency virus coinfection. Int J Mycobacteriol 2020; 8:244-251. [PMID: 31512600 DOI: 10.4103/ijmy.ijmy_101_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Tuberculosis (TB) with human immunodeficiency virus (HIV) coinfection is the highest clinical epidemiology and public health issue. Despite many programs established to tackle the epidemic, TB target controls have not been reached. One of the many factors attributed to the failure in TB treatment is HIV coinfection. The aim of this study is to assess the survival rate of HIV infection among TB patients and the risk factors of death among the TB patients with HIV coinfection during the retro of directly observed treatment, short-course (DOTS) program. Methods This study is a retrospective cohort conducted to compare the survivorship between TB/HIV patients for 8 months DOTS. Death among TB patients was considered as failures and those defaulted or survived were censored. The Cox proportional-hazards regression and log-linear model were used to establish the hazard ratio (HR) of death for each variable at baseline and estimate the risk factors effect among TB patients. Results The findings revealed that 50% of death from TB/HIV patients were from HIV coinfection (advanced HR = 2.01, 95% confidence interval = 1.13-3.17). The risk of death was significantly higher in HIV-positive TB patients (P = 0.000) during the extension care phase. TB/HIV-positive patients on antiretroviral therapy have decreased survival rate (log-rank test = 14.88, df = 2, P = 0.0001). The probability of TB patients surviving is significantly decreased in HIV positive with some factors such as age, weight, smoking, and alcohol found significant. Conclusion The probability of survival in HIV-positive TB patients was significantly lower during the TB treatment. Weight loss, age, alcohol, smoking, and pregnancy were showed to affect the survival probability of TB/HIV patients' coinfection significantly.
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Affiliation(s)
- Adeboye Azeez
- Department of Statistics, University of Fort Hare, Alice, Eastern Cape, South Africa
| | - Ruffin Mutambayi
- Department of Statistics, University of Fort Hare, Alice, Eastern Cape, South Africa
| | - Akinwumi Odeyemi
- Department of Statistics, University of Fort Hare, Alice, Eastern Cape, South Africa
| | - James Ndege
- Department of Statistics, University of Fort Hare, Alice, Eastern Cape, South Africa
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3
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Kempker RR, Chkhartishvili N, Kinkladze I, Schechter MC, Harrington K, Rukhadze N, Dzigua L, Tserstvadze T, Del Rio C, Blumberg HM, Tukvadze N. High Yield of Active Tuberculosis Case Finding Among HIV-Infected Patients Using Xpert MTB/RIF Testing. Open Forum Infect Dis 2019; 6:ofz233. [PMID: 31211163 PMCID: PMC6559269 DOI: 10.1093/ofid/ofz233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022] Open
Abstract
Objective Conduct an active case finding study in Tbilisi, Georgia, for pulmonary tuberculosis (TB) among people living with HIV (PLWH). Methods Newly diagnosed HIV patients were assessed for symptoms and asked to submit sputum samples for smear microscopy, culture, and molecular diagnostic testing (Xpert MTB/RIF). Results Among 276 PLWH, 131 agreed to participate and 103 submitted sputum samples. Most participants were male (70%) and mean age of 43 years. There were high rates of a positive hepatitis C virus (HCV) antibody test (46%) and the median CD4 count was 122 cells/mm3. A total of 15 (11.5%) persons were diagnosed with pulmonary TB, including 1 each with multidrug-resistant and isoniazid-resistant disease. Twelve had a positive culture for Mycobacterium tuberculosis and Xpert TB/RIF assay, and 4 had positive smear microscopy. Patients with pulmonary TB were more likely to use injection drugs (67% vs 36%, P = .02) and have a positive HCV antibody (73% vs 42%, P = .02). The presence and absence of any TB symptom had a sensitivity and negative predictive value for TB of 93% and 98%, respectively. Conclusion Our findings highlight the high prevalence of TB among newly diagnosed HIV-infected patients in an area with high rates of drug-resistant TB and the utility of an active case finding strategy for TB diagnosis.
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Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Inga Kinkladze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Nino Rukhadze
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Lela Dzigua
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Tengiz Tserstvadze
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
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4
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Mulongeni P, Hermans S, Caldwell J, Bekker LG, Wood R, Kaplan R. HIV prevalence and determinants of loss-to-follow-up in adolescents and young adults with tuberculosis in Cape Town. PLoS One 2019; 14:e0210937. [PMID: 30721239 PMCID: PMC6363173 DOI: 10.1371/journal.pone.0210937] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/04/2019] [Indexed: 01/12/2023] Open
Abstract
TB remains a leading cause of mortality and morbidity in sub-Saharan Africa, due to the HIV epidemic. As TB treatment is lengthy, the completion of the full course of treatment may be especially challenging for young people. We therefore aimed to identify the extent of and reasons underlying loss to follow-up from TB treatment among young people in Cape Town. Accordingly, we reviewed the outcomes of young people treated for TB in Cape Town during 2009-2013, across three age groups: younger adolescents (10-14 years); older adolescents; (15-19 years) and young adults (20-24 years). We employed logistic regression analysis to identify risk factors for loss from TB care. 23,737 patients aged 10-24 were treated for drug sensitive TB over the study period. Of these, the HIV co-infection prevalence was 18.5% for younger adolescents, 12.9% for older adolescents and 33.1% for young adults. From age 16, HIV prevalence increased disproportionately among young women: by age 22, over 50% of women were TB/HIV co-infected compared to 14% of men. TB treatment success (cure plus completion) was 84.4%, while 1.7% of patients died, 9.5% were lost-to follow-up and 0.4% failed treatment. Being an older adolescent (aOR 1.75 [95% CI: 1.38-2.21]) or young adult (aOR: 1.96 [95% CI: 1.57-2.45]) increased the risk of loss-to-follow up, relative to being a younger adolescent. Further risk factors for loss from TB care were male gender (aOR: 1.33 [95% CI:1.20-1.46]), being a TB/HIV co-infected young person (aOR 1.74 [95% CI: 1.57-1.93]) and having had prior treatment for TB (aOR 3.17 [95% CI 2.87-3.51]). We identified risk factors for loss to follow-up and highlighted the need to focus on HIV prevention and retention in TB care among young people. TB care tailored to the needs of young people could improve patient retention, similar to improved outcomes reported by youth friendly HIV clinics.
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Affiliation(s)
- Pancho Mulongeni
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- School of Public Health and Community Medicine, University of New South Wales, Sydney Australia
| | - Sabine Hermans
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Judy Caldwell
- City Health, City of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Richard Kaplan
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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5
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Vinh DN, Ha DTM, Hanh NT, Thwaites G, Boni MF, Clapham HE, Thuong NTT. Modeling tuberculosis dynamics with the presence of hyper-susceptible individuals for Ho Chi Minh City from 1996 to 2015. BMC Infect Dis 2018; 18:494. [PMID: 30285633 PMCID: PMC6167874 DOI: 10.1186/s12879-018-3383-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 09/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The depletion of CD4 cell is the underlying reason for TB hyper-susceptibility among people with HIV. Consequently, the trend of TB dynamics is usually hidden by the HIV outbreak. METHODS Here, we aim to evaluate the trend of TB dynamics quantitatively by a simple mathematical model using the known prevalence of hyper-susceptible individuals in the population. In order to estimate the parameters governing transmission we fit this model in a maximum likelihood framework to both reported TB cases and data from samples tested with Interferon Gamma Assay from Ho Chi Minh City - a city with high TB transmission and strong synchronization between HIV/AIDS and TB dynamics. RESULTS Our results show that TB transmission in HCMC has been declining among people without HIV; we estimate a 18% (95% CI: 9-25%) decline in the transmission parameter between 1996 and 2015. Furthermore, we show that co-infected patients have limited contribution to the transmission process. For hyper-susceptible individuals, our model suggests that the risk of a new active TB infection occurring is significantly higher than the risk of relapsed active TB, while this is not the case for people without hyper-susceptibility. CONCLUSIONS The increase of TB notifications in Ho Chi Minh City from 1996 to 2008 is evitable when, as occurred, the number of hyper-susceptible individuals increased faster than the decrease of TB transmission rate. The sharp decrease in TB notifications observed in this city from 2008 to 2015 is the combined result of the decrease of TB transmission rate and the decrease of hyper-susceptible individuals in the population. For hyper-susceptible individuals, we propose that the reason for the reduced relapsed active TB risk is HIV treatment delay. According to HIV treatment guidelines issued by Vietnam's Ministry of Health, hyper-susceptible individuals usually have to wait until their CD4 cell count falls under 350 cells/μl to start ART. Once patients begin ART, they will remain on ART for the rest of their life and thus have greater protection against relapses of TB. We therefore hypothesize that the delay in using ART imposes considerable TB burden on HCMC despite the declining transmission process.
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Affiliation(s)
- Dao Nguyen Vinh
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, 764 Vo Van Kiet Street, District 5, Ho Chi Minh City, Vietnam.
| | - Dang Thi Minh Ha
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, 764 Vo Van Kiet Street, District 5, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Hanh
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, 764 Vo Van Kiet Street, District 5, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, 764 Vo Van Kiet Street, District 5, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Maciej F Boni
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, Pennsylvania, USA
| | - Hannah E Clapham
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, 764 Vo Van Kiet Street, District 5, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nguyen Thuy Thuong Thuong
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, 764 Vo Van Kiet Street, District 5, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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6
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Kaplan R, Hermans S, Caldwell J, Jennings K, Bekker LG, Wood R. HIV and TB co-infection in the ART era: CD4 count distributions and TB case fatality in Cape Town. BMC Infect Dis 2018; 18:356. [PMID: 30064368 PMCID: PMC6069570 DOI: 10.1186/s12879-018-3256-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/16/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In Cape Town, the roll-out of antiretroviral therapy (ART) has increased over the last decade with an estimated coverage of 63% of HIV- positive patients in 2013. The influence of ART on the characteristics of the population of HIV-positive patients presenting to the primary care TB programme is unknown. In this study, we examined trends in CD4 count distribution, ART usage and treatment outcomes among HIV-positive TB patients in Cape Town from 2009 to 2013. METHODS Data from the electronic TB register on all newly registered drug-sensitive TB patients ≥18 years were analyzed retrospectively. Descriptive statistics were used to compare baseline characteristics, the CD4 count distribution and TB treatment outcomes both by year of treatment and ART status at the start of TB treatment. Survival analyses were used to assess the change in mortality risk during TB treatment over time, stratified by ART status at start of TB treatment. RESULTS 118,989 patients were treated over 5 years. HIV prevalence among TB patients decreased from 50.9% in 2009 to 49.0% in 2013. The absolute number of HIV-positive TB cases declined by 13.2% between 2010 and 2013. More patients entered the TB programme on ART in 2013 compared to 2009 (30.0% vs 9.9%). Among these, the CD4 count distribution showed a year by year shift to higher CD4 counts. In 2013, over 75% of ART-naïve TB patients still had a CD4 count < 350 cells/mm3. ART initiation among ART-naive patients increased from 37.0 to 77.7% and TB case fatality declined from 7.4 to 5.2% (p < 0.001). In multivariate analysis a decrease in TB mortality was most strongly associated with CD4 count (Adjusted HR 0.82 per increase of 50 cells/mm3, 95% CI: 0.81-0.83, p < 001) and the initiation of ART during TB treatment (Adjusted HR 0.39, 95% CI: 0.35-0.42, p < 0.001). CONCLUSION Comprehensive changes in the ART and TB treatment programmes resulted in incremental increases in ART coverage for HIV-positive TB patients and a subsequent decrease in TB case fatality due to increased ART uptake in HIV-positive ART-naïve patients. However TB still remained a major presenting opportunistic infection with the majority of cases occurring at low CD4 counts.
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Affiliation(s)
- Richard Kaplan
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Sabine Hermans
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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7
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Schechter MC, Bizune D, Kagei M, Holland DP, Del Rio C, Yamin A, Mohamed O, Oladele A, Wang YF, Rebolledo PA, Ray SM, Kempker RR. Challenges Across the HIV Care Continuum for Patients With HIV/TB Co-infection in Atlanta, GA [corrected]. Open Forum Infect Dis 2018; 5:ofy063. [PMID: 29657955 PMCID: PMC5890473 DOI: 10.1093/ofid/ofy063] [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] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background Antiretroviral therapy (ART) for persons with HIV infection prevents tuberculosis (TB) disease. Additionally, sequential ART after initiation of TB treatment improves outcomes. We examined ART use, retention in care, and viral suppression (VS) before, during, and 3 years following TB treatment for an inner-city cohort in the United States. Methods Retrospective cohort study among persons treated for culture-confirmed TB between 2008 and 2015 at an inner-city hospital. Results Among 274 persons with culture-confirmed TB, 96 (35%) had HIV co-infection, including 23 (24%) new HIV diagnoses and 73 (76%) previous diagnoses. Among those with known HIV prior to TB, the median time of known HIV was 6 years, and only 10 (14%) were on ART at the time of TB diagnosis. The median CD4 at TB diagnosis was 87 cells/uL. Seventy-four (81%) patients received ART during treatment for TB, and 47 (52%) has VS at the end of TB treatment. Only 32% of patients had continuous VS 3 years after completing TB treatment. There were 3 TB recurrences and 3 deaths post–TB treatment; none of these patients had retention or VS after TB treatment. Conclusions Among persons with active TB co-infected with HIV, we found that the majority had known HIV and were not on ART prior to TB diagnosis, and retention in care and VS post–TB treatment were very low. Strengthening the HIV care continuum is needed to improve HIV outcomes and further reduce rates of active TB/HIV co-infection in our and similar settings.
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Affiliation(s)
- Marcos C Schechter
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Destani Bizune
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - David P Holland
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.,Communicable Disease Prevention Branch, Fulton County Health Board of Health, Atlanta, Georgia
| | - Carlos Del Rio
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Aliya Yamin
- Communicable Disease Prevention Branch, Fulton County Health Board of Health, Atlanta, Georgia
| | - Omar Mohamed
- Communicable Disease Prevention Branch, Fulton County Health Board of Health, Atlanta, Georgia
| | | | - Yun F Wang
- Department of Pathology and Laboratory Medicine, School of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Pathology, Grady Memorial Hospital, Atlanta, Georgia
| | - Paulina A Rebolledo
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Susan M Ray
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
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8
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The impact of rural residence and HIV infection on poor tuberculosis treatment outcomes in a large urban hospital: a retrospective cohort analysis. Int J Equity Health 2018; 17:4. [PMID: 29310659 PMCID: PMC5759183 DOI: 10.1186/s12939-017-0714-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 12/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful tuberculosis (TB) treatment is essential to effective TB control. TB-HIV coinfection, social determinants and access to services influenced by rural residence can affect treatment outcome. We examined the separate and joint effects of rural residence and HIV infection on poor treatment outcome among patients enrolled in a large TB treatment centre in Kano, Nigeria. METHODS We retrospectively analysed a cohort of patients with TB enrolled in a large urban TB clinic in northern Nigeria, from January 2010 to December 2014. Poor treatment outcome was defined as death, default or treatment failure. We used Poisson regression to model rates and determine the relative risks (and 95% confidence intervals, CI) of poor treatment outcomes. RESULTS Among 1381 patients included in the analysis, 28.4% were rural residents; 39.8% were HIV-positive; and 46.1% had a poor treatment outcome. Approximately 65 and 38% of rural and urban residents, respectively, had a poor treatment outcome. Rural residents had 2.74 times (95% CI: 2.27-3.29) the risk of having a poor treatment outcome compared to urban residents. HIV-positive patients had 1.4 times (95% CI: 1.16-1.69) the risk of poor treatment outcome compared to HIV-negative patients. The proportion of poor treatment outcome attributable to rural residence (population attributable fraction, PAF) was 25.6%. The PAF for HIV infection was 11.9%. The effect of rural residence on poor treatment outcome among HIV-negative patients (aRR:4.07; 95%CI:3.15-5.25) was more than twice that among HIV-positive patients (aRR:1.99; 95%CI:1.49-2.64). CONCLUSION Rural residents attending a large Nigerian TB clinic are at increased risk of having poor treatment outcomes, and this risk is amplified among those that are HIV-negative. Our findings indicate that rural coverage of HIV services may be better than TB services. These findings highlight the importance of expanding coverage of TB services to ensure prompt diagnosis and commencement of treatment, especially among rural-dwellers in resource-limited settings.
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9
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Mchunu G, van Griensven J, Hinderaker SG, Kizito W, Sikhondze W, Manzi M, Dlamini T, Harries AD. High mortality in tuberculosis patients despite HIV interventions in Swaziland. Public Health Action 2016; 6:105-10. [PMID: 27358803 PMCID: PMC4913672 DOI: 10.5588/pha.15.0081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/23/2016] [Indexed: 12/12/2022] Open
Abstract
SETTING All health facilities providing tuberculosis (TB) care in Swaziland. OBJECTIVE To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure. DESIGN A retrospective descriptive study using aggregated national TB programme data. RESULTS Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%). CONCLUSION Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.
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Affiliation(s)
- G. Mchunu
- National TB Control Programme, Ministry of Health, Manzini, Swaziland
| | | | | | - W. Kizito
- Médecins Sans Frontières (MSF), Operational Centre Brussels, Kenya Mission, Nairobi, Kenya
| | - W. Sikhondze
- National TB Control Programme, Ministry of Health, Manzini, Swaziland
| | - M. Manzi
- MSF, Medical Department, Operational Research Unit, Luxembourg
| | - T. Dlamini
- National TB Control Programme, Ministry of Health, Manzini, Swaziland
| | - A. D. Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France
- London School of Hygiene & Tropical Medicine, London, UK
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10
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Peter JG, Zijenah LS, Chanda D, Clowes P, Lesosky M, Gina P, Mehta N, Calligaro G, Lombard CJ, Kadzirange G, Bandason T, Chansa A, Liusha N, Mangu C, Mtafya B, Msila H, Rachow A, Hoelscher M, Mwaba P, Theron G, Dheda K. Effect on mortality of point-of-care, urine-based lipoarabinomannan testing to guide tuberculosis treatment initiation in HIV-positive hospital inpatients: a pragmatic, parallel-group, multicountry, open-label, randomised controlled trial. Lancet 2016; 387:1187-97. [PMID: 26970721 DOI: 10.1016/s0140-6736(15)01092-2] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND HIV-associated tuberculosis is difficult to diagnose and results in high mortality. Frequent extra-pulmonary presentation, inability to obtain sputum, and paucibacillary samples limits the usefulness of nucleic-acid amplification tests and smear microscopy. We therefore assessed a urine-based, lateral flow, point-of-care, lipoarabinomannan assay (LAM) and the effect of a LAM-guided anti-tuberculosis treatment initiation strategy on mortality. METHODS We did a pragmatic, randomised, parallel-group, multicentre trial in ten hospitals in Africa--four in South Africa, two in Tanzania, two in Zambia, and two in Zimbabwe. Eligible patients were HIV-positive adults aged at least 18 years with at least one of the following symptoms of tuberculosis (fever, cough, night sweats, or self-reported weightloss) and illness severity necessitating admission to hospital. Exclusion criteria included receipt of any anti-tuberculosis medicine in the 60 days before enrolment. We randomly assigned patients (1:1) to either LAM plus routine diagnostic tests for tuberculosis (smear microscopy, Xpert-MTB/RIF, and culture; LAM group) or routine diagnostic tests alone (no LAM group) using computer-generated allocation lists in blocks of ten. All patients were asked to provide a urine sample of at least 30 mL at enrolment, and trained research nurses did the LAM test in patients allocated to this group using the Alere Determine tuberculosis LAM Ag lateral flow strip test (Alere, USA) at the bedside on enrolment. On the basis of a positive test result, the nurses made a recommendation for initiating anti-tuberculosis treatment. The attending physician made an independent decision about whether to start treatment or not. Neither patients nor health-care workers were masked to group allocation and test results. The primary endpoint was 8-week all-cause mortality assessed in the modified intention-to-treat population (those who received their allocated intervention). This trial is registered with ClinicalTrials.gov, number NCT01770730. FINDINGS Between Jan 1, 2013, and Oct 2, 2014, we screened 8728 patients and randomly assigned 2659 to treatment (1336 to LAM, 1323 to no LAM). 108 patients did not receive their allocated treatment, mainly because they did not meet the inclusion criteria, and 23 were excluded from analysis, leaving 2528 in the final modified intention-to-treat analysis (1257 in the LAM group, 1271 in the no LAM group). Overall all-cause 8-week mortality occurred in 578 (23%) patients, 261 (21%) in LAM and 317 (25%) in no LAM, an absolute reduction of 4% (95% CI 1-7). The risk ratio adjusted for country was 0·83 (95% CI 0·73-0·96), p=0·012, with a relative risk reduction of 17% (95% CI 4-28). With the time-to-event analysis, there were 159 deaths per 100 person-years in LAM and 196 per 100 person-years in no LAM (hazard ratio adjusted for country 0·82 [95% CI 0·70-0·96], p=0·015). No adverse events were associated with LAM testing. INTERPRETATION Bedside LAM-guided initiation of anti-tuberculosis treatment in HIV-positive hospital inpatients with suspected tuberculosis was associated with reduced 8-week mortality. The implementation of LAM testing is likely to offer the greatest benefit in hospitals where diagnostic resources are most scarce and where patients present with severe illness, advanced immunosuppression, and an inability to self-expectorate sputum. FUNDING European Developing Clinical Trials Partnership, the South African Medical Research Council, and the South African National Research Foundation.
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Affiliation(s)
- Jonny G Peter
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Division of Clinical Immunology and Allergology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Lung Infection and Immunity Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Lynn S Zijenah
- University of Zimbabwe College of Health Sciences, Department of Immunology, Harare, Zimbabwe
| | - Duncan Chanda
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa; University Teaching Hospital, Lusaka, Zambia; Institute for Medical Research & Training, University Teaching Hospital, Lusaka, Zambia
| | - Petra Clowes
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania; Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | - Maia Lesosky
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phindile Gina
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nirja Mehta
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Greg Calligaro
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Carl J Lombard
- Biostatistics Unit, South African Medical Research Council, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gerard Kadzirange
- University of Zimbabwe College of Health Sciences, Department of Medicine, Harare, Zimbabwe
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Abidan Chansa
- University Teaching Hospital, Lusaka, Zambia; Institute for Medical Research & Training, University Teaching Hospital, Lusaka, Zambia
| | - Namakando Liusha
- University Teaching Hospital, Lusaka, Zambia; Institute for Medical Research & Training, University Teaching Hospital, Lusaka, Zambia
| | - Chacha Mangu
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Bariki Mtafya
- Biomedical Research and Training Institute, Harare, Zimbabwe; National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Henry Msila
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Andrea Rachow
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania; Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany; German Centre for Infection Research, Munich, Germany
| | - Michael Hoelscher
- National Institute for Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania; Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany; German Centre for Infection Research, Munich, Germany
| | - Peter Mwaba
- University Teaching Hospital, Lusaka, Zambia
| | - Grant Theron
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Department of Science and Technology/National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research and Medical Research Council Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Keertan Dheda
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Division of Clinical Immunology and Allergology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Lung Infection and Immunity Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
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11
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Blaser N, Zahnd C, Hermans S, Salazar-Vizcaya L, Estill J, Morrow C, Egger M, Keiser O, Wood R. Tuberculosis in Cape Town: An age-structured transmission model. Epidemics 2016; 14:54-61. [PMID: 26972514 PMCID: PMC4791535 DOI: 10.1016/j.epidem.2015.10.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 10/05/2015] [Accepted: 10/11/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is the leading cause of death in South Africa. The burden of disease varies by age, with peaks in TB notification rates in the HIV-negative population at ages 0-5, 20-24, and 45-49 years. There is little variation between age groups in the rates in the HIV-positive population. The drivers of this age pattern remain unknown. METHODS We developed an age-structured simulation model of Mycobacterium tuberculosis (Mtb) transmission in Cape Town, South Africa. We considered five states of TB progression: susceptible, infected (latent TB), active TB, treated TB, and treatment default. Latently infected individuals could be re-infected; a previous Mtb infection slowed progression to active disease. We further considered three states of HIV progression: HIV negative, HIV positive, on antiretroviral therapy. To parameterize the model, we analysed treatment outcomes from the Cape Town electronic TB register, social mixing patterns from a Cape Town community and used literature estimates for other parameters. To investigate the main drivers behind the age patterns, we conducted sensitivity analyses on all parameters related to the age structure. RESULTS The model replicated the age patterns in HIV-negative TB notification rates of Cape Town in 2009. Simulated TB notification rate in HIV-negative patients was 1000/100,000 person-years (pyrs) in children aged <5 years and decreased to 51/100,000 in children 5-15 years. The peak in early adulthood occurred at 25-29 years (463/100,000 pyrs). After a subsequent decline, simulated TB notification rates gradually increased from the age of 30 years. Sensitivity analyses showed that the dip after the early adult peak was due to the protective effect of latent TB and that retreatment TB was mainly responsible for the rise in TB notification rates from the age of 30 years. CONCLUSION The protective effect of a first latent infection on subsequent infections and the faster progression in previously treated patients are the key determinants of the age-structure of TB notification rates in Cape Town.
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Affiliation(s)
- Nello Blaser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Cindy Zahnd
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Sabine Hermans
- Desmond Tutu HIV Centre, Institute for Infectious Disease & Molecular Medicine, University of Cape Town, South Africa; Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development,The Netherlands; Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Luisa Salazar-Vizcaya
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Janne Estill
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Carl Morrow
- Desmond Tutu HIV Centre, Institute for Infectious Disease & Molecular Medicine, University of Cape Town, South Africa
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Olivia Keiser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute for Infectious Disease & Molecular Medicine, University of Cape Town, South Africa; Department of Medicine, University of Cape Town,, South Africa; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
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12
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Nglazi MD, Bekker LG, Wood R, Kaplan R. The impact of HIV status and antiretroviral treatment on TB treatment outcomes of new tuberculosis patients attending co-located TB and ART services in South Africa: a retrospective cohort study. BMC Infect Dis 2015; 15:536. [PMID: 26584607 PMCID: PMC4653912 DOI: 10.1186/s12879-015-1275-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 11/06/2015] [Indexed: 12/16/2022] Open
Abstract
Background The implementation of collaborative TB-HIV services is challenging. We, therefore, assessed TB treatment outcomes in relation to HIV infection and antiretroviral therapy (ART) among TB patients attending a primary care service with co-located ART and TB clinics in Cape Town, South Africa. Methods In this retrospective cohort study, all new TB patients aged ≥ 15 years who registered and initiated TB treatment between 1 October 2009 and 30 June 2011 were identified from an electronic database. The effects of HIV-infection and ART on TB treatment outcomes were analysed using a multinomial logistic regression model, in which treatment success was the reference outcome. Results The 797 new TB patients included in the analysis were categorized as follows: HIV- negative, in 325 patients (40.8 %); HIV-positive on ART, in 339 patients (42.5 %) and HIV-positive not on ART, in 133 patients (16.7 %). Overall, bivariate analyses showed no significant difference in death and default rates between HIV-positive TB patients on ART and HIV-negative patients. Statistically significant higher mortality rates were found among HIV-positive patients not on ART compared to HIV-negative patients (unadjusted odds ratio (OR) 3.25; 95 % confidence interval (CI) 1.53–6.91). When multivariate analyses were conducted, the only significant difference between the patient categories on TB treatment outcomes was that HIV-positive TB patients not on ART had significantly higher mortality rates than HIV-negative patients (adjusted OR 4.12; 95 % CI 1.76–9.66). Among HIV-positive TB patients (n = 472), 28.2 % deemed eligible did not initiate ART in spite of the co-location of TB and ART services. When multivariate analyses were restricted to HIV-positive patients in the cohort, we found that being HIV-positive not on ART was associated with higher mortality (adjusted OR 7.12; 95 % CI 2.95–18.47) and higher default rates (adjusted OR 2.27; 95 % CI 1.15–4.47). Conclusions There was no significant difference in death and default rates between HIV-positive TB patients on ART and HIV negative TB patients. Despite the co-location of services 28.2 % of 472 HIV-positive TB patients deemed eligible did not initiate ART. These patients had a significantly higher death and default rates.
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Affiliation(s)
- Mweete D Nglazi
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. .,International Union against Tuberculosis and Lung Disease, Paris, France. .,Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Cape Town, South Africa.
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Richard Kaplan
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and the Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Abstract
PURPOSE OF REVIEW Globally, the number of deaths associated with tuberculosis (TB) and HIV coinfection remains unacceptably high. We review the evidence around the impact of strengthening the HIV treatment cascade in TB patients and explore recent findings about how best to deliver integrated TB/HIV services. RECENT FINDINGS There is clear evidence that the timely provision of antiretroviral therapy (ART) reduces mortality in TB/HIV coinfected adults. Despite this, globally in 2013, only around a third of known HIV-positive TB cases were treated with ART. Although there is some recent evidence exploring the barriers to achieve high coverage of HIV testing and ART initiation in TB patients, our understanding of which factors are most important and how best to address these within different health systems remains incomplete. There are some examples of good practice in the delivery of integrated TB/HIV services to improve the HIV treatment cascade. However, evidence of the impact of such strategies is of relatively low quality for informing integrated TB/HIV programming more broadly. In most settings, there remain barriers to higher-level organizational and functional integration. SUMMARY There remains a need for commitment to patient-centred integrated TB/HIV care in countries affected by the dual epidemic. There is a need for better quality evidence around how best to deliver integrated services to strengthen the HIV treatment cascade in TB patients, both at primary healthcare level and within community settings.
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Affiliation(s)
- Richard J. Lessells
- Department of Clinical Research
- TB Centre, London School of Hygiene and Tropical Medicine, London, UK
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
| | | | - Peter Godfrey-Faussett
- Department of Clinical Research
- TB Centre, London School of Hygiene and Tropical Medicine, London, UK
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14
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The impact of antiretroviral therapy on mortality in HIV positive people during tuberculosis treatment: a systematic review and meta-analysis. PLoS One 2014; 9:e112017. [PMID: 25391135 PMCID: PMC4229142 DOI: 10.1371/journal.pone.0112017] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 10/11/2014] [Indexed: 01/25/2023] Open
Abstract
Objective To quantify the impact of antiretroviral therapy (ART) on mortality in HIV-positive people during tuberculosis (TB) treatment. Design We conducted a systematic literature review and meta-analysis. Studies published from 1996 through February 15, 2013, were identified by searching electronic resources (Pubmed and Embase) and conference books, manual searches of references, and expert consultation. Pooled estimates for the outcome of interest were acquired using random effects meta-analysis. Subjects The study population included individuals receiving ART before or during TB treatment. Main Outcome Measures Main outcome measures were: (i) TB-case fatality ratio (CFR), defined as the proportion of individuals dying during TB treatment and, if mortality in HIV-positive people not on ART was also reported, (ii) the relative risk of death during TB treatment by ART status. Results Twenty-one studies were included in the systematic review. Random effects pooled meta-analysis estimated the CFR between 8% and 14% (pooled estimate 11%). Among HIV-positive TB cases, those receiving ART had a reduction in mortality during TB treatment of between 44% and 71% (RR = 0.42, 95%CI: 0.29–0.56). Conclusion Starting ART before or during TB therapy reduces the risk of death during TB treatment by around three-fifths in clinical settings. National programmes should continue to expand coverage of ART for HIV positive in order to control the dual epidemic.
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