Tuberculosis among people living with HIV/AIDS in the German ClinSurv HIV Cohort: long-term incidence and risk factors

Incidence and risk factors for HIV-tuberculosis coinfection in the Cologne-Bonn region: a retrospective cohort study

PURPOSE

The risk of developing active tuberculosis (TB) is considerably increased in people living with HIV/AIDS (PLWH). However, incidence of HIV/TB coinfection is difficult to assess as surveillance data are lacking in many countries. Here, we aimed to perform a quantitative analysis of HIV/TB coinfections within the Cologne/Bonn HIV cohort and to determine risk factors for active TB.

METHODS

We systematically evaluated data of patients with HIV/TB coinfection between 2006 and 2017. In this retrospective analysis, we compared HIV/TB-coinfected patients with a cohort of HIV-positive patients. The incidence density rate (IDR) was calculated for active TB cases at different time points.

RESULTS

During 2006-2017, 60 out of 4673 PLWH were diagnosed with active TB. Overall IDR was 0.181 cases/100 patient-years and ranged from 0.266 in 2006-2009 to 0.133 in 2014-2017. Patients originating from Sub-Saharan Africa had a significantly (p < 0.001) higher IDR (0.694/100 patient-years of observation, 95% CI [0.435-1.050]) in comparison to patients of German origin (0.053/100 patient-years of observation, 95% CI [0.028-0.091]). In terms of TB-free survival, individuals originating from countries with a TB incidence higher than 10/100,000 exhibited a markedly reduced TB-free survival compared to those originating from regions with lower incidence (p < 0.001). In 22 patients, TB and HIV infection were diagnosed simultaneously.

CONCLUSION

Overall, we observed a decline in the incidence density rate (IDR) of HIV/TB coinfections between 2006 and 2017. Patients originating from regions with high incidence bear a higher risk of falling ill with active TB. For PLWH born in Germany, the observed risk of active TB appears to be lower compared to other groups within the cohort. These findings should be considered when developing TB containment and screening strategies for PLWH in low-incidence countries.

Determinants of tuberculosis among adult people living with HIV on antiretroviral therapy at public hospitals in Hawassa City, South Ethiopia

Background

The burden of tuberculosis (TB)/HIV co-infection is high in sub-Saharan African countries. The aim of the present study was to identify determinants of TB among people living with HIV (PLHIV) on antiretroviral therapy (ART) at public hospitals in Hawassa City Administration, Sidama Region, Ethiopia.

Methods

A facility-based case-control study was conducted between 30 March and 30 April 2023. We employed a systematic random sampling to recruit participants. The cases were all adult PLHIV who developed TB after ART initiation, and the group without TB were all adult PLHIV who did not develop TB after their ART initiation. Data were collected from patients' medical records using Kobo-tool and then exported to SPSS Version 26 for analysis. A multivariable logistic regression was used to identify the predictors of TB. Statistical significance was defined using the 95% confidence interval (CI).

Result

A total of 124 cases and 249 people without TB participated in the study. In a multivariable logistic regression analysis, we identified five independent determinants of TB. These include age (adjusted odds ratio (AOR) = 2.7; 95% CI 1.4-5.2), patients' residency (AOR = 6.4; 95% CI 2.8-14.5), WHO clinical stage III or IV (AOR = 6.7; 95% CI 3.2-14.0), isoniazid plus rifapentine (3HP) prophylaxis using (AOR = 0.5; 95% CI 0.2-0.9), and having other opportunistic infections (AOR = 3.6; 95% CI 1.7-7.6).

Conclusion and recommendation

Several risk factors for TB were identified among PLHIV. Strengthening TB screening in advanced disease conditions, encouraging use of 3HP prophylaxis, and early diagnosis and treatment of opportunistic infections were recommended to reduce the incidence of TB among PLHIV.

Tuberkulose im Erwachsenenalter

Die Tuberkulose ist in Deutschland eine seltene, überwiegend gut behandelbare Erkrankung. Weltweit ist sie eine der häufigsten Infektionserkrankungen mit ca. 10 Millionen Neuerkrankungen/Jahr. Auch bei einer niedrigen Inzidenz in Deutschland bleibt Tuberkulose insbesondere aufgrund der internationalen Entwicklungen und Migrationsbewegungen eine wichtige Differenzialdiagnose. In Deutschland besteht, aufgrund der niedrigen Prävalenz der Erkrankung und der damit verbundenen abnehmenden klinischen Erfahrung, ein Informationsbedarf zu allen Aspekten der Tuberkulose und ihrer Kontrolle. Diese Leitlinie umfasst die mikrobiologische Diagnostik, die Grundprinzipien der Standardtherapie, die Behandlung verschiedener Organmanifestationen, den Umgang mit typischen unerwünschten Arzneimittelwirkungen, die Besonderheiten in der Diagnostik und Therapie resistenter Tuberkulose sowie die Behandlung bei TB-HIV-Koinfektion. Sie geht darüber hinaus auf Versorgungsaspekte und gesetzliche Regelungen wie auch auf die Diagnosestellung und präventive Therapie einer latenten tuberkulösen Infektion ein. Es wird ausgeführt, wann es der Behandlung durch spezialisierte Zentren bedarf.

Die Aktualisierung der S2k-Leitlinie „Tuberkulose im Erwachsenenalter“ soll allen in der Tuberkuloseversorgung Tätigen als Richtschnur für die Prävention, die Diagnose und die Therapie der Tuberkulose dienen und helfen, den heutigen Herausforderungen im Umgang mit Tuberkulose in Deutschland gewachsen zu sein.

Predicting the risk of active pulmonary tuberculosis in people living with HIV: development and validation of a nomogram

BACKGROUND

Diagnosis of pulmonary tuberculosis (PTB) among people living with HIV (PLHIV) was challenging. The study aimed to develop and validated a simple, convenient screening model for prioritizing TB among PLHIV.

METHODS

The study included eligible adult PLHIV participants who attended health care in Yunnan, China, from January 2016 to July 2019. Participants included before June 2018 were in the primary set; others were in the independent validation set. The research applied the least absolute shrinkage and selection operator regression to identify predictors associated with bacteriological confirmed PTB. The TB nomogram was developed by multivariate logistic regression. The C-index, receiver operating characteristic curve (ROC), the Hosmer-Lemeshow goodness of fit test (H-L), and the calibration curves were applied to evaluate and calibrate the nomogram. The developed nomogram was validated in the validation set. The clinical usefulness was assessed by cutoff analysis and decision curve analysis in the primary set.

RESULT

The study enrolled 766 PLHIV, of which 507 were in the primary set and 259 in the validation set, 21.5% and 14.3% individuals were confirmed PTB in two sets, respectively. The final nomogram included 5 predictors: current CD 4 cell count, the number of WHO screen tool, previous TB history, pulmonary cavity, and smoking status (p < 0.05). The C-statistic was 0.72 (95% CI 0.66-0.77) in primary set and 0.68 (95% CI 0.58-0.75) in validation set, ROC performed better than other models. The nomogram calibration was good (H-L χ² = 8.14, p = 0.15). The area under the decision curve (0.025) outperformed the existing models. The optimal cutoff for screening TB among PLHIV was the score of 100 (sensitivity = 0.93, specificity = 0.35).

CONCLUSION

The study developed and validated a discriminative TB nomogram among PLHIV in the moderate prevalence of TB and HIV. The easy-to-use and straightforward nomogram would be beneficial for clinical practice and rapid risk screening in resource-limited settings.

Tuberculosis screening coverage and isoniazid preventive therapy among people living with HIV at Gambella Hospital, southwest Ethiopia: a retrospective study design

Objective

We aimed to assess the coverage of tuberculosis screening and isoniazid preventive therapy (IPT) among people living with human immunodeficiency virus (PLHIV) at Gambella Hospital, southwest Ethiopia.

Methods

We conducted a 5-year retrospective study of PLHIV receiving care in an antiretroviral therapy clinic from 1 January 2011 to 30 December 2015. We reviewed a total of 900 medical records of patients with complete information.

Result

Of the total, 897 (99.7%) PLHIV were screened for tuberculosis, among which 77 (8.6%) were found to be positive for active tuberculosis. Among 820 (91.4%) individuals eligible for IPT, only 545 (66.5%) were provided IPT; 275 (33.5%) eligible PLHIV were not provided IPT. Male sex (adjusted odds ratio [AOR] 1.63) and ages 18–29 years (AOR 0.33) and 30–44 years (AOR 0.31) were significantly associated with the likelihood of tuberculosis infection.

Conclusion

The present study findings demonstrated that tuberculosis screening for PLHIV at Gambella Hospital was improved in comparison with reports from many African countries and other parts of Ethiopia. Despite this improvement, the implementation rate of IPT was below national and World Health Organization recommendations. Overall, tuberculosis diagnostic approaches and available preventive measures should be strengthened in the study area.

The Diagnosis and Treatment of Tuberculosis

BACKGROUND

Around 10 million people worldwide contract tuberculosis every year. According to the World Health Organization (WHO), approximately one-quarter of the world's population is latently infected with Mycobacterium tuberculosis. In Ger- many, the incidence of tuberculosis was in decline over several decades but rose in 2015 to 7.3 new cases per 100 000 persons. In 2018, a total of 5429 new cases were documented, corresponding to 6.5 new cases per 100 000 persons.

METHODS

This article is based on literature retrieved by a selective search in PubMed and on the authors' clinical experience.

RESULTS

Tuberculosis involves the lungs in almost 75% of patients but can generally involve any organ. In Germany, the majority of patients come from high-incidence countries. If a patient's differential diagnosis includes tuberculosis, the main tests for the detection of the pathogen in sputum and tissue samples are culture (the gold standard), microscopy, and nucleic acid amplification tests. Imaging studies are also used for diagnosis and follow-up. The standard treatment consists of a combination of isoniazid, rifampicin, ethambutol, and pyrazinamide, followed by a combination of isoniazid and rifampicin only. Liver damage is one of the more common adverse effects of this treatment, arising in 2.4% of patients. Multidrug-resistant tuberculosis, which is rare in Germany (around 100 cases per year), should be treated in special- ized centers.

CONCLUSION

Rapid diagnosis and targeted treatment are essential to prevent an unfavorable course of the disease as well as its transmission to other individuals. In patients presenting with unclear symptoms, tuberculosis should always be considered as a differential diagnosis. The diagnosis of latent tuberculosis and decision-making regarding its treatment are difficult because of the lack of specific biomarkers and of relevant data from clinical trials.

Determinants of Active Tuberculosis Occurrences after ART Initiation among Adult HIV-Positive Clients in West Showa Zone Public Hospitals, Ethiopia: A Case-Control Study

Introduction. Tuberculosis is a major public health concern globally, especially in sub-Saharan African countries. It is the most common opportunistic infection and leading cause of mortality among people living with human immunodeficiency virus despite increased deliverance of antiretroviral therapy. Objectives. The aim of this study was to identify determinants of active tuberculosis among adult HIV positive patients after ART initiation in West Showa Zone public hospitals, Ethiopia. Methods. Multicentred unmatched case-control study was conducted on selected public hospitals in West Showa Zone from February to June, 2019. A total of 406 participants (203 cases and 203 controls) were included in the study. Cases were adult HIV patients who developed tuberculosis after ART initiation while controls were adult HIV patients who did not develop tuberculosis after ART initiation. Data were collected using interviewer administered structured questionnaire. Logistic regression analysis was performed using SPSS version 24 statistical software. Statistical significance test was set at 95% confidence level. Results. This study identified that patient’s previous TB history (AOR = 2.41; 95% CI: 1.49, 3.90; P value<0.001), haemoglobin level (AOR = 3.67; 95% CI: 1.98, 6.79; P value<0.001), CD4 cells count (AOR = 2.02; CI: 1.24, 3.29; P value=0.004), adherence level (AOR = 19.00; CI: 5.59, 64.59; P vaue<0.001), and WHO HIV/AIDS clinical stage (AOR = 2.58; CI: 1.59, 4.18; P vaue<0.001) were found to be statistically significant determinants for the occurrence of tuberculosis among PLHIV after ART initiation. Conclusion. Patient’s previous TB history, haemoglobin level, CD4 cells count, adherence level, and WHO clinical stage were significant determinants of occurrence of tuberculosis after ART initiation in PLHIV.

Time delay and associated mortality from negative smear to positive Xpert MTB/RIF test among TB/HIV patients: a retrospective study

Background

The GeneXpert MTB/RIF Assay (Xpert®) is known to be a feasible, effective and a hopeful tool for rapid tuberculosis (TB) diagnosis and treatment. However, little is known about the time delay caused by initial negative sputum smear microscopy (NSSM), but consecutive positive Xpert TB test (PXTBt) and its association with TB mortality in resource-constrained settings. We aimed to estimate the median time delay between initial NSSM but consecutive PXTBt and TB treatment initiation and its association with TB mortality among TB/HIV co-infected patients in Beira, Mozambique.

Methods

we used data from a retrospective cohort study of TB/HIV co-infected patients in six TB services in Beira city. The study included all patients that tested NSSM, followed by a PXTBt in the six health centers with TB services during the year 2015. Data were extracted from the laboratory and TB treatment registers. To assess the difference in median time delays between groups, Mann-Whitney and Kruskal-Wallis tests were computed. To analyze the associations between the time delays and TB mortality, logistic regression model was used.

Results

Among the 283 patients included in the study, median (IQR) age was 31 (17) years, 59.0% were males, 57.6% in the WHO clinical fourth stage of HIV. The median (IQR) values for diagnostic delay, treatment delay and total time delay was 10 (9) days, 13 (12) days and 28 (20) days, respectively. For TB/HIV co-infected patients who tested negative for smear microscopy initially, a total time delay of one month or longer was associated with high mortality (aOR = 12.40, 95% CI: 5.70–22.10).

Conclusion

Our study indicates that delays in TB diagnosis and treatment resulting from initial NSSM, but consecutive PXTBt are common in Beira city and are one of the main factors associated with TB mortality among TB/HIV co-infected patients. Applying GeneXpert assay as gold standard for HIV-positive patients with suspected pulmonary TB or replacing the sputum smear microscopy by Xpert assay and its availability within 24 h is urgently needed to ensure early diagnosis and treatment, and to maximize the impact of the few resources available in the country.

Incidence of tuberculosis and the need of prophylactic treatment in persons living with HIV in Stockholm during the era of anti-retroviral therapy 1996-2013

BACKGROUND

The aim of this observational cohort study was to determine the incidence and risk factors of active tuberculosis (TB) in persons living with HIV in a low endemic setting over a 17-year time period when combination antiretroviral therapy (ART) has been available. We thereby aimed to understand the usefulness of TB chemoprophylaxis among HIV patients with latent TB.

METHODS

All 2127 adult patients diagnosed with HIV January 1996-December 2013 at the Karolinska University Hospital in Stockholm County were eligible. After exclusion of 259 patients transferred to other clinics, 1868 were followed until TB diagnosis, death or end of study period (December 2013). The median follow-up time was 7.9 years (interquartile range, 3.9-11.5).

RESULTS

Active TB was diagnosed in 92 patients, corresponding to an incidence rate of 6.2 cases (95% CI 5.1-7.6) per 1000 person-years with a significant decline over time. The majority (52%) of TB cases were diagnosed within 1 month from HIV diagnosis. Being a migrant from a TB-endemic region, was the only patient characteristic associated with significantly higher risk of active TB (Hazard Ration, HR: 8.54, 95% confidence interval, CI: 3.09-23.61 in a multivariate regression analysis controlling for route of HIV transmission, year of HIV diagnosis and CD4-cell count and viral load at HIV diagnosis. The number needed to treat to prevent one case of TB among patients in this high-risk group was 22 (95% CI 26-47).

CONCLUSION

The incidence of active TB in persons living with HIV in Stockholm County declined significantly after the introduction of ART but was still 80 times higher than in the general population at the end of the study period. The therapeutic gain of chemoprophylaxis in low endemic settings should be weighed against costs and side effects.

Increasing incidence of HIV- associated tuberculosis in Romanian injecting drug users

BACKGROUND

A high prevalence of tuberculosis (TB) among HIV-positive injecting drug users (IDUs) may fuel the TB epidemic in the general population of Romania. We determined the frequency and characteristics of TB in HIV-infected IDUs referred to a national centre.

METHODS

Prospective observational cohort study of all newly-diagnosed HIV-positive IDUs admitted to Victor Babes Hospital, Bucharest, between January 2009 and December 2014. Socio-demographics, clinical characteristics and outcomes of HIV/TB co-infected IDUs were compared to HIV-positive IDUs without TB.

RESULTS

170/598 (28.5%) HIV-infected IDUs were diagnosed with TB. The prevalence increased from 12.5% in 2009 to 32.1% in 2014 (P < 0.001). HIV/TB co-infected individuals had lower median CD4 cell counts 75 (vs. 450/mm³ , P < 0.0001) and higher median HIV viral loads 5.6 log₁₀ (vs. 4.9 log₁₀ , P < 0.0001) when presenting to healthcare services. 103/170 (60.6%) HIV/TB co-infected IDUs were diagnosed with pulmonary TB. Resistant Mycobacterium tuberculosis strains were common, with 18/105 (17.1%) of patients having Multi-Drug Resistant (MDR) disease. Higher mortality rate was associated with TB co-infection (P < 0.0001), extra-pulmonary TB (P = 0.0026) and extensively drug resistant TB (P = 0.024).

CONCLUSIONS

Tuberculosis (TB) is an increasing problem in HIV-infected IDUs in Romania. Presentation is often with advanced HIV, significant TB drug resistance and consequent outcomes are poor.

Injecting drug use predicts active tuberculosis in a national cohort of people living with HIV

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.

HIV and tuberculosis co-infection among migrants in Europe: A systematic review on the prevalence, incidence and mortality

Background

International human migration has been rapidly growing. Migrants coming from low and middle income countries continue to be considerably vulnerable and at higher risk for infectious diseases, namely HIV (Human Immunodeficiency Virus) and tuberculosis (TB). In Europe, the number of patients with HIV-TB co-infection has been increasing and migration could be one of the potential driving forces.

Objective

This systematic review aims to improve the understanding on the burden of HIV-TB co-infection among migrants in Europe and to assess whether these populations are particularly vulnerable to this co-infection compared to nationals.

Design

MEDLINE^®, Web of Science^® and Scopus^® databases were searched from March to April 2016 using combinations of keywords. Titles and abstracts were screened and studies meeting the inclusion criteria proceeded for full-text revision. These articles were then selected for data extraction on the prevalence, incidence and mortality.

Results

The majority of HIV-TB prevalence data reported in the analysed studies, including extrapulmonary/disseminated TB forms, was higher among migrant vs. nationals, some of the studies even showing increasing trends over time. Additionally, while HIV-TB incidence rates have decreased among migrants and nationals, migrants are still at a higher risk for this co-infection. Migrants with HIV-TB co-infection were also more prone to unsuccessful treatment outcomes, death and drug resistant TB. However, contradicting results also showed lower mortality compared to nationals.

Conclusions

Overall, a disproportionate vulnerability of migrants to acquire the HIV-TB co-infection was observed across studies. Such vulnerability has been associated to low socioeconomic status, poor living conditions and limited access to healthcare. Adequate social support, early detection, appropriate treatment, and adequate access to healthcare are key improvements to tackle HIV-TB co-infection among these populations.

Is systematic screening and treatment for latent tuberculosis infection in HIV patients useful in a low endemic setting?

OBJECTIVES

A decreasing incidence of tuberculosis (TB) among HIV patients has been documented in high-income settings and screening for tuberculosis is not systematically performed in many clinics (such as ours). Our objectives are to evaluate whether a same decline of incidence was seen in our Belgian tertiary center and to evaluate whether systematic screening and prophylaxis of tuberculosis should remain part of routine practice.

METHODS

Between 2005 and 2012, the annual incidence of tuberculosis among adult HIV patients was measured. The impact of demographic characteristics and CD₄ nadir on the incidence of active TB was evaluated.

RESULTS

Among the 1167 patients who entered the cohort, 42 developed active TB with a significant decrease of annual incidence from 28/1000 patient-years in 2005 to 3/1000 patient-years in 2012. Among the 42 cases, 83% were of sub-Saharan origin. Median CD4 cell count upon HIV diagnosis was significantly lower in TB cases and 60% had a nadir CD4 below 200/μl. Thirty-six percent of incident TB occurred within 14 days after HIV diagnosis.

CONCLUSION

A significant decline of TB incidence in HIV patients was observed. Incident TB occurred mainly in African patients, with low CD4 upon HIV diagnosis. A significant proportion of TB cases were discovered early in follow-up which probably reflects TB already present upon HIV diagnosis. In a low endemic setting, exclusion of active TB upon HIV diagnosis remains a priority and screening for LTBI should focus on HIV patients from high risk groups such as migrants from endemic regions, especially in patients with low CD4 nadir.

Immunological recovery in tuberculosis/HIV co-infected patients on antiretroviral therapy: implication for tuberculosis preventive therapy

BACKGROUND

Understanding the immune response to combination antiretroviral therapy (cART) is essential for a clear approach to tuberculosis (TB) preventive therapy. We investigated the immunological recovery in cART-treated HIV-infected patients developing TB compared to those who remained free of TB.

METHODS

We extracted data of HIV-infected patients from a multicenter cohort for the HIV clinical surveillance in Germany. No patients included in our study had TB at the beginning of the observation. Using a longitudinal mixed model, we assessed the differences in the mean change of biomarkers (CD4+ cell count, CD8+ cell count, CD4:CD8 ratio and viral load) since cART initiation in patients who remained free of TB vs. those developing TB. To detect the best-fit trajectories of the immunological biomarkers, we applied a multivariable fractional polynomials model.

RESULTS

We analyzed a total of 10,671 HIV-infected patients including 139 patients who developed TB during follow-up. The highest TB incidences were observed during the first two years since cART initiation (0.32 and 0.50 per 100 person-years). In an adjusted multivariable mixed model, we found that the average change in CD4+ cell count recovery was significantly greater by 33 cells/μl in patients who remained free of TB compared with those developing TB. After the initial three months of cART, 65.6% of patients who remaining free of TB achieved CD4+ count of ≥400 cells/μl, while only 11.3% of patients developing TB reached this immunological status after the three months of cART. We found no differences in the average change of CD8+ cell count, CD4:CD8 ratio or viral load between the two-patient groups.

CONCLUSION

All HIV-infected patients responded to cART. However, patients developing TB showed reduced recovery in CD4+ cell count and this might partly explain the incident TB in HIV-infected patients receiving cART. These findings reinforce the importance of adjunctive TB preventive therapy for patients with reduced recovery in CD4+ cell count.

Survival of people living with HIV who defaulted from tuberculosis treatment in a cohort, Recife, Brazil

Background

Tuberculosis is a serious public health problem worldwide. It is the leading cause of death amongst people living with HIV, and default from tuberculosis (TB) treatment in people living with HIV increases the probability of death. The aim of this study was to estimate the survival probability of people living with HIV who default treatment for TB compared to those who complete the treatment.

Methods

This was a longitudinal cohort study of people living with HIV, from June 2007 to December 2013 with two components: a retrospective (for those who started tuberculosis treatment before 2013 for whom failure (death) or censoring occurred before 2013), and prospective (those who started tuberculosis treatment at any time between 2007 and June 2013 and for whom death or censoring occurred after the beginning of 2013), at two referral hospitals for people living with HIV (Correia Picanço Hospital - HCP and at Hospital Universitário Oswaldo Cruz – HUOC), in Recife/PE. A total of 317 patients who initiated TB treatment were studied. Default from TB treatment was defined as any patient who failed to attend their pre-booked return appointment at the health center for more than 30 consecutive days, in accordance with Brazilian Ministry of Health recommendations.

Results

From a cohort of 2372 people living with HIV we analyzed 317 patients who had initiated TB treatment. The incidence of death was 5.6 deaths per 100 persons per year (CI 95% 4.5 to 7.08). Independent factors associated with death: default from TB treatment 3.65 HR (95% CI 2.28 to 5.83); CD4 < 200 cells/mm³ 2.39 HR (95% CI 1.44 to 3.96); extrapulmonary tuberculosis 1.56 HR (95% CI 0.93 to 2.63); smoking 2.28 HR (95% CI 1.33 to 3.89); alcohol light 0.13 HR (95% CI 0.03 to 0.56).

Conclusion

The probability of death in people living with HIV who default TB treatment is approximately four times greater when compared to those who do not default from treatment.

Intensified tuberculosis case finding, implementation of isoniazid preventive therapy and associated factors among people living with human immunodeficiency virus at public health facilities of Harari Region, Eastern Ethiopia: A cross-sectional study

OBJECTIVE

Globally, the number of people living with human immunodeficiency virus (PLHIV) particularly in sub-Saharan Africa is growing. This has been resulted in increased number of tuberculosis (TB) new cases. To control burden of TB among PLHIV, a number of collaborative TB/HIV activities were recommended. However, data about collaborative TB/HIV services in the study area is scarce. The objective of this study is to assess intensified TB case finding, implementation of isoniazid preventive therapy (IPT) and associated factors among PLHIV.

METHODS

A facility based cross-sectional study design was employed among 419 randomly selected PLHIV from public health facilities of Harari region. Systematic sampling method was used to obtain sample from each health facilities. Interviewer-administered questionnaire was used to collect data. Data were entered into EpiData and analyzed by SPSS statistical software. Multivariate logistic regression analysis was conducted to determine the presence of association between variables using odds ratio with 95% confidence interval and association was declared significant at P ≤ 0.05.

RESULTS

One hundred fifteen (75.2%) of the respondents reported that they offered screening for TB during their HIV chronic cares and 94 (29.8%) of them were found to be positive for active TB. Female sex [AOR 2.51; 95%CI (1.52, 6.14)], educated patients [AOR 0.52; 95%CI (0.21, 0.83)], CD4 count greater than 350 cells/dl³ [AOR 0.62; 95%CI(0.22,0.82)], Antiretroviral Therapy (ART) initiation [AOR 0.50; 95%CI (0.35, 0.88)] and missing dose of ART [AOR 2.57; 95%CI (1.21, 5.32)] were significantly associated with TB infection. Nearly four-fifth (78.7 %) of the study participants were provided IPT.

CONCLUSIONS

Screening of TB among PLHIV and implementation of IPT in the region is lower when compared to the findings of other studies conducted in different parts of the country and needs to be improved through implementation of national and international guidelines.

Screening and treatment of latent tuberculosis infection among HIV-infected patients in resource-rich settings

Current international guidelines recommend screening and treatment of latent tuberculosis (TB) infection in HIV-infected patients in all settings. The main factors affecting the risk of TB in HIV-infected patients include the level of immunosuppression, coverage of antiretroviral therapy and local TB burden. In resource-rich settings where antiretroviral therapy is more accessible and HIV-infected patients are expected to be diagnosed at an earlier stage, local TB burden remains a key factor on their risk of TB. This article reviewed the epidemiology of latent TB infection among the adult HIV-infected patients, and the use and benefit of screening and treatment of latent TB infection in resource-rich settings in the past decade. While such practice should be continued in countries with medium or high TB burden, targeted screening and treatment only for HIV-infected patients with additional risk factors for TB might be a more practical option in resource-rich countries with low TB burden.

Tuberculosis and HIV coinfection in Europe: looking at one reality from two angles

Objective:

To better understand the epidemiology of tuberculosis (TB)/HIV coinfection in the European Union (EU) and European Economic Area (EEA) for planning of prevention and control measures.

Design:

Analysis of surveillance data.

Methods:

We performed an analysis of the 2014 TB and AIDS data to assess the burden of TB/HIV coinfection and we applied multivariable logistic regression to evaluate predictors for coinfection.

Results:

Twenty-one of 31 EU/EEA countries reported HIV testing results for 64.6% of the 32 892 notified TB cases. Of those, 1051 (4.9%) were reported as HIV-positive. Males [adjusted odds ratio (aOR) 1.25; 95% confidence interval (CI) 1.07–1.46] and those in age group 25–44 years were more frequently coinfected. TB cases originating from the WHO African region had the highest proportion of coinfection (aOR 3.28 versus origin in EU/EEA; 95% CI 2.35–4.57). TB treatment was completed successfully by 57.9% of HIV-positive TB cases and 83.5% of HIV-negative cases. In 2014, 3863 cases of AIDS were reported by 29 EU/EEA countries; 691 (17.9%) of these cases presented with TB as an AIDS-defining illness. Persons who had acquired HIV through injecting drug use had higher odds of TB as an AIDS-defining illness (aOR 1.78 versus heterosexual route of transmission; 95% CI 1.37–2.32).

Conclusion:

TB/HIV coinfection is a substantial problem in the EU/EEA. The occurrence of TB in HIV-positive cases and the low TB treatment success rate suggest that international guidelines for prevention and treatment of TB in HIV-infected adults need to be better implemented.

[Migration and infectious disease surveillance in Germany: Analyses of Tuberculosis, HIV and Syphilis surveillance data]

BACKGROUND

Migration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information.

OBJECTIVES

The objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations.

METHODS

We describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002-2013.

RESULTS

Migration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13% of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants.

DISCUSSION

A standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.

Impact of HIV infection on treatment outcome of tuberculosis in Europe

BACKGROUND

The effect of HIV on tuberculosis (TB) treatment outcomes has not been well established. We aimed to assess the impact of HIV infection on TB treatment outcomes by using data from notifiable disease surveillance in Europe.

METHODS

We analyzed the treatment outcomes of TB cases reported from nine European countries during 2010-2012. We investigate the effect of HIV on TB treatment outcomes using a multilevel and a multinomial logistic model, and considering the interaction between HIV and multidrug-resistant (MDR) TB.

RESULTS

A total of 61,138 TB cases including 5.5% HIV-positive were eligible for our analysis. In the multilevel model adjusted for age and an interaction with MDR TB, HIV was significantly associated with lower treatment success in all MDR strata [non-MDR TB: odds ratio (OR) 0.24 CI (confidence interval) 0.20-0.29; unknown MDR TB status: OR 0.26 CI 0.23-0.30; MDR TB: OR 0.57 CI 0.35-0.91]. In the multinomial regression model, HIV-positive cases had significantly higher relative risk ratio (RRR) for death (non-MDR TB: RRR 4.30 CI 2.31-7.99; unknown MDR TB status: 5.55 CI 3.10-9.92; MDR TB: 3.59 CI 1.56-8.28) and being 'still on treatment' (non-MDR TB: RRR 7.27 CI 3.00-17.6; unknown MDR TB status: 5.36 CI 2.44-11.8; MDR TB: 3.76 CI 2.48-5.71). We did not find any significant association between HIV and TB treatment failure (non-MDR TB: RRR 0.50 CI 0.15-1.67; unknown MDR TB status: 1.51 CI 0.86-2.64; MDR TB: 0.51 CI 0.13-1.87).

CONCLUSION

This large study confirms that HIV is a strong risk factor for an adverse TB treatment outcome, which is mainly manifested by an increased risk of death and still being on TB treatment.

Detecting latent tuberculosis in compromised patients

PURPOSE OF REVIEW

The detection of latent tuberculosis infection (LTBI) in different categories of compromised patients is reviewed with focus on the role of strategies incorporating immunodiagnostic tests and analysis of epidemiological and clinical risk factors.

RECENT FINDINGS

The development of active tuberculosis (TB) is increased in compromised patients and is closely related to determinants for disease reactivation or newly acquired TB infection. A targeted detection of LTBI in these high-risk groups should be performed especially if preventive treatment is planned. The performance of immunodiagnostic tests is highly variable among different groups of immunocompromised individuals. Findings of cross-sectional studies indicate a better diagnostic accuracy of interferon-γ release assays over the tuberculin skin test. The critical issue is that in low-incidence countries, the positive and negative predictive values of any of immunodiagnostic tests were very poor. A targeted testing process involving analysis of TB risk factors increases the predictive positive values of immunodiagnostic tests and may improve LTBI detection.

SUMMARY

The LTBI detection in immunocompromised patients is a challenge. The development of new immunological biomarkers and integrated clinical and epidemiological strategies are needed to identify LTBI in compromised individuals and to plan preventive chemotherapies in those at risk of developing active TB.

Clinical Application of Interferon-γ Release Assays for the Prevention of Tuberculosis in Countries with Low Incidence

Despite global efforts to control tuberculosis (TB) the estimated number of people who developed TB worldwide increased to an all-time record of more than 10 million in 2015. The goal of the World Health Organization (WHO) to reduce the global incidence of TB to less than 100 cases per million by 2035, cannot be reached unless TB prevention is markedly improved. There is a need for an improved vaccine that better protects individuals who are exposed to Mycobacterium tuberculosis from infection and active disease compared to the current M. bovis Bacille Calmette Guérin (BCG) vaccine. In the absence of such a vaccine, prevention relies on infection control measures and preventive chemotherapy for people with latent infection with M. tuberculosis (LTBI), who have the highest risk of progression to active TB. During the past decade, interferon-γ release assays (IGRAs) have increasingly replaced the tuberculin skin test as screening tools for the diagnosis of LTBI in countries with a low incidence of TB. Despite recent WHO guidelines on the management of LTBI, the definition of groups at risk for TB remains controversial, and the role of IGRAs for TB prevention in low-incidence countries remains uncertain. We reviewed the scientific literature and provide recommendations for the use of IGRAs for LTBI diagnosis in low-incidence countries. These recommendations are based on the number of patients needing treatment in order to prevent one case of TB. As the positive predictive value of IGRAs for the development of TB is sub-optimal, research must focus on the identification of alternative biomarkers that offer better predictive ability in order to substantially reduce the number needing treatment while improving the prevention of TB and improving the effectiveness of targeted preventive chemotherapy.

TB-HIV co-infection in the Netherlands: estimating prevalence and under-reporting in national registration databases using a capture-recapture analysis

BACKGROUND

Knowledge of the HIV status in patients with tuberculosis (TB) and vice versa is crucial for proper individual patient management, while knowledge of the prevalence of co-infection guides preventive and therapeutic strategies. The aim of the study was to assess if national disease databases on TB and HIV are adequate sources to provide this information.

METHODS

A two way capture-recapture analysis to assess the completeness of the registers, and to obtain the prevalence of TB-HIV co-infection in the Netherlands in the years 2002-2012.

RESULTS

HIV testing was performed in less than 50% of the patients with TB. Of the 932 TB-HIV infected patients, just 293 (31.4%) were registered in both registers. Under-reporting of TB-HIV co-infection ranged from 50% to 70% in the national TB register, and from 31% to 37% in the HIV database. Prevalence of TB-HIV co-infection in the Netherlands in 2012 was 7.1% (95% CI 6.0% to 8.3%), which was more than double of the prevalence estimated from the national TB database.

CONCLUSIONS

TB-HIV co-infection is markedly under-reported in national disease databases. There is an urgent need for improved registration and preferably a routine data exchange between the two surveillance systems.

Prevalence, incidence, and associated risk factors of tuberculosis in children with HIV living in the UK and Ireland (CHIPS): a cohort study

BACKGROUND

Tuberculosis is the most common serious co-infection in people living with HIV worldwide, but little is known about its incidence in HIV-infected children living in high-resource settings with low tuberculosis prevalence. We aimed to assess the incidence and prevalence of tuberculosis in children with HIV living in the UK and Ireland to understand rates, risk factors, and outcomes of the disease in this group.

METHODS

We did an analysis of children enrolled in CHIPS, an observational multicentre cohort of children receiving HIV care in the UK and Ireland. We assessed characteristics and prevalence of tuberculosis at baseline, measured incidence of disease through the follow-up period using the CHIPS database, and calculated associated risk factors in these children with multivariable logistic and Cox regression models.

FINDINGS

Between Jan 1, 1996, to Sept 18, 2014, data for 1848 children with 14 761 years of follow-up were reported to CHIPS. 57 (3%) children were diagnosed with tuberculosis: 29 children had tuberculosis at presentation (prevalent tuberculosis) and 29 had the disease diagnosed during follow-up (incident tuberculosis), including one child with recurrent tuberculosis events. Median age at diagnosis was 9 years (IQR 5-12). 25 (43%) children had pulmonary tuberculosis, 24 (41%) had extrapulmonary tuberculosis with or without pulmonary involvement, and the remainder (n=9; 16%) had unspecified-site tuberculosis. The overall incidence rate for the follow-up period was 196 cases per 100 000 person-years (95% CI 137-283). In our multivariable model, tuberculosis at presentation was associated with more severe WHO immunological stage at baseline (odds ratio 0·25, 95% CI 0·08-0·74; p=0·0331; for none vs severe) and being born abroad (odds ratio 0·28, 0·10-0·73; p=0·0036; for UK and Ireland vs abroad). Incident tuberculosis was associated with time-updated more severe WHO immunological stage (hazard ratio 0·15, 95% CI 0·06-0·41; p=0·0056; for none vs severe) and older age at baseline (1·11, 0·47-2·63; p=0·0027; for age >10 years vs 5-9 years).

INTERPRETATION

Tuberculosis rates in HIV-infected children in the UK and Ireland were higher than those reported in the general paediatric population. Further study is warranted of tuberculosis screening and preventive treatment for children at high-risk of this disease to avoid morbidity and mortality in this population.

FUNDING

NHS England, PENTA Foundation.

Does antiretroviral therapy reduce HIV-associated tuberculosis incidence to background rates? A national observational cohort study from England, Wales, and Northern Ireland

BACKGROUND

Whether the incidence of tuberculosis in HIV-positive people receiving long-term antiretroviral therapy (ART) remains above background population rates is unclear. We compared tuberculosis incidence in people receiving ART with background rates in England, Wales, and Northern Ireland.

METHODS

We analysed a national cohort of HIV-positive individuals linked to the national tuberculosis register. Tuberculosis incidence in the HIV-positive cohort (2007-11) was stratified by ethnic origin and time on ART and compared with background rates (2009). Ethnic groups were defined as follows: the black African group included all individuals of black African origin, including those born in the UK and overseas; the white ethnic group included all white individuals born in the UK and overseas; the south Asian group included those of Indian, Pakistani, and Bangladeshi origin, born in the UK and overseas; and the other ethnic group included all other ethnic origins, including black Afro-Caribbeans.

FINDINGS

The HIV-positive cohort comprised 79 919 individuals, in whom there were 1550 incident cases in 231 664 person-years of observation (incidence 6·7 cases per 1000 person-years). Incidence of tuberculosis in the HIV-positive cohort was 13·6 per 1000 person-years in black Africans and 1·7 per 1000 person-years in white individuals. Incidence of tuberculosis during long-term ART (≥5 years) in black Africans with HIV was 2·4 per 1000 person-years, similar to background rates of 1·9 per 1000 person-years in this group (rate ratio 1·2, 95% CI 0·96-1·6; p=0·083); but in white individuals with HIV on long-term ART the incidence of 0·5 per 1000 person-years was higher than the background rate of 0·04 per 1000 person-years (rate ratio 14·5, 9·4-21·3; p<0·0001). The increased incidence relative to background in white HIV-positive individuals persisted when analysis was restricted to person-time accrued on ART with CD4 counts of at least 500 cells per μL and when white HIV-positive individuals born abroad were excluded.

INTERPRETATION

Tuberculosis incidence is unacceptably high irrespective of HIV status in black Africans. In white individuals with HIV, tuberculosis incidence is significantly higher than background rates in white people despite long-term ART. Expanded testing and treatment for latent tuberculosis infection to all HIV-infected adults, irrespective of ART status and CD4 cell count, might be warranted.

FUNDING

Public Health England.

Impact of TB on the survival of people living with HIV infection in England, Wales and Northern Ireland

INTRODUCTION

The impact of TB disease on survival in people living with HIV in high resource settings is not well documented in the antiretroviral treatment (ART) era. We calculated TB incidence rates and compared the mortality of persons with and without HIV-TB in a UK HIV cohort in the post-ART era, to determine the impact of HIV-TB on survival in the UK.

METHODS

We linked the national cohort of persons (aged ≥15 years) diagnosed with HIV between 2000 and 2008 in England, Wales and Northern Ireland with the national TB register and deaths from the Office of National Statistics. We compared all-cause and AIDS-specific mortality in patients with and without TB by estimating HRs using Cox regression modelling allowing for potential predictors.

RESULTS

Overall, 3188 (7.2%) individuals developed TB infection among a cohort of 44 050 HIV-diagnosed persons and 149 663 person-years. The cumulative TB incidence rate was 2.13 per 100 person-years with a spike within the first 6 months after HIV diagnosis. TB coinfected patients comprised 18% of the 1880 deaths during follow-up and 79% of deaths (n=967) in the year following HIV diagnosis. TB coinfection (HR 4.77, 95% CI 4.11 to 5.54) was significantly associated with increased all-cause mortality. Analysis of AIDS-related survival showed similar results.

DISCUSSION

The unexpected high mortality in patients with HIV-TB in a population with good healthcare access and ART availability highlights the importance of improving active and latent TB case-finding among patients with HIV, and HIV-testing among patients with TB, to ensure appropriate and prompt treatment initiation for both diseases.

Attitudes about tuberculosis prevention in the elimination phase: a survey among physicians in Germany

Background

Targeted and stringent measures of tuberculosis prevention are necessary to achieve the goal of tuberculosis elimination in countries of low tuberculosis incidence.

Methods

We ascertained the knowledge about tuberculosis risk factors and stringency of tuberculosis prevention measures by a standardized questionnaire among physicians in Germany involved in the care of individuals from classical risk groups for tuberculosis.

Results

510 physicians responded to the online survey. Among 16 risk factors immunosuppressive therapy, HIV-infection and treatment with TNF-antagonist were thought to be the most important risk factors for the development of tuberculosis in Germany. Exposure to a patient with tuberculosis ranked on the 10^th position. In the event of a positive tuberculin-skin-test or interferon-γ release assay only 50%, 40%, 36% and 25% of physicians found that preventive chemotherapy was indicated for individuals undergoing tumor necrosis factor-antagonist therapy, close contacts of tuberculosis patients, HIV-infected individuals and migrants, respectively.

Conclusions

A remarkably low proportion of individuals with latent infection with Mycobacterium tuberculosis belonging to classical risk groups for tuberculosis are considered candidates for preventive chemotherapy in Germany. Better knowledge about the risk for tuberculosis in different groups and more stringent and targeted preventive interventions will probably be necessary to achieve tuberculosis elimination in Germany.

Impact of co-infections and BCG immunisation on immune responses among household contacts of tuberculosis patients in a Ugandan cohort

BACKGROUND

Tuberculosis incidence in resource poor countries remains high. We hypothesized that immune modulating co-infections such as helminths, malaria, and HIV increase susceptibility to latent tuberculosis infection (LTBI), thereby contributing to maintaining the tuberculosis epidemic.

METHODS

Adults with sputum-positive tuberculosis (index cases) and their eligible household contacts (HHCs) were recruited to a cohort study between May 2011 and January 2012. HHCs were investigated for helminths, malaria, and HIV at enrolment. HHCs were tested using the QuantiFERON-TB Gold In-Tube (QFN) assay at enrolment and six months later. Overnight whole blood culture supernatants from baseline QFN assays were analyzed for cytokine responses using an 11-plex Luminex assay. Associations between outcomes (LTBI or cytokine responses) and exposures (co-infections and other risk factors) were examined using multivariable logistic and linear regression models.

RESULTS

We enrolled 101 index cases and 291 HHCs. Among HHCs, baseline prevalence of helminths was 9% (25/291), malaria 16% (47/291), HIV 6% (16/291), and LTBI 65% (179/277). Adjusting for other risk factors and household clustering, there was no association between LTBI and any co-infection at baseline or at six months: adjusted odds ratio (95% confidence interval (CI); p-value) at baseline for any helminth, 1.01 (0.39-2.66; 0.96); hookworm, 2.81 (0.56-14.14; 0.20); malaria, 1.06 (0.48-2.35; 0.87); HIV, 0.74 (0.22-2.47; 0.63). HHCs with LTBI had elevated cytokine responses to tuberculosis antigens but co-infections had little effect on cytokine responses. Exploring other risk factors, Th1 cytokines among LTBI-positive HHCs with BCG scars were greatly reduced compared to those without scars: (adjusted geometric mean ratio) IFNγ 0.20 (0.09-0.42), <0.0001; IL-2 0.34 (0.20-0.59), <0.0001; and TNFα 0.36 (0.16-0.79), 0.01.

CONCLUSIONS

We found no evidence that co-infections increase the risk of LTBI, or influence the cytokine response profile among those with LTBI. Prior BCG exposure may reduce Th1 cytokine responses in LTBI.