Addressing TB-related mortality in adults living with HIV: a review of the challenges and potential solutions

Trends in tuberculosis and inequality-adjusted Human Development Index in Brazil, 2018-2022

Tuberculosis (TB) remains a significant global health concern, causing 1.5 million deaths annually. We conducted an ecological analysis to examine TB prevalence in Brazil from 2018 to 2022, focusing on its relationship with the Human Development Index (HDI) and its inequality-adjusted version HDI (IHDI). We determined significant correlation between HDI and TB prevalence for the period of 2018-2021 (P = 0.044 in 2018, P = 0.041 in 2019, P = 0.044 in 2020, and P = 0.043 in 2021). However, an unexpected rise in TB cases in 2022, despite an increase in HDI, disrupted this trend (P = 0.12), indicating additional influencing factors. The IHDI showed correlation with TB prevalence, underscoring the importance of addressing socio-economic inequalities. These findings suggest the need for targeted interventions, particularly for vulnerable populations.

Global, regional, and national burden of HIV and tuberculosis and predictions by Bayesian age-period-cohort analysis: a systematic analysis for the global burden of disease study 2021

Objective

To assess sex, age, regional differences, and the changing trend in human immunodeficiency virus and tuberculosis (HIV-TB) in different regions from 1990 to 2021, and project future trends.

Methods

Global Burden of Disease Study 2021 data were analyzed to assess HIV-TB incidence, death, prevalence, and DALY rates from 1990 to 2021, including different types of TB co-infections (drug-susceptible, multidrug-resistant, and extensively drug-resistant). Bayesian age-period-cohort models were used to forecast age-standardized DALY rates through 2035.

Results

In 2021, there were approximately 1.76 million HIV-TB infections and 200,895 deaths globally. The highest burden of HIV-DS-TB and HIV-MDR-TB was found in Southern Sub-Saharan Africa, while HIV-XDR-TB was most prevalent in Eastern Europe. The co-infection burden was highest among individuals aged 30-49. Key risk factors were unsafe sex, drug use, and intimate partner violence, with regional variations. The global burden of HIV-TB remains high, and age-standardized DALY rates are expected to increase in the coming years, especially in regions with low socio-demographic indices (SDI).

Conclusion

The burden of HIV-TB co-infection correlates with the socio-demographic index (SDI): countries with a low SDI have a higher burden. Therefore, clinical diagnosis and treatment in such areas are more challenging and may warrant more attention. High death rates underscore the importance of early management.

Burden of mortality and its predictors among TB-HIV co-infected patients in Ethiopia: Systematic review and meta-analysis

BACKGROUND

Human immunodeficiency virus (HIV) and tuberculosis (TB) are still the two major deadly pandemics globally, causes 167,000 deaths in 2022. The two lethal combinations pose a substantial challenge to public health, especially in areas with high burden of both diseases such as Sub-Saharan Africa including Ethiopia. However, there is no study that showed national figure on mortality of TB/HIV co-infected patients. Hence, this review intended to provide pooled mortality rate and its predictors among patients co- infected with twin pandemics.

METHODS

Using reputable electronic data bases, primary studies were searched from January 25 to February 5, 2024. The review included papers published in English language conducted between 2004 and 2024. Heterogeneity between included studies was evaluated using Cochrane Q-test and the I2 statistics. Sub-group analysis was done to mitigate significant heterogeneity. Sensitivity analysis was also done to evaluate the effect of single studies on pooled estimated result.

RESULTS

In this systematic review and meta-analysis a total of 5,210 study participants were included from 15 primary studies. The review disclosed that the pooled proportion and incidence of mortality were 18.73% (95% CI: 15.92-20.83) and 4.94 (95% CI: 2.98-6.89) respectively. Being bedridden and ambulatory functional status, poor ART adherence, CD4 count below the threshold (<200 cells/mm3), advanced WHO clinical staging, not provision of cotrimoxazole and isoniazid preventing therapy, anemia and extra pulmonary TB were significant predictors of mortality.

CONCLUSION AND RECOMMENDATIONS

The analyzed data of this systematic review and meta-analysis depicted that the national pooled proportion and incidence of mortality among TB-HIV co-infected patients were considered to be still high. The authors strongly recommended scale up and continuous provision of cotrimoxazole and isoniazid preventive therapy. In addition, early identification and treatment of anemia will greatly halt the high burden of mortality. Generally, to reduce mortality and improve survival, a collaborative effort is mandatory to emphasize close follow up of patients with identified predictors.

Toward a Clinical Decision Support System for Monitoring Therapeutic Antituberculosis Medical Drugs in Tanzania (Project TuberXpert): Protocol for an Algorithm' Development and Implementation

BACKGROUND

The end tuberculosis (TB) strategy requires a novel patient treatment approach contrary to the one-size-fits-all model. It is well known that each patient's physiology is different and leads to various rates of drug elimination. Therapeutic drug monitoring (TDM) offers a way to manage drug dosage adaptation but requires trained pharmacologists, which is scarce in resource-limited settings.

OBJECTIVE

We will develop an automated clinical decision support system (CDSS) to help practitioners with the dosage adaptation of rifampicin, one of the essential medical drugs targeting TB, that is known for large pharmacokinetic variability and frequent suboptimal blood exposure. Such an advanced system will encourage the spread of a dosage-individualization culture, including among practitioners not specialized in pharmacology. Thus, the objectives of this project are to (1) develop the appropriate population pharmacokinetic (popPK) model for rifampicin for Tanzanian patients, (2) optimize the reporting of relevant information to practitioners for drug dosage adjustment, (3) automate the delivery of the report in line with the measurement of drug concentration, and (4) validate and implement the final system in the field.

METHODS

A total of 3 teams will combine their efforts to deliver the first automated TDM CDSS for TB. A cross-sectional study will be conducted to define the best way to display information to clinicians. In parallel, a rifampicin popPK model will be developed taking advantage of the published literature, complemented with data provided by existing literature data from the Pan-African Consortium for the Evaluation of Antituberculosis Antibiotics (panACEA), and samples collected within this project. A decision tree will be designed and implemented as a CDSS, and an automated report generation will be developed and validated through selected case studies. Expert pharmacologists will validate the CDSS, and finally, field implementation in Tanzania will occur, coupled with a prospective study to assess clinicians' adherence to the CDSS recommendations.

RESULTS

The TuberXpert project started in November 2022. In July 2024, the clinical study in Tanzania was completed with the enrollment of 50 patients to gather the required data to build a popPK model for rifampicin, together with a qualitative study defining the report design, as well as the CDSS general architecture definition.

CONCLUSIONS

At the end of the TuberXpert project, Tanzania will possess a new tool to help the practitioners with the adaptation of drug dosage targeting complicated TB cases (TB or HIV, TB or diabetes mellitus, and TB or malnutrition). This automated system will be validated and used in the field and will be proposed to other countries affected by endemic TB. In addition, this approach will serve as proof of concept regarding the feasibility and suitability of CDSS-assisted TDM for further anti-TB drugs in TB-burdened areas deprived of TDM experts, including second-line treatments considered important to monitor.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58720.

Incidence rate of mortality and its predictors among tuberculosis and human immunodeficiency virus coinfected patients on antiretroviral therapy in Ethiopia: systematic review and meta-analysis

Background

Tuberculosis (TB) is the leading cause of death among HIV-infected adults and children globally. Therefore, this study was aimed at determining the pooled mortality rate and its predictors among TB/HIV-coinfected patients in Ethiopia.

Methods

Extensive database searching was done via PubMed, EMBASE, SCOPUS, ScienceDirect, Google Scholar, and Google from the time of idea conception on March 1, 2023, to the last search via Google on March 31, 2023. A meta-analysis was performed using the random-effects model to determine the pooled mortality rate and its predictors among TB/HIV-coinfected patients. Heterogeneity was handled using subgroup analysis, meta-regression, and sensitivity analysis.

Results

Out of 2,100 records, 18 articles were included, with 26,291 total patients. The pooled incidence rate of mortality among TB/HIV patients was 12.49 (95% CI: 9.24-15.74) per 100 person-years observation (PYO); I2 = 96.9%. The mortality rate among children and adults was 5.10 per 100 PYO (95% CI: 2.15-8.01; I2 = 84.6%) and 15.78 per 100 PYO (95% CI: 10.84-20.73; I2 = 97.7%), respectively. Age ≥ 45 (pooled hazard ratios (PHR) 2.58, 95% CI: 2.00- 3.31), unemployed (PHR 2.17, 95% CI: 1.37-3.46), not HIV-disclosed (PHR = 2.79, 95% CI: 1.65-4.70), bedridden (PHR 5.89, 95% CI: 3.43-10.12), OI (PHR 3.5, 95% CI: 2.16-5.66), WHO stage IV (PHR 3.16, 95% CI: 2.18-4.58), BMI < 18.5 (PHR 4.11, 95% CI: 2.28-7.40), anemia (PHR 4.43, 95% CI: 2.73-7.18), EPTB 5.78, 95% CI: 2.61-12.78 significantly affected the mortality. The effect of TB on mortality was 1.95 times higher (PHR 1.95, 95% CI: 1.19-3.20; I2 = 0) than in TB-free individuals.

Conclusions

The mortality rate among TB/HIV-coinfected patients in Ethiopia was higher compared with many African countries. Many clinical factors were identified as significant risk factors for mortality. Therefore, TB/HIV program managers and clinicians need to design an intervention early.

Nurses' experiences of self-management support for adults with tuberculosis and human immunodeficiency virus coinfection

Background

Professional nurses provide self-management support to adults (18 years and older) living with tuberculosis (TB) and human immunodeficiency virus (HIV) coinfection to enable them to mitigate its impact on their lives. However, the experiences of professional nurses providing self-management support to adults with TB-HIV coinfection remain unclear.

Aim

This study explored and described the experiences of professional nurses on the provision of self-management support to adults living with TB-HIV coinfection in Greater Accra, Ghana.

Setting

Three public primary health facilities in Greater Accra, Ghana.

Methods

An exploratory, descriptive qualitative design was used. Twenty-two purposively sampled professional nurses were interviewed face-to-face individually using an interview guide. Interviews were recorded with participants' permission, transcribed and analysed thematically using MAXQDA software.

Results

The three themes generated revealed that the: (1) self-management problems of adults living with TB-HIV coinfection included their recurring physical, mental and social problems, (2) the support provided to adults with TB-HIV coinfection included symptom, nutritional, medication and psychosocial self-management support, (3) the factors related to providing self-management support showed that self-management support was influenced by patient, nurse and health facility-related factors but was feasible, equitable and acceptable to patients and stakeholders.

Conclusion

Professional nurses' self-management support practice entailed improvising limited resources to address the recurring problems of adults living with TB-HIV coinfection. Nurses require adequate resources to provide comprehensive self-management support.

Contribution

The contextual evidence provides insight into the self-management problems of adults with TB-HIV coinfection and the factors influencing professional nurses' self-management support.

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

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.

Factors associated with mortality in HIV-TB co-infected patients during and after the course of TB treatment in high-burden settings, Mumbai, India: A cohort analysis

BACKGROUND

Knowledge of factors associated with TB mortality during treatment and post treatment will help us develop better monitoring and implementation strategies for TB control. We designed the present study to examine the factors associated with mortality in HIV-TB co-infected patients during and after the course of TB treatment.

METHODS

This study is a cohort analysis of secondary data collected from 1804 HIV-TB co-infected individuals from 16 anti-retroviral therapy (ART) centres affiliated with the Mumbai Districts AIDS Control Society, Mumbai, India. We used Kaplan Meier survival curves and hazard ratios to estimate the mortality in patients.

RESULTS

The overall mortality rate in this cohort was 1.14 per 100 per month. The mortality proportion was 18% (95% CI: 16.1%, 20.1%) during treatment and 10.6% (95% CI: 8.9%, 12.5%) in the post-treatment period. Mortality was significantly higher in those with a CD4 count 0-200 cells/mm3 (HR: 3.04, 95% CI: 2.13, 4.15; p < 0.001), and in patients who were ART naïve and referred to the ART centre with a diagnosis of TB (HR: 1.39, 95% CI: 1.06, 1.82; p = 0.016). Mortality was also significantly higher in the first 6 months after initiation of ART (HR: 1.36, 95% CI: 1.06, 1.75; p = 0.016). A decrease in the CD4 counts from initial levels at start of TB treatment to end of TB treatment was associated with higher mortality in the post-treatment period.

DISCUSSION

The overall mortality remains high; early identification of TB and HIV disease, and use of rapid point of care tests for diagnosis of TB are needed across all health care facilities. Post-treatment follow-up and monitoring is important in HIV-TB co-infected patients, and post-treatment mortality should also be considered as one of the indicators for successful TB control programmes.