HIV care and treatment factors associated with improved survival during TB treatment in Thailand: an observational study

Gastrointestinal tuberculosis: An autopsy-based study

BACKGROUND

Tuberculosis is a disease of great relevance since it is one of the leading causes of morbidity and mortality worldwide. Gastrointestinal tuberculosis is an unusual presentation. It is defined as the involvement of any segment of the digestive tract, associated viscera, and peritoneum. The study's main objective is to collect information from autopsies of patients diagnosed with gastrointestinal tuberculosis in a Pathology reference center in Colombia.

METHODS

This is a retrospective and descriptive study of autopsy reports. A total of 4,500 autopsies were performed between January 2004 and December 2020. The inclusion criteria were authorization of a family member following local law regulations and a final autopsy diagnosis of gastrointestinal tuberculosis using microscopic visualization.

RESULTS

Forty-eight patients with gastrointestinal tuberculosis autopsies were included in our study. Most of the patients were male (n = 35, 72.9%) with a median age of 40.5 years old. Human immunodeficiency virus infection history was reported in 28 cases (58.33%). The most affected gastrointestinal tract site was the terminal ileum. Ulcers and thickened epithelium were common autopsies macroscopic findings. Tuberculosis multiorgan compromise was a relevant finding in patients with gastrointestinal tuberculosis.

CONCLUSIONS

Gastrointestinal tuberculosis is a disease of great importance, being its diagnosis a clinical challenge. Underdiagnosis can be reported in a high percentage of cases, so autopsy diagnosis can help reveal more accurate data about this condition.

Adherence measured using electronic dose monitoring is associated with emergent antiretroviral resistance and poor outcomes in patients co-infected with HIV/AIDS and multidrug-resistant tuberculosis

BACKGROUND

Medication adherence is known to challenge treatment of HIV/AIDS and multidrug-resistant tuberculosis (MDR-TB). We hypothesized that electronic dose adherence monitoring (EDM) would identify an ART adherence threshold for emergent ART resistance and predict treatment outcomes in patients with MDR-TB and HIV on ART and bedaquiline-containing TB regimens.

METHODS

A prospective cohort of adults with MDR-TB and HIV, on ART and initiating MDR-TB treatment with bedaquiline, were enrolled at a public TB referral hospital in KwaZulu-Natal, South Africa (PRAXIS Study, Clinicaltrials.gov NCT03162107). Participants received separate EDM devices measuring adherence to bedaquiline and ART (nevirapine or lopinavir/ritonavir). Adherence was calculated cumulatively over six months. Participants were followed through completion of MDR-TB treatment. HIV genome sequencing was performed at baseline, 2 and 6 months on samples with HIV RNA ≥1000 copies/mL.

FINDINGS

From November 2016 through February 2018, 198 MDR-TB and HIV co-infected participants were enrolled and followed (median 17.2 months, IQR 12.2 - 19.6). Eleven percent had baseline ART resistance mutations, and 7.5% developed emergent ART resistance at 6 months. ART adherence was independently associated with both emergent ART resistance and mortality. Modeling identified a significant (p<0.001), but linear association between ART adherence and emergent resistance, suggesting a strong association without a specific threshold.

INTERPRETATION

Our findings highlight the need for ART resistance testing, especially in MDR-TB HIV co-infected patients, which is currently not standard of care in resource-limited settings. Despite short follow-up duration, reduced ART adherence was significantly associated with emergent resistance and increased mortality.

Delayed HIV treatment, barriers in access to care and mortality in tuberculosis/HIV co-infected patients in Cali, Colombia

OBJECTIVE

To determine factors associated with mortality in tuberculosis/HIV co-infected patients in Cali, Colombia.

METHODS

This retrospective cohort design included tuberculosis/HIV co-infected persons. Kaplan-Meier and Cox regression were used to estimate survival and risk factors associated with mortality.

RESULTS

Of the 279 tuberculosis/HIV co-infected participants, 27.2% died during the study. Participants mainly were adults and males. CD4 count information was available for 41.6% (the median count was 83 cells/mm³), and half were subject to tuberculosis susceptibility testing. The median time between HIV diagnosis and antiretroviral therapy initiation was 372 days. HIV was identified prior to tuberculosis in 53% and concurrent HIV-tuberculosis were diagnosed in 37% of patients. 44.8% had tuberculosis treatment success. Body mass index above 18 kg/m², initiation of tuberculosis treatment within two weeks, having any health insurance coverage and CD4 count information conferred a survival advantage.

CONCLUSIONS

Delays in treatment initiation and factors associated with limited health care access or utilization were associated with mortality. As HIV and tuberculosis are both reportable conditions in Colombia, strategies should be focused on optimizing treatment outcomes within both tuberculosis and HIV programs, particularly improving early HIV diagnosis, early antiretroviral therapy treatment initiation, and adherence to tuberculosis treatment.

Delayed diagnosis of tuberculosis in persons living with HIV in Eastern Europe: associated factors and effect on mortality-a multicentre prospective cohort study

BACKGROUND

Early diagnosis of tuberculosis (TB) is important to reduce transmission, morbidity and mortality in people living with HIV (PLWH).

METHODS

PLWH with a diagnosis of TB were enrolled from HIV and TB clinics in Eastern Europe and followed until 24 months. Delayed diagnosis was defined as duration of TB symptoms (cough, weight-loss or fever) for ≥ 1 month before TB diagnosis. Risk factors for delayed TB diagnosis were assessed using multivariable logistic regression. The effect of delayed diagnosis on mortality was assessed using Kaplan-Meier estimates and Cox models.

FINDINGS

480/740 patients (64.9%; 95% CI 61.3-68.3%) experienced a delayed diagnosis. Age ≥ 50 years (vs. < 50 years, aOR = 2.51; 1.18-5.32; p = 0.016), injecting drug use (IDU) (vs. non-IDU aOR = 1.66; 1.21-2.29; p = 0.002), being ART naïve (aOR = 1.77; 1.24-2.54; p = 0.002), disseminated TB (vs. pulmonary TB, aOR = 1.56, 1.10-2.19, p = 0.012), and presenting with weight loss (vs. no weight loss, aOR = 1.63; 1.18-2.24; p = 0.003) were associated with delayed diagnosis. PLWH with a delayed diagnosis were at 36% increased risk of death (hazard ratio = 1.36; 1.04-1.77; p = 0.023, adjusted hazard ratio 1.27; 0.95-1.70; p = 0.103).

CONCLUSION

Nearly two thirds of PLWH with TB in Eastern Europe had a delayed TB diagnosis, in particular those of older age, people who inject drugs, ART naïve, with disseminated disease, and presenting with weight loss. Patients with delayed TB diagnosis were subsequently at higher risk of death in unadjusted analysis. There is a need for optimisation of the current TB diagnostic cascade and HIV care in PLWH in Eastern Europe.

Improving survival with tuberculosis & HIV treatment integration: A mini-review

Tuberculosis (TB) is a leading cause of morbidity and mortality among HIV-infected patients while HIV remains a key risk factor for the development of active TB infection. Treatment integration is a key in reducing mortality in patients with HIV-TB co-infection. However, this opportunity to improve outcomes of both infections is often missed or poorly implemented. Challenges in TB-HIV treatment integration range from complexities involving clinical management of co-infected patients to obstacles in health service-organization and prioritization. This is evident in high prevalence settings such as in sub-Saharan Africa where TB-HIV co-infection rates reach up to 80 per cent. This review discusses published literature on clinical trials and cohort studies of strategies for TB-HIV treatment integration aimed at reducing co-infection mortality. Studies published since 2009, when several treatment guidelines recommended treatment integration, were included. A total of 43 articles were identified, of which a total of 23 observational studies and nine clinical trials were informative on TB-HIV treatment integration. The data show that the survival benefit of AIDS therapy in patients infected with TB can be maximized among patients with advanced immunosuppression by starting antiretroviral therapy (ART) soon after TB treatment initiation, i.e. in patients with CD4+ cell counts <50 cells/μl. However, patients with greater CD4+ cell counts should defer initiation of ART to no less than eight weeks after initiation of TB treatment to reduce the occurrence and extent of immune reconstitution disease and subsequent hospitalization. Addressing operational challenges in integrating TB-HIV care can significantly improve patient outcomes, generate substantial public health impact by decreasing morbidity and death in settings with a high burden of HIV and TB.

Modeling the causal effect of treatment initiation time on survival: Application to HIV/TB co-infection

The timing of antiretroviral therapy (ART) initiation for HIV and tuberculosis (TB) co-infected patients needs to be considered carefully. CD4 cell count can be used to guide decision making about when to initiate ART. Evidence from recent randomized trials and observational studies generally supports early initiation but does not provide information about effects of initiation time on a continuous scale. In this article, we develop and apply a highly flexible structural proportional hazards model for characterizing the effect of treatment initiation time on a survival distribution. The model can be fitted using a weighted partial likelihood score function. Construction of both the score function and the weights must accommodate censoring of the treatment initiation time, the outcome, or both. The methods are applied to data on 4903 individuals with HIV/TB co-infection, derived from electronic health records in a large HIV care program in Kenya. We use a model formulation that flexibly captures the joint effects of ART initiation time and ART duration using natural cubic splines. The model is used to generate survival curves corresponding to specific treatment initiation times; and to identify optimal times for ART initiation for subgroups defined by CD4 count at time of TB diagnosis. Our findings potentially provide 'higher resolution' information about the relationship between ART timing and mortality, and about the differential effect of ART timing within CD4 subgroups.

Long-term audit of platelet consumption in a university hospital

OBJECTIVES

To determine the long-term trend in platelet consumption in a university hospital.

MATERIALS AND METHODS

The annual consumption of platelets concentrate (PC) was analyzed over 23 years (1985-2007) in King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia.

RESULTS

The total 23 years consumption was 100,466 units of PC. Consumption went through 3 phases: the first, 1985-1994: the annual consumption increased from 1706 to 5912 which coincided with the increase in the number of patient admissions; the second, 1994-2003:featured a remarkable drop (48.9%) in annual consumption while patient admission remained stable. There was a concurrent decline in platelet consumption and all-cause mortality/patient. Third phase: 2003-2007, the consumption increased to reach 5642 units/year in 2007. The Department of Medicine consumed (52%), followed by Pediatrics (21%), and General Surgery (16%).

CONCLUSION

This audit uncovered evidence of inappropriate platelet consumption that reached 48.9% in the period 1994 to 2003, which coincided with widely publicized HIV scare that dominated blood transfusion during that period. We also found evidence suggesting that reducing platelet transfusion could improve patient outcome.

Total Delay Is Associated with Unfavorable Treatment Outcome among Pulmonary Tuberculosis Patients in West Gojjam Zone, Northwest Ethiopia: A Prospective Cohort Study

BACKGROUND

delay in diagnosis and treatment of tuberculosis (TB) may worsen the disease, increase mortality and enhance transmission in the community. This study aimed at assessing the association between total delay and unfavorable treatment outcome among newly diagnosed pulmonary TB (PTB) patients.

METHODS

A prospective cohort study was conducted in West Gojjam Zone, Amhara Region of Ethiopia from October 2013 to May 2015. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study from 30 randomly selected public health facilities. Total delay (the time period from onset of TB symptoms to first start of anti-TB treatment) was measured. Median total delay was calculated. Mixed effect logistics regression was used to analyze factors associated with unfavorable treatment outcome.

RESULTS

Seven hundred six patients were enrolled in the study. The median total delay was 60 days. Patients with total delay of > 60 days were more likely to have unfavorable TB treatment outcome than patients with total delay of ≤ 60 days (adjusted odds ratio [AOR], 2.33; 95% confidence interval [CI], 1.04-5.26). Human immunodeficiency virus (HIV) positive TB patients were 8.46 times more likely to experience unfavorable treatment outcome than HIV negative TB patients (AOR, 8.46; 95% CI, 3.14-22.79).

CONCLUSIONS

Long total delay and TB/HIV coinfection were associated with unfavorable treatment outcome. Targeted interventions that can reduce delay in diagnosis and treatment of TB, and early comprehensive management of TB/HIV coinfection are needed to reduce increased risk of unfavorable treatment outcome.

The Impact and Cost-Effectiveness of a Four-Month Regimen for First-Line Treatment of Active Tuberculosis in South Africa

Background

A 4-month first-line treatment regimen for tuberculosis disease (TB) is expected to have a direct impact on patient outcomes and societal costs, as well as an indirect impact on Mycobacterium tuberculosis transmission. We aimed to estimate this combined impact in a high TB-burden country: South Africa.

Method

An individual based M. tb transmission model was fitted to the TB burden of South Africa using a standard TB natural history framework. We measured the impact on TB burden from 2015–2035 of introduction of a non-inferior 4-month regimen replacing the standard 6-month regimen as first-line therapy. Impact was measured with respect to three separate baselines (Guidelines, Policy and Current), reflecting differences in adherence to TB and HIV treatment guidelines. Further scenario analyses considered the variation in treatment-related parameters and resistance levels. Impact was measured in terms of differences in TB burden and Disability Adjusted Life Years (DALYs) averted. We also examined the highest cost at which the new regimen would be cost-effective for several willingness-to-pay thresholds.

Results

It was estimated that a 4-month regimen would avert less than 1% of the predicted 6 million person years with TB disease in South Africa between 2015 and 2035. A similarly small impact was seen on deaths and DALYs averted. Despite this small impact, with the health systems and patient cost savings from regimen shortening, the 4-month regimen could be cost-effective at $436 [NA, 5983] (mean [range]) per month at a willingness-to-pay threshold of one GDP per capita ($6,618).

Conclusion

The introduction of a non-inferior 4-month first-line TB regimen into South Africa would have little impact on the TB burden. However, under several scenarios, it is likely that the averted societal costs would make such a regimen cost-effective in South Africa.

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

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.

Impact of combination antiretroviral therapy initiation on adherence to antituberculosis treatment

Background

Healthcare workers are often reluctant to start combination antiretroviral therapy (ART) in patients receiving tuberculosis (TB) treatment because of the fear of high pill burden, immune reconstitution inflammatory syndrome, and side-effects.

Object

To quantify changes in adherence to tuberculosis treatment following ART initiation.

Design

A prospective observational cohort study of ART-naïve individuals with baseline CD4 count between 50 cells/mm³ and 350 cells/mm³ at start of TB treatment at a primary care clinic in Johannesburg, South Africa. Adherence to TB treatment was measured by pill count, self-report, and electronic Medication Event Monitoring System (eMEMS) before and after initiation of ART.

Results

ART tended to negatively affect adherence to TB treatment, with an 8% - 10% decrease in the proportion of patients adherent according to pill count and an 18% - 22% decrease in the proportion of patients adherent according to eMEMS in the first month following ART initiation, independent of the cut-off used to define adherence (90%, 95% or 100%). Reasons for non-adherence were multifactorial, and employment was the only predictor for optimal adherence (adjusted odds ratio 4.11, 95% confidence interval 1.06-16.0).

Conclusion

Adherence support in the period immediately following ART initiation could optimise treatment outcomes for people living with TB and HIV.

The Impact of Implementation Fidelity on Mortality Under a CD4-Stratified Timing Strategy for Antiretroviral Therapy in Patients With Tuberculosis

Among patients with tuberculosis and human immunodeficiency virus type 1, CD4-stratified initiation of antiretroviral therapy (ART) is recommended, with earlier ART in those with low CD4 counts. However, the impact of implementation fidelity to this recommendation is unknown. We examined a prospective cohort study of 395 adult patients diagnosed with tuberculosis and human immunodeficiency virus between August 2007 and November 2009 in Kinshasa, Democratic Republic of the Congo. ART was to be initiated after 1 month of tuberculosis treatment at a CD4 count of <100 cells/mm(3) or World Health Organization stage 4 (other than extrapulmonary tuberculosis) and after 2 months of tuberculosis treatment at a CD4 count of 100-350 cells/mm(3). We used the parametric g-formula to estimate the impact of implementation fidelity on 6-month mortality. Observed implementation fidelity was low (46%); 54% of patients either experienced delays in ART initiation or did not initiate ART, which could be avoided under perfect implementation fidelity. The observed mortality risk was 12.0% (95% confidence interval (CI): 8.2, 15.7); under complete (counterfactual) implementation fidelity, the mortality risk was 7.8% (95% CI: 2.4, 12.3), corresponding to a risk reduction of 4.2% (95% CI: 0.3, 8.1) and a preventable fraction of 35.1% (95% CI: 2.9, 67.9). Strategies to achieve high implementation fidelity to CD4-stratified ART timing are needed to maximize survival benefit.

Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection

SETTING

Five primary health care clinics in Kinshasa, Democratic Republic of Congo.

OBJECTIVE

To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment.

DESIGN

Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm(3) or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100-350 cells/mm(3), or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤ 350 cells/mm(3) or patient has WHO Clinical Stage 4.

RESULTS

Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm(3)), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and non-disclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation.

CONCLUSION

Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.

The impact of antiretroviral therapy on mortality in HIV positive people during tuberculosis treatment: a systematic review and meta-analysis

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.

Retention and risk factors for attrition in a large public health ART program in Myanmar: a retrospective cohort analysis

Background

The outcomes from an antiretroviral treatment (ART) program within the public sector in Myanmar have not been reported. This study documents retention and the risk factors for attrition in a large ART public health program in Myanmar.

Methods

A retrospective analysis of a cohort of adult patients enrolled in the Integrated HIV Care (IHC) Program between June 2005 and October 2011 and followed up until April 2012 is presented. The primary outcome was attrition (death or loss-follow up); a total of 10,223 patients were included in the 5-year cumulative survival analysis. Overall 5,718 patients were analyzed for the risk factors for attrition using both logistic regression and flexible parametric survival models.

Result

The mean age was 36 years, 61% of patients were male, and the median follow up was 13.7 months. Overall 8,564 (84%) patients were retained in ART program: 750 (7%) were lost to follow-up and 909 (9%) died. During the 3 years follow-up, 1,542 attritions occurred over 17,524 person years at risk, giving an incidence density of 8.8% per year. The retention rates of participants at 12, 24, 36, 48 and 60 months were 86, 82, 80, 77 and 74% respectively. In multivariate analysis, being male, having high WHO staging, a low CD4 count, being anaemic or having low BMI at baseline were independent risk factors for attrition; tuberculosis (TB) treatment at ART initiation, a prior ART course before program enrollment and literacy were predictors for retention in the program.

Conclusion

High retention rate of IHC program was documented within the public sector in Myanmar. Early diagnosis of HIV, nutritional support, proper investigation and treatment for patients with low CD4 counts and for those presenting with anaemia are crucial issues towards improvement of HIV program outcomes in resource-limited settings.

Clinical and immunologic predictors of death after an acute opportunistic infection: results from ACTG A5164

BACKGROUND

In the pre-antiretroviral therapy (ART) era, markers of increased disease severity during an acute opportunistic infection (OI) were associated with mortality. Even with ART, mortality remains high during the first year after an OI in persons with advanced HIV infection, but it is unclear whether previous predictors of mortality remain valid in the current era.

OBJECTIVE

To determine clinical and immunological predictors of death after an OI.

METHODS

We used clinical data and stored plasma from ACTG A5164, a multicenter study evaluating the optimal timing of ART during a nontuberculous OI. We developed Cox models evaluating associations between clinical parameters and plasma marker levels at entry and time to death over the first 48 weeks after the diagnosis of OI. We developed multivariable models incorporating only clinical parameters, only plasma marker levels, or both.

RESULTS

The median CD4+ T-cell count in study participants at baseline was 29 cells/µL. Sixty-four percent of subjects had Pneumocystis jirovecii pneumonia (PCP). Twenty-three of 282 (8.2%) subjects died. In univariate analyses, entry mycobacterial infection, OI number, hospitalization, low albumin, low hemoglobin, lower CD4, and higher IL-8 and sTNFrII levels and lower IL-17 levels were associated with mortality. In the combined model using both clinical and immunologic parameters, the presence of an entry mycobacterial infection and higher sTNFrII levels were significantly associated with death.

CONCLUSIONS

In the ART era, clinical risk factors for death previously identified in the pre-ART era remain predictive. Additionally, activation of the innate immune system is associated with an increased risk of death following an acute OI.

The impact of HAART initiation timing on HIV-TB co-infected patients, a retrospective cohort study

BACKGROUND

Optimal timing for initiating highly active antiretroviral therapy (HAART) in HIV-TB coinfected patients is challenging for clinicians. We aim to evaluate the impact of different timing of HAART initiation on TB outcome of HIV-infected adults in Taiwan.

METHODS

A population-based retrospective cohort study was conducted through linking the HIV and TB registries of Taiwan Centers for Disease Control (CDC) during 1997 to 2006. Clinical data of HIV-TB co-infected patients, including the presence of immune reconstitution inflammatory syndrome (IRIS), was collected through medical records review. The outcome of interest was all-cause mortality within 1 year following TB diagnosis. The Cox proportional hazard model was used to explore the probability of death and IRIS after TB diagnosis by adjusting for confounding factors and factors of interest. The probability of survival and TB IRIS were calculated by the Kaplan-Meier method and compared between different HAART initiation timing groups by the log-rank test.

RESULTS

There were 229 HIV-TB co-infected patients included for analysis and 60 cases (26.2%) died within one year. Besides decreasing age and increasing CD4 lymphocyte count, having started HAART during TB treatment was significantly associated with better survival (adjusted Hazard Ratio was 0.11, 95% CI 0.06-0.21). As to the timing of HAART initiation, there was only non-significant benefit on survival among cases initiating HAART within 15 days, at 16-30 days and at 31-60 days of TB treatment than initiating after 60 days. Cases with HAART initiated after 30 days had lower risk in developing IRIS than cases with HAART initiated earlier. Cases with IRIS had significantly higher rate of re-hospitalization (49% vs. 4%, p < 0.001) and prolonged hospitalization (28 days vs. 18.5 days, p < 0.01).

CONCLUSION

The present study found that starting HAART during TB treatment is associated with better one-year survival, although earlier initiation within 60 days of TB treatment did not show statistical differences in survival than later initiation. Initiation of HAART within 30 days appeared to increase the risk of IRIS. Deferring HAART to 31-60 days of TB treatment might be optimal after considering the risks and benefits.

Timely HIV diagnosis and HIV/TB comanagement among California patients in 2008

OBJECTIVE

National guidelines highlight the roles of early HIV diagnosis and effective comanagement for HIV and tuberculosis (TB) to prevent mortality and morbidity from HIV-related TB. We assessed HIV diagnosis timing and HIV/TB comanagement for California HIV/TB patients.

METHODS

We reviewed and analyzed public health charts for California HIV/TB patients reported during 2008. HIV diagnoses fewer than three months before TB diagnosis were considered new HIV diagnoses. We determined the proportion of patients with new HIV diagnoses, risk factors for new HIV diagnoses, and proportion of patients receiving recommended CD4 cell count measurements, supervised TB therapy, and antiretroviral therapy (ART).

RESULTS

Of 130 HIV/TB patients, 51% had new HIV diagnoses. Foreign-born patients were more likely than U.S.-born patients to have new HIV diagnoses. Supervised TB therapy and CD4 cell count measurements followed national recommendations for 91% and 74% of patients, respectively. At least 73% of patients started ART before completing TB therapy. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses started ART later and had lower CD4 cell counts and higher viral loads at TB diagnosis.

CONCLUSIONS

Although most HIV/TB patients received the recommended treatment, half had new HIV diagnoses. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses had greater immunosuppression at TB diagnosis. A new diagnosis indicates that HIV could have been diagnosed earlier and ART or treatment for latent TB infection could have been initiated to prevent TB development.

Nevirapine versus efavirenz-based antiretroviral therapy regimens in antiretroviral-naive patients with HIV and tuberculosis infections in India: a pilot study

Background

Administration of rifampicin along with nevirapine reduces the plasma concentration of nevirapine in human immunodeficiency virus positive individuals with concomitant tuberculosis (HIV-TB patients). Nevirapine is a much cheaper drug than its alternative efavirenz, and might be beneficial in resource constrained settings.

Methods

A randomised open label trial was conducted at All India Institute of Medical Sciences, New Delhi, India. During the regimen of an antiretroviral therapy (ART), naive HIV-TB patients were randomly assigned to receive either nevirapine or efavirenz based ART with concomitant rifampicin based anti-tubercular therapy (ATT). Participants were followed for 24 months after starting ART. The end points were virological, immunological and clinical responses, and progression of HIV disease marked by failure of ART.

Results

Of the 135 HIV-TB patients, who were receiving rifampicin based ATT, 68 were selected randomly to receive efavirenz based ART and 67 to receive nevirapine based ART. The virological failure rates in the overall population, and the nevirapine and efavirenz groups were 14.1% (19/135); 14.9% (10/67) and 13.2% (9/68), respectively (p = 0.94). No significant difference was found between the groups in the rate of clinical, immunological or virological failures. The overall mortality was 17% with no significant difference between the two groups. Except for the lead in period on day 14, the mean nevirapine concentration remained above 3 mg/L. No association was found between plasma levels of nevirapine and incidence of unfavourable outcomes in this group.

Conclusions

Outcome of ART in HIV-TB patients on rifampicin based ATT showed no significant difference, irrespective of whether efavirenz or nevirapine was used. Therefore, nevirapine based ART could be an alternative in the resource limited settings in patients with HIV and tuberculosis co-infection.

Trial registration

NCT No. 01805258.

Predictors of death during tuberculosis treatment in TB/HIV co-infected patients in Malaysia

Background

Mortality among TB/HIV co-infected patients is still high particularly in developing countries. This study aimed to determine the predictors of death in TB/HIV co-infected patients during TB treatment.

Methods

We reviewed medical records at the time of TB diagnosis and subsequent follow-up of all newly registered TB patients with HIV co-infection at TB clinics in the Institute of Respiratory Medicine and three public hospitals in the Klang Valley between January 2010 and September 2010. We reviewed these medical records again twelve months after their initial diagnosis to determine treatment outcomes and survival. We analysed using Kaplan-Meier and conducted multivariate Cox proportional hazards analysis to identify predictors of death during TB treatment in TB/HIV co-infected patients.

Results

Of the 227 patients studied, 53 (23.3%) had died at the end of the study with 40% of deaths within two months of TB diagnosis. Survival at 2, 6 and 12 months after initiating TB treatment were 90.7%, 82.8% and 78.8% respectively. After adjusting for other factors, death in TB/HIV co-infected patients was associated with being Malay (aHR 4.48; 95%CI 1.73-11.64), CD4 T-lymphocytes count < 200 cells/µl (aHR 3.89; 95% CI 1.20-12.63), three or more opportunistic infections (aHR 3.61; 95% CI 1.04-12.55), not receiving antiretroviral therapy (aHR 3.21; 95% CI 1.76-5.85) and increase per 10³ total white blood cell count per microliter (aHR 1.12; 95% CI 1.05-1.20)

Conclusion

TB/HIV co-infected patients had a high case fatality rate during TB treatment. Initiation of antiretroviral therapy in these patients can improve survival by restoring immune function and preventing opportunistic infections.

Predictors of mortality among TB-HIV Co-infected patients being treated for tuberculosis in Northwest Ethiopia: a retrospective cohort study

BACKGROUND

Tuberculosis (TB) is the leading cause of mortality in high HIV-prevalence populations. HIV is driving the TB epidemic in many countries, especially those in sub-Saharan Africa. The aim of this study was to assess predictors of mortality among TB-HIV co-infected patients being treated for TB in Northwest Ethiopia.

METHODS

An institution-based retrospective cohort study was conducted between April, 2009 and January, 2012. Based on TB, antiretroviral therapy (ART), and pre-ART registration records, TB-HIV co-infected patients were categorized into "On ART" and "Non-ART" cohorts. A Chi-square test and a T-test were used to compare categorical and continuous variables between the two groups, respectively. A Kaplan-Meier test was used to estimate the probability of death after TB diagnosis. A log-rank test was used to compare overall mortality between the two groups. A Cox proportional hazard model was used to determine factors associated with death after TB diagnosis.

RESULTS

A total of 422 TB-HIV co-infected patients (i.e., 272 On ART and 150 Non-ART patients) were included for a median of 197 days. The inter-quartile range (IQR) for On ART patients was 140 to 221 days and the IQR for Non-ART patients was 65.5 to 209.5 days. In the Non-ART cohort, more TB-HIV co-infected patients died during TB treatment: 44 (29.3%) Non-ART patients died, as compared to 49 (18%) On ART patients died. Independent predictors of mortality during TB treatment included: receiving ART (Adjusted Hazard Ratio (AHR) =0.35 [0.19-0.64]); not having initiated cotrimoxazole prophylactic therapy (CPT) (AHR = 3.03 [1.58-5.79]); being ambulatory (AHR = 2.10 [1.22-3.62]); CD4 counts category being 0-75 cells/micro liter, 75-150 cells/micro liter, or 150-250 cells/micro liter (AHR = 4.83 [1.98-11.77], 3.57 [1.48-8.61], and 3.07 [1.33-7.07], respectively); and treatment in a hospital (AHR = 2.64 [1.51-4.62]).

CONCLUSIONS

Despite the availability of free ART from health institutions in Northwest Ethiopia, mortality was high among TB-HIV co-infected patients, and strongly associated with the absence of ART during TB treatment. In addition cotrimoxazol prophylactic therapy remained important factor in reduction of mortality during TB treatment. The study also noted importance of early ART even at higher CD4 counts.

Anti-tuberculosis drug induced hepatotoxicity among TB/HIV co-infected patients at Jimma University Hospital, Ethiopia: nested case-control study

BACKGROUND

This study was carried out to determine the incidence and predictors of anti-tuberculosis drug induced hepatotoxicity among TB/HIV co-infected patients at Jimma University Hospital, Ethiopia.

METHODS/PRINCIPAL FINDINGS

A nested case-control study was conducted by reviewing charts of all TB/HIV co-infected patients who commenced anti-TB treatment from January 2008 to December 2011 at Jimma University Hospital. Patients who had developed hepatotoxicity after at least 5 days of standard doses of anti-TB drug therapy were labeled as "cases" and those without hepatotoxicity were "controls". Each case with anti-TB drug induced hepatotoxicity was compared with 3 controls selected randomly from the cohort. From a cohort of 296 TB/HIV co-infected patients 8 were excluded from the study as the causality between anti-TB drugs and hepatotoxicity was not confirmed, 33 had developed hepatotoxicity. On bivariate logistic regression analysis, body mass index (BMI) <18.5 Kg/m(2) [P = 0.01; OR (95%CI): 3.6 (1.4-9.5)], disseminated pulmonary TB [P = 0.00; OR (95%CI): 5.6 (2.2-14.6)], CD4 count ≤50 [P = 0.016; OR (95%CI): 3.6(1.27-10.23)] and WHO stage 4 [P = 0.004, OR (95%CI): 3.8 (1.68-8.77)] were significantly associated with anti-TB drug induced hepatotoxicity. Predictor variables with p-value <0.05 by bivariate analysis were analyzed using multivariable logistic regression analysis and identified disseminated pulmonary TB [P = 0.001; AOR (95%CI) = 5.6 (2.1-15.0)] and BMI <18.5 [P = 0.014; AOR (95%CI)= 3.6 (1.3-10.1)] as independent predictors of anti-TB drug induced hepatotoxicity.

CONCLUSIONS

The incidence of anti-TB drug induced hepatotoxicity was 11.5%. The results suggest that in the presence of disseminated pulmonary TB and/or BMI <18.5 Kg/m(2), TB/HIV co-infected patients should be closely followed for the occurrence of hepatotoxicity during the intensive phase of TB treatment to prevent morbidity and mortality.

Treatment outcomes of patients co-infected with tuberculosis and HIV at Chiang Mai University Hospital, Thailand

Thailand has been greatly affected by the tuberculosis (TB) and HIV syndemic. This study aimed to determine treatment outcomes among HIV/TB co-infected patients. A retrospective cohort study was conducted at Chiang Mai University Hospital from 1 January 2000 to 31 December 2009. Of 171 patients, 100 patients were male (58.5%) and the mean age was 36.8 ± 8.0 years. Seventy-two patients (42.1%) had pulmonary tuberculosis. Median CD4+ count before TB treatment was 69 cells/mm(3) (interquartile range [IQR] 33, 151). The overall mortality was 3.5% (6 patients). Immune reconstitution inflammatory syndrome (IRIS) occurred in eight patients (6.0%). Disseminated TB infections increased risk of death (odds ratio [OR] = 2.55, 95% confidence interval [CI] 1.25, 5.18) and IRIS (OR = 9.16, 95% CI 1.67, 50.07). Initiating combination antiretroviral therapy (cART) within two months after TB treatment increased risk of IRIS (OR = 6.57, 95% CI 1.61-26.86) and physicians caring for HIV/TB co-infected patients should be aware of this condition.

Determinants of unsuccessful tuberculosis treatment outcomes in Malaysian HIV-infected patients

OBJECTIVES

To determine predictors of unsuccessful treatment in HIV-infected tuberculosis (TB) patients.

METHODS

We reviewed medical records at the time of TB diagnosis and subsequent follow-up of all registered TB patients with HIV co-infection at TB clinics in the Institute of Respiratory Medicine and three public hospitals in Malaysia between January 2010 and September 2010. We reviewed these medical records again twelve months after their initial diagnosis to determine treatment outcomes. Multiple logistic regression was conducted to identify risk factors for unsuccessful TB treatment.

RESULTS

Among the 219 patients analyzed, 53.4% achieved successful outcomes (cure, completed treatment) while 46.6% of patients had unsuccessful outcomes (default, treatment failure, died). After adjusting for other factors, unsuccessful outcome was associated with intravenous drug use (OR 2.72; 95% CI 1.44-5.16), not receiving antiretroviral therapy (OR 5.10; 95% CI 2.69-9.69), lymphadenopathy (OR 2.01; 95% CI 1.09-3.72) and low serum albumin (OR 4.61; 95% CI 1.73-12.27).

CONCLUSION

Anti-retroviral treatment must be provided to all HIV-infected tuberculosis patients. Good immune and nutritional status needs to be assured in all HIV-infected tuberculosis patients. More studies are required in intravenous drug users to understand why tuberculosis treatment outcomes are poor in this group.

Use of anti-retroviral therapy in tuberculosis patients on second-line anti-TB regimens: a systematic review

INTRODUCTION

Use of antiretroviral therapy (ART) during treatment of drug susceptible tuberculosis (TB) improves survival. However, data from HIV infected individuals with drug resistant TB are lacking. Second line TB drugs when combined with ART may increase drug interactions and lead to higher rates of toxicity and greater noncompliance. This systematic review sought to determine the benefit of ART in the setting of second line drug therapy for drug resistant TB.

METHODS

We included individual patient data from studies that evaluated treatment of drug-resistant tuberculosis in HIV-1 infected individuals published between January 1980 and December of 2009. We evaluated the effect of ART on treatment outcomes, time to smear and culture conversion, and adverse events.

RESULTS

Ten observational studies, including data from 217 subjects, were analyzed. Patients using ART during TB treatment had increased likelihood of cure (hazard ratio (HR) 3.4, 95% CI 1.6-7.4) and decreased likelihood of death (HR 0.4, 95% CI 0.3-0.6) during treatment for drug resistant TB. These associations remained significant in patients with a CD4 less than 200 cells/mm(3) and less than 50 cells/mm(3), and when correcting for drug resistance pattern.

LIMITATIONS

We identified only observational studies from which individual patient data could be drawn. Limitations in study design, and heterogeneity in a number of the outcomes of interest had the potential to introduce bias.

DISCUSSION

While there are insufficient data to determine if ART use increases adverse drug interactions when used with second line TB drugs, ART use during treatment of drug resistant TB appears to improve cure rates and decrease risk of death. All individuals with HIV appear to benefit from ART use during treatment for TB.

The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study

BACKGROUND

Studies have shown that early ART initiation in TB/HIV co-infected patients lowers mortality. One way to implement earlier ART commencement could be through integration of TB and HIV services, a more efficient model of care than separate, vertical programs. We present a model of full TB/HIV integration and estimate its effect on time to initiation of ART.

METHODOLOGY/PRINCIPAL FINDINGS

We retrospectively reviewed TB registers and clinical notes of 209 TB/HIV co-infected adults with a CD4 count <250 cells/µl and registered for TB treatment at one primary care clinic in a South African township between June 2008 and May 2009. Using Kaplan-Meier and Cox proportional hazard analysis, we compared time between initiation of TB treatment and ART for the periods before and after full, "one-stop shop" integration of TB and HIV services (in December 2009). Potential confounders were determined a priori through directed acyclic graphs. Robustness of assumptions was investigated by sensitivity analyses. The analysis included 188 patients (100 pre- and 88 post-integration), yielding 56 person-years of observation. Baseline characteristics of the two groups were similar. Median time to ART initiation decreased from 147 days (95% confidence interval [CI] 85-188) before integration of services to 75 days (95% CI 52-119) post-integration. In adjusted analyses, patients attending the clinic post-integration were 1.60 times (95% CI 1.11-2.29) more likely to have started ART relative to the pre-integration period. Sensitivity analyses supported these findings.

CONCLUSIONS/SIGNIFICANCE

Full TB/HIV care integration is feasible and led to a 60% increased chance of co-infected patients starting ART, while reducing time to ART initiation by an average of 72 days. Although these estimates should be confirmed through larger studies, they suggest that scale-up of full TB/HIV service integration in high TB/HIV prevalence settings may shorten time to ART initiation, which might reduce excess mortality and morbidity.

Causes of mortality among tuberculosis and HIV co-infected patients in Chiang Rai, Northern Thailand

BACKGROUND

The case fatality rate in patients with tuberculosis (TB) associated with human immunodeficiency virus (HIV) has been particularly high in Chiang Rai, Northern Thailand. It was almost 50% before the introduction of antiretroviral therapy in the last decade, and was still at 28% in 2008, despite expanding access to antiretroviral therapy. Reviewing the causes of death may lead to further understanding of the timeline and natural history of TB-HIV coinfection, and in so doing help to devise an effective prevention strategy in Chiang Rai. In this study, we aimed to investigate the distribution of confirmed causes of death in patients coinfected with TB and HIV in Chiang Rai, describe the causes of such deaths along the timeline of TB treatment, and identify predictors of each cause of death.

METHODS

In this retrospective study, we reviewed the causes of death for 331 patients who died of TB-HIV coinfection at Chiang Rai Prachanukroh Hospital from 2005 to 2008. Causes of death were confirmed by reviewing medical records, vital registration, and the TB register in the province, as well as obtaining reconfirmation by two experienced HIV physicians.

RESULTS

The confirmed causes of death were TB (39%), acquired immune deficiency syndrome (AIDS)-related opportunistic infections other than TB (AOI) (29%), and other systemic diseases which were neither TB nor AIDS-related opportunistic infections (nonTB-nonAOI) (16%). The definitive cause could not be confirmed in the remaining 16% of deaths. After starting the TB treatment, deaths caused by TB occurred earlier compared with deaths caused by AOI, which occurred steadily throughout the course of TB treatment, whilst deaths caused by non-TB-nonAOI increased gradually in later months. Further analysis by multivariate multinomial regression analysis showed that deaths in the first month (adjusted odds ratio [aOR] 4.64, 95% confidence interval [CI] 2.49-8.63), CD4 count ≥ 200 cells/mm(3) (aOR 5.33, CI 1.05-26.10), non-category 1 TB treatment regimens (aOR 5.23, CI 1.04-9.77), and TB meningitis (aOR 3.27, CI 1.37-7.82) were significant predictors of confirmed TB deaths. Moreover, age over 45 years (aOR 3, CI 1.32-6.84) and admission as an inpatient were predictors of death caused by neither TB nor AIDS-related opportunistic infections (aOR 3.08, CI 1.39-6.80). Additional analysis showed that non-Thai patients (aOR 0.35, CI 0.12-0.99), those with an unknown CD4 count at TB diagnosis (aOR 0.16, CI 0.08-0.33), and those without an HIV diagnosis before TB treatment (aOR 0.32, CI 0.18-0.59) were less able to access antiretroviral therapy.

CONCLUSION

The timeline and predictors of causes of death may assist in devising an intervention strategy for further reduction of the TB-HIV case fatality rate.

Factors associated with survival among adults with HIV-associated TB in Guangxi, China: a retrospective cohort study

Aim: Although China has the second highest burden of TB in the world and faces a burgeoning HIV epidemic, the epidemiology and 12-month clinical outcomes of HIV-infected TB patients have not previously been reported. Methods: We reviewed records of all HIV-infected adults diagnosed with culture-confirmed TB from four HIV clinics in Guangxi, China from August 2006 to December 2008. Factors associated with patients’ survival within 12 months after TB diagnosis were evaluated in Cox proportional hazards models. Results: Among the 201 patients included, 47 (23%) died within 12 months. Median CD4 count at TB diagnosis was 37 cells/mm3 (interquartile range: 16–102). Receiving HAART (adjusted hazard ratio [AHR]: 4.2; 95% CI: 1.6–10.8), receiving TB treatment (AHR: 9.0; 95% CI: 1.5–53.5) and baseline BMI ≥ 18.5 (AHR: 8.4; 95% CI: 1.9–35.8) were independently associated with survival. Among 171 (85%) patients who received TB treatment, receiving HAART (HR: 5.1; 95% CI: 2.4–10.7) was the only factor significantly associated with survival. Conclusion: HIV-infected Chinese patients diagnosed with TB in Guangxi are at high risk of death within 12 months, a risk that is strongly mitigated by antiretroviral therapy. Improving survival from HIV-associated TB in China will require the integration of TB and HIV programs to improve access to treatment for both diseases.

Assessment at antiretroviral clinics during TB treatment reduces loss to follow-up among HIV-infected patients

SETTING

A South African township clinic where loss to follow-up during TB treatment may prevent HIV-infected TB patients from receiving life-saving ART.

OBJECTIVE

To determine factors associated with loss to follow-up during TB treatment.

DESIGN

Regression analyses of a cohort of ART-eligible TB patients who commenced TB treatment and were followed for 24 weeks.

RESULTS

Of 111 ART-eligible TB patients, 15 (14%) died in the ensuing 24 weeks. Of the remaining 96 TB patients, 11 (11%) were lost to follow-up. All TB patients lost to follow-up did not initiate ART. Of 85 TB patients in follow-up, 62 (73%) initiated ART 56 days after TB diagnosis (median, IQR 33-77 days) and 31 days after initial assessment at an ART clinic (median, IQR: 18-55 days). The median duration from TB diagnosis to initial assessment at an ART clinic was 19 days (IQR: 7-48 days). At 24 weeks, 6 of 85 (7%) TB patients who presented to an ART clinic for assessment were lost to follow-up, compared to 5 of 11 (45%) TB patients who did not present to an ART clinic for assessment. Logistic regression analysis (adjusted odds ratio = 0.1, 95% confidence interval [95% CI]: 0.03-0.66) and our Cox proportional hazards model (hazard ratio = 0.2, 95% CI: 0.04-0.68) confirmed that assessment at an ART clinic during TB treatment reduced loss to follow-up.

CONCLUSION

Assessment at antiretroviral clinics for HIV care by trained health-care providers reduces loss to follow-up among HIV-infected patients with TB.

Antiretroviral treatment as prevention: impact of the 'test and treat' strategy on the tuberculosis epidemic

Antiretroviral therapy (ART) has been remarkably effective in ameliorating Human Immunodeficiency Virus (HIV)-associated morbidity and mortality. The rapid decline in viral load during ART also presents an opportunity to develop a “treatment as prevention” strategy in order to reduce HIV transmission at a population level. Modelling exercises have demonstrated that for this strategy to be effective, early initiation of ART with high coverage of the HIV-infected population will be required. The HIV epidemic has fueled a resurgence of tuberculosis (TB) particularly in sub-Saharan Africa and widespread early initiation of ART could also impact this epidemic via several mechanisms. The proportion of patients with low CD4 cell counts who are at high risk of TB disease from progression of both latent and new TB infection would be greatly reduced. Entry into a life-long ART program provides an ongoing opportunity for intensified TB case finding among the HIV-infected population. Regular screening for HIV infection also presents an opportunity for intensified TB case finding in the general population. The combined effect of reduced progression of infection to disease and intensified case finding could reduce the overall prevalence of infectious TB, thereby further decreasing TB transmission. In addition, decreasing prevalence of HIV infection would reduce the TB-susceptible pool within the population. The ‘test and treat’ strategy therefore has potential to reduce the TB risk at both an individual and a population level. In this paper we explore the expected “TB dividend” of wider access to ART and also explore the potential of the “test and treat” strategy to impact on TB transmission, particularly in the heavily burdened setting of sub-Saharan Africa.

Health related quality of life among patients with tuberculosis and HIV in Thailand

Introduction

Health utilities of tuberculosis (TB) patients may be diminished by side effects from medication, prolonged treatment duration, physical effects of the disease itself, and social stigma attached to the disease.

Methods

We collected health utility data from Thai patients who were on TB treatment or had been successfully treated for TB for the purpose of economic modeling. Structured questionnaire and EuroQol (EQ-5D) and EuroQol visual analog scale (EQ-VAS) instruments were used as data collection tools. We compared utility of patients with two co-morbidities calculated using multiplicative model (U_CAL) with the direct measures and fitted Tobit regression models to examine factors predictive of health utility and to assess difference in health utilities of patients in various medical conditions.

Results

Of 222 patients analyzed, 138 (62%) were male; median age at enrollment was 40 years (interquartile range [IQR], 35–47). Median monthly household income was 6,000 Baht (187 US$; IQR, 4,000–15,000 Baht [125–469 US$]). Concordance correlation coefficient between utilities measured using EQ-5D and EQ-VAS (U_EQ-5D and U_VAS, respectively) was 0.6. U_CAL for HIV-infected TB patients was statistically different from the measured U_EQ-5D (p-value<0.01) and U_VAS (p-value<0.01). In tobit regression analysis, factors independently predictive of U_EQ-5D included age and monthly household income. Patients aged ≥40 years old rated U_EQ-5D significantly lower than younger persons. Higher U_EQ-5D was significantly associated with higher monthly household income in a dose response fashion. The median U_EQ-5D was highest among patients who had been successfully treated for TB and lowest among multi-drug resistant TB (MDR-TB) patients who were on treatment.

Conclusions

U_CAL of patients with two co-morbidities overestimated the measured utilities, warranting further research of how best to estimate utilities of patients with such conditions. TB and MDR-TB treatments impacted on patients' self perceived health status. This effect diminished after successful treatment.

Efficacy and safety of once-daily nevirapine- or efavirenz-based antiretroviral therapy in HIV-associated tuberculosis: a randomized clinical trial

BACKGROUND

Nevirapine (NVP) can be safely and effectively administered once-daily but has not been assessed in human immunodeficiency virus (HIV)-infected patients with tuberculosis (TB). We studied the safety and efficacy of once-daily NVP, compared with efavirenz (EFV; standard therapy); both drugs were administered in combination with 2 nucleoside reverse-transcriptase inhibitors.

METHODS

An open-label, noninferiority, randomized controlled clinical trial was conducted at 3 sites in southern India. HIV-infected patients with TB were treated with a standard short-course anti-TB regimen (2EHRZ(3)/4RH(3); [2 months of Ethambutol, Isoniazid, Rifampicin, Pyrazinamide / 4 months of Isoniazid and Rifampicin] thrice weekly) and randomized to receive once-daily EFV at a dose of 600 mg or NVP at a dose of 400 mg (after 14 days of 200 mg administered once daily) with didanosine 250/400 mg and lamivudine 300 mg after 2 months. Sputum smears and mycobacterial cultures were performed every month. CD4+ cell count, viral load, and liver function test results were monitored periodically. Primary outcome was a composite of death, virological failure, default, or serious adverse event (SAE) at 24 weeks. Both intent-to-treat and per protocol analyses were done, and planned interim analyses were performed.

RESULTS

A total of 116 patients (75% [87 patients] of whom had pulmonary TB), with a mean age of 36 years, a median CD4+ cell count of 84 cells/mm(3), and a median viral load of 310 000 copies/mL, were randomized. At 24 weeks, 50 of 59 patients in the EFV group and 37 of 57 patients in the NVP group had virological suppression (P = .024). There were no deaths, 1 SAE, and 5 treatment failures in the EFV arm, compared with 5 deaths, 2 SAEs, and 10 treatment failures in the NVP arm. The trial was halted by the data and safety monitoring board at the second interim analysis. Favorable TB treatment outcomes were observed in 93% of the patients in the EFV arm and 84% of the patients in the NVP arm (P = .058).

CONCLUSIONS

Compared with a regimen of didanosine, lamivudine, and EFV, a regimen of once-daily didanosine, lamivudine, and NVP was inferior and was associated with more frequent virologic failure and death. Clinical Trials Registration. NCT00332306.

Rapid diagnosis of tuberculosis with the Xpert MTB/RIF assay in high burden countries: a cost-effectiveness analysis

BACKGROUND

Xpert MTB/RIF (Xpert) is a promising new rapid diagnostic technology for tuberculosis (TB) that has characteristics that suggest large-scale roll-out. However, because the test is expensive, there are concerns among TB program managers and policy makers regarding its affordability for low- and middle-income settings.

METHODS AND FINDINGS

We estimate the impact of the introduction of Xpert on the costs and cost-effectiveness of TB care using decision analytic modelling, comparing the introduction of Xpert to a base case of smear microscopy and clinical diagnosis in India, South Africa, and Uganda. The introduction of Xpert increases TB case finding in all three settings; from 72%-85% to 95%-99% of the cohort of individuals with suspected TB, compared to the base case. Diagnostic costs (including the costs of testing all individuals with suspected TB) also increase: from US$28-US$49 to US$133-US$146 and US$137-US$151 per TB case detected when Xpert is used "in addition to" and "as a replacement of" smear microscopy, respectively. The incremental cost effectiveness ratios (ICERs) for using Xpert "in addition to" smear microscopy, compared to the base case, range from US$41-$110 per disability adjusted life year (DALY) averted. Likewise the ICERS for using Xpert "as a replacement of" smear microscopy range from US$52-$138 per DALY averted. These ICERs are below the World Health Organization (WHO) willingness to pay threshold.

CONCLUSIONS

Our results suggest that Xpert is a cost-effective method of TB diagnosis, compared to a base case of smear microscopy and clinical diagnosis of smear-negative TB in low- and middle-income settings where, with its ability to substantially increase case finding, it has important potential for improving TB diagnosis and control. The extent of cost-effectiveness gain to TB programmes from deploying Xpert is primarily dependent on current TB diagnostic practices. Further work is required during scale-up to validate these findings.

Earlier versus later start of antiretroviral therapy in HIV-infected adults with tuberculosis

BACKGROUND

Tuberculosis remains an important cause of death among patients infected with the human immunodeficiency virus (HIV). Robust data are lacking with regard to the timing for the initiation of antiretroviral therapy (ART) in relation to the start of antituberculosis therapy.

METHODS

We tested the hypothesis that the timing of ART initiation would significantly affect mortality among adults not previously exposed to antiretroviral drugs who had newly diagnosed tuberculosis and CD4+ T-cell counts of 200 per cubic millimeter or lower. After beginning the standard, 6-month treatment for tuberculosis, patients were randomly assigned to either earlier treatment (2 weeks after beginning tuberculosis treatment) or later treatment (8 weeks after) with stavudine, lamivudine, and efavirenz. The primary end point was survival.

RESULTS

A total of 661 patients were enrolled and were followed for a median of 25 months. The median CD4+ T-cell count was 25 per cubic millimeter, and the median viral load was 5.64 log(10) copies per milliliter. The risk of death was significantly reduced in the group that received ART earlier, with 59 deaths among 332 patients (18%), as compared with 90 deaths among 329 patients (27%) in the later-ART group (hazard ratio, 0.62; 95% confidence interval [CI]; 0.44 to 0.86; P=0.006). The risk of tuberculosis-associated immune reconstitution inflammatory syndrome was significantly increased in the earlier-ART group (hazard ratio, 2.51; 95% CI, 1.78 to 3.59; P<0.001). Irrespective of the study group, the median gain in the CD4+ T-cell count was 114 per cubic millimeter, and the viral load was undetectable at week 50 in 96.5% of the patients.

CONCLUSIONS

Initiating ART 2 weeks after the start of tuberculosis treatment significantly improved survival among HIV-infected adults with CD4+ T-cell counts of 200 per cubic millimeter or lower. (Funded by the French National Agency for Research on AIDS and Viral Hepatitis and the National Institutes of Health; CAMELIA ClinicalTrials.gov number, NCT01300481.).

Integrated surveillance of HIV care in low-income and middle-income countries

PURPOSE OF REVIEW

HIV care should be seen as a continuum of health interventions that starts from HIV testing and counselling and ends with life-long provision of antiretroviral therapy (ART). All the interventions should be monitored with appropriate methods and indicators to constitute an integrated surveillance system of HIV care. This review outlines the different elements of this comprehensive surveillance, highlighting their public health importance.

RECENT FINDINGS

Data on HIV care programmes in developing countries are generally fragmented and weak, focusing primarily on outcomes of patients on ART. A global scale-up of ART should be accompanied by robust programmatic assessment of the whole spectrum of HIV care components, which include monitoring pre-ART and ART programmatic elements, routine surveillance of HIV drug resistance, pharmacovigilance and appropriate surveillance of HIV-related mortality.

SUMMARY

Comprehensive surveillance of HIV care that integrates multiple elements is needed in order to provide evidence-based data to optimize quality of care and improve survival. However, due to the increasing number of patients, the need for life-long interventions and the weakness of the health system, the implementation and sustainability of an integrated surveillance programme is challenging.

Evaluation of the rapid scale-up of collaborative TB/HIV activities in TB facilities in Rwanda, 2005-2009

BACKGROUND

In 2005, Rwanda drafted a national TB/HIV policy and began scaling-up collaborative TB/HIV activities. Prior to the scale-up, we evaluated existing TB/HIV practices, possible barriers to policy and programmatic implementation, and patient treatment outcomes. We then used our evaluation data as a baseline for evaluating the national scale-up of collaborative TB/HIV activities from 2005 through 2009.

METHODS

Our baseline evaluation included a cross-sectional evaluation of 23/161 TB clinics. We conducted structured interviews with patients and clinic staff and reviewed TB registers and patient records to assess HIV testing practices, provision of HIV care and treatment for people with TB that tested positive for HIV, and patients' TB treatment outcomes. Following our baseline evaluation, we used nationally representative TB/HIV surveillance data to monitor the scale-up of collaborative TB/HIV activities

RESULTS

Of 207 patients interviewed, 76% were offered HIV testing, 99% accepted, and 49% reported positive test results. Of 40 staff interviewed, 68% reported offering HIV testing to >50% of patients. From 2005-2009, scaled-up TB/HIV activities resulted in increased HIV testing of patients with TB (69% to 97%) and provision of cotrimoxazole (15% to 92%) and antiretroviral therapy (13% to 49%) for patients with TB disease and HIV infection (TB/HIV). The risk of death among patients with TB/HIV relative to patients with TB not infected with HIV declined from 2005 (RR = 6.1, 95%CI 2.6, 14.0) to 2007 (RR = 1.8, 95%CI 1.68, 1.94).

CONCLUSIONS

Our baseline evaluation highlighted that staff and patients were receptive to HIV testing. However, expanded access to testing, care, and treatment was needed based on the proportion of patients with TB having unknown HIV status and the high rate of HIV infection and poorer TB treatment outcomes for patients with TB/HIV. Following our evaluation, scale-up of TB/HIV services resulted in almost all patients with TB knowing their HIV status. Scale-up also resulted in dramatic increases in the uptake of lifesaving HIV care and treatment coinciding with a decline in the risk of death among patients with TB/HIV.

Lives saved by tuberculosis control and prospects for achieving the 2015 global target for reducing tuberculosis mortality

OBJECTIVE

To assess whether the global target of halving tuberculosis (TB) mortality between 1990 and 2015 can be achieved and to conduct the first global assessment of the lives saved by the DOTS/Stop TB Strategy of the World Health Organization (WHO).

METHODS

Mortality from TB since 1990 was estimated for 213 countries using established methods endorsed by WHO. Mortality trends were estimated separately for people with and without human immunodeficiency virus (HIV) infection in accordance with the International classification of diseases. Lives saved by the DOTS/Stop TB Strategy were estimated with respect to the performance of TB control in 1995, the year that DOTS was introduced.

FINDINGS

TB mortality among HIV-negative (HIV-) people fell from 30 to 20 per 100,000 population (36%) between 1990 and 2009 and could be halved by 2015. The overall decline (when including HIV-positive [HIV+] people, who comprise 12% of all TB cases) was 19%. Between 1995 and 2009, 49 million TB patients were treated under the DOTS/Stop TB Strategy. This saved 4.6-6.3 million lives, including those of 0.23-0.28 million children and 1.4-1.7 million women of childbearing age. A further 1 million lives could be saved annually by 2015.

CONCLUSION

Improvements in TB care and control since 1995 have greatly reduced TB mortality, saved millions of lives and brought within reach the global target of halving TB deaths by 2015 relative to 1990. Intensified efforts to reduce deaths among HIV+ TB cases are needed, especially in sub-Saharan Africa.

Effectiveness of early antiretroviral therapy initiation to improve survival among HIV-infected adults with tuberculosis: a retrospective cohort study

BACKGROUND

Randomized clinical trials examining the optimal time to initiate combination antiretroviral therapy (cART) in HIV-infected adults with sputum smear-positive tuberculosis (TB) disease have demonstrated improved survival among those who initiate cART earlier during TB treatment. Since these trials incorporated rigorous diagnostic criteria, it is unclear whether these results are generalizable to the vast majority of HIV-infected patients with TB, for whom standard diagnostic tools are unavailable. We aimed to examine whether early cART initiation improved survival among HIV-infected adults who were diagnosed with TB in a clinical setting.

METHODS AND FINDINGS

We retrospectively reviewed charts for 308 HIV-infected adults in Rwanda with a CD4 count ≤ 350 cells/µl and a TB diagnosis. We estimated the effect of cART on survival using marginal structural models and simulated 2-y survival curves for the cohort under different cART strategies:start cART 15, 30, 60, or 180 d after TB treatment or never start cART. We conducted secondary analyses with composite endpoints of (1) death, default, or lost to follow-up and (2) death, hospitalization, or serious opportunistic infection. Early cART initiation led to a survival benefit that was most marked for individuals with low CD4 counts. For individuals with CD4 counts of 50 or 100 cells/µl, cART initiation at day 15 yielded 2-y survival probabilities of 0.82 (95% confidence interval: [0.76, 0.89]) and 0.86 (95% confidence interval: [0.80, 0.92]), respectively. These were significantly higher than the probabilities computed under later start times. Results were similar for the endpoint of death, hospitalization, or serious opportunistic infection. cART initiation at day 15 versus later times was protective against death, default, or loss to follow-up, regardless of CD4 count. As with any observational study, the validity of these findings assumes that biases from residual confounding by unmeasured factors and from model misspecification are small.

CONCLUSIONS

Early cART reduced mortality among individuals with low CD4 counts and improved retention in care, regardless of CD4 count. Please see later in the article for the Editors' Summary.

Antiretroviral therapy and TB notification rates in a high HIV prevalence South African community

BACKGROUND

Antiretroviral therapy (ART) has been proposed as an intervention for reducing tuberculosis (TB) burdens in areas with high HIV prevalence. However, little data is available on the impact of ART on population-level TB.

METHODS

Trends in adult TB case fatality and notifications were assessed before and during increasing ART coverage in a well-defined periurban community, from 1997 to 2008. Mean changes in TB rates were measured using linear autoregression models. ART coverage increased from 1% in 2003 to 5%, 13%, and 21% of HIV-infected population in 2004, 2005, and 2008, respectively.

RESULTS

From 1997 to end of 2004 TB notification rates increased by an average of 187 cases/100,000/year (P < 0.001), reaching a peak of 2536/100,000 in 2005. From 2005 to 2008, TB notification rates declined by approximately 202 cases/100,000/year (P < 0.001). TB rates were initially stable in HIV-uninfected individuals, but declined moderately from 2005. TB rates declined in HIV-infected adults from 6513/100,000 in 2005 to 4741/100,000 in 2008. The predominant decline in TB notifications occurred among HIV-infected patients receiving ART (1156 cases/100,000/year) and was less marked in those not receiving ART (416 cases/100,000/year). Similarly, TB case fatality was constant for HIV-uninfected individuals, but declined in HIV-infected individuals from 23% in 2002 to 8% in 2008 (P = 0.01).

CONCLUSIONS

In this community heavily affected by both HIV and TB epidemics, rapid and high ART coverage was associated with significant reductions in TB notifications and TB-associated case fatality.

Efavirenz or nevirapine in three-drug combination therapy with two nucleoside-reverse transcriptase inhibitors for initial treatment of HIV infection in antiretroviral-naïve individuals

BACKGROUND

The advent of highly active antiretroviral therapy (HAART) has reduced the morbidity and mortality due to HIV. The World Health Organisation (WHO) antiretroviral treatment (ART) guidelines focus on three classes of antiretroviral drugs, namely: nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI) and protease inhibitors (PI). Two of the most common medications given in first-line treatment are the NNRTIs, efavirenz (EFV) and nevirapine (NVP). It is unclear which NNRTI is more efficacious for initial therapy.

OBJECTIVES

To determine which NNRTI, EFV or NVP, is more efficacious when given in combination with two NRTIs as part of initial ART for HIV infection in adults and children.

SEARCH STRATEGY

We used a comprehensive and exhaustive strategy in an attempt to identify all relevant studies, regardless of language or publication status, in electronic databases and conference proceedings from 1996 to 2009.

SELECTION CRITERIA

All randomised controlled trials comparing EFV to NVP in HIV-infected individuals without prior exposure to ART, irrespective of the dosage or NRTI backbone.The primary outcome of interest was virologic response to ART. Other primary outcomes included mortality, clinical progression, severe adverse events, and discontinuation of therapy for any reason. Secondary outcomes were immunologic response to ART, treatment failure, development of ART drug resistance, and prevention of sexual transmission of HIV.

DATA COLLECTION AND ANALYSIS

Two authors assessed each reference for inclusion and exclusion criteria established a priori. Data were abstracted independently using a standardised abstraction form. Data were analysed on an intention-to-treat basis and reported as per dosage of NVP.

MAIN RESULTS

We identified seven randomised controlled trials that met our inclusion criteria.The trials were pooled as per dosage of NVP. None of these trials included children.The seven trials enrolled 1,688 participants and found no critical differences between EFV and NVP, except for different toxicity profiles. EFV is more likely to cause central nervous system side-effects, while NVP is more likely to result in raised transaminases and neutropoenia. There was a higher mortality rate in the NVP 400mg once daily arm.The quality of literature to support these conclusions is moderate to high. Drug resistance was slightly less common with EFV than NVP, but the quality of this literature is low since only one of the seven studies reported on this outcome. No studies reported on sexual transmission of HIV. The length of follow-up time, study settings, and NRTI backbone varied greatly.

AUTHORS' CONCLUSIONS

Both drugs have equivalent efficacies in initial treatment of HIV infection when combined with two NRTIs, but different side effects.

'When I get better I will do the test': Facilitators and barriers to HIV testing in Northwest Region of Cameroon with implications for TB and HIV/AIDS control programmes

The World Health Organization has recommended collaborative activities between TB and HIV programmes with routine counseling and testing for HIV among TB patients in order to improve the uptake of HIV services. We carried out qualitative research interviews with 21 TB patients in four selected TB and HIV/AIDS treatment centres in the Northwest Region of Cameroon to explore the facilitators and barriers to HIV testing. The desire to be healthy and live longer from knowing one's status inspired by the anticipated support from loved ones, faith in a supreme being, influence and trust in the medical authority, encouraged HIV testing. Men also demonstrated their masculinity by testing, thus portraying themselves as positive role models for other men. Meanwhile, the overwhelming burden of facing both TB and HIV simultaneously, influenced by the fear of disclosure of results, harmful gender norms and practices, fear of stigma and discrimination, and misconceptions surrounding HIV/AIDS deterred HIV testing. However, as a result of conflicting emotional experiences regarding to test or not to test, the decision-making process was not straightforward and this complex process needs to be acknowledged by health care providers when advocating for routine HIV testing among TB patients.

Scale-up of national antiretroviral therapy programs: progress and challenges in the Asia Pacific region

BACKGROUND

There has been tremendous scale-up of antiretroviral therapy (ART) services in the Asia Pacific region, which is home to an estimated 4.7 million persons living with HIV/AIDS. We examined treatment scale-up, ART program practices, and clinical outcome data in the nine low-and-middle-income countries that share over 95% of the HIV burden in the region.

METHODS

Standardized indicators for ART scale-up and treatment outcomes were examined for Cambodia, China, India, Indonesia, Myanmar, Nepal, Papua New Guinea, Thailand, and Vietnam using data submitted by each country to the WHO/The Joint United Nations Programme on HIV/AIDS (UNAIDS)/UNICEF joint framework tool for monitoring the health sector response to HIV/AIDS. Data on ART program practices were abstracted from National HIV Treatment Guidelines for each country.

RESULTS

At the end of 2009, over 700,000 HIV-infected persons were receiving ART in the nine focus countries. Treatment coverage varies widely in the region, ranging from 16 to 93%. All nine countries employ a public health approach to ART services and provide a standardized first-line nonnucleoside reverse transcriptase inhibitor-based regimen. Among patients initiated on first-line ART in these countries, 65-88% remain alive and on treatment 12 months later. Over 50% of mortality occurs in the first 6 months of therapy, and losses to follow-up range from 8 to 16% at 2 years.

CONCLUSION

Impressive ART scale-up efforts in the region have resulted in significant improvements in survival among persons receiving therapy. Continued funding support and political commitment will be essential for further expansion of public sector ART services to those in need. To improve treatment outcomes, national programs should focus on earlier identification of persons requiring ART, decentralization of ART services, and the development of stronger healthcare systems to support the provision of a continuum of HIV care.

Surveillance of pyrazinamide susceptibility among multidrug-resistant Mycobacterium tuberculosis isolates from Siriraj Hospital, Thailand

Background

Susceptibility testing of pyrazinamide (PZA) against Mycobacterium tuberculosis is difficult to perform because the acidity of culture medium that is required for drug activity also inhibits the growth of bacteria. In Thailand, very limited information has been generated on PZA resistance, particularly among multidrug-resistant tuberculosis (MDR-TB) isolated from Thailand. Only two studies on PZA susceptibility among Thai M. tuberculosis strains have been reported; one used a pyrazinamidase assay, and the other used the BACTEC 460 TB for PZA susceptibility testing. In this study, we determined the percentage of strains possessing pyrazinamide resistance among pan-susceptible M. tuberculosis and MDR-TB isolates by using the pyrazinamidase assay, BACTEC MGIT 960 PZA method and pncA sequencing, and assessed the correlation in the data generated using these methods. The type and frequency of mutations in pncA were also determined.

Results

Overall, 150 M. tuberculosis isolates, consisting of 50 susceptible and 100 MDR-TB isolates, were tested for PZA susceptibility by BACTEC MGIT 960 PZA, the pyrazinamidase assay and pncA sequencing. The study indicated PZA resistance in 6% and 49% of susceptible and MDR-TB isolates, respectively. In comparison to the BACTEC MGIT 960 PZA, the PZase assay showed 65.4% sensitivity and 100% specificity, whereas pncA sequencing showed 75% sensitivity and 89.8% specificity. Twenty-four mutation types were found in this study, with the most frequent mutation (16%) being His71Asp. Of these mutations, eight have not been previously described. The Ile31Ser and Ile31Thr mutations were found both in PZA susceptible and resistant isolates, suggesting that mutation of this codon might not play a role on PZA resistance.

Conclusions

Our findings suggest that phenotypic susceptibility testing is still essential for the detection of PZA resistance, especially for MDR-TB isolates. Some mutations were not associated with resistance and could lead to misinterpretation of the genotypic methods. This information could be helpful for clinicians in managing tuberculosis patients and frequencies, and the types of pncA mutations should offer baseline information on PZA resistance.

The predictors of complications in patients with drug-induced liver injury caused by antimicrobial agents

BACKGROUND

Antimicrobials are the leading cause of idiosyncratic drug-induced liver injury in most series.

AIM

To determine the incidence and the predictors of complications in patients with drug-induced liver injury caused by antimicrobial agents requiring hospitalization.

METHODS

Medical records of patients with drug-induced liver injury caused by antimicrobial agents were identified by ICD-10, for the period between 2002 and 2006. Clinical information and blood tests during hospitalization were recorded. The causality assessment of drug-induced liver injury was determined by the Roussel UCLAF causality assessment method (RUCAM) scale.

RESULTS

Of 47 594 in-patient admissions per year, the annual incidence of drug-induced liver injury was 0.03%. Male: female ratio was 7:3 with a median age of 47 years. Eighty reactions of drug-induced liver injury were caused by anti-tuberculosis drugs (85%) and by antibiotics (15%). The median (IQR) of RUCAM scale was 6 (5-8). A total of 36% had HIV infection and 9% of patients had diabetes mellitus. Median (IQR) duration of hospitalization was 9 (5-15) days. Serious complications and death were found in 27.5% and 26%, respectively. By a multivariable logistic analysis, the presence of jaundice was found to be significantly associated with an unfavourable outcome.

CONCLUSION

Although rare, antimicrobial agents-related drug-induced liver injury requiring hospitalization has a high mortality rate. The presence of jaundice predicts poor outcome.

Pediatric infectious diseases: 2009 update for the Rogers' Textbook of Pediatric Intensive Care

OBJECTIVE

To review important articles in the field of infectious diseases that pertain to the care of children in pediatric critical care units, published subsequent to the fourth edition of the Rogers' Textbook of Pediatric Intensive Care.

DATA SOURCES

The U.S. National Library of Medicine was searched for the terms: critical care, nosocomial, antimicrobial resistance, opportunistic infection, sepsis, central nervous system infections, encephalitis, meningitis-bacterial, meningitis-tuberculous, brain abscess, measles, dengue, hemorrhagic fever, human immunodeficiency virus infection (HIV), opportunistic infections, fungal infections, tetanus, diphtheria, botulism, toxic shock syndrome, and pediatrics.

STUDY SELECTION AND DATA EXTRACTION

Promising articles were reviewed and the decision to include them or not in this review was made by the authors, based on clinical relevance.

DATA SYNTHESIS

Articles were included based on their relevance to specific chapters included in this section of the textbook.

CONCLUSIONS

Significant advances continue to be made in our understanding of specific diseases as well as the approach to treatment. There are significant variations in outcome from specific infectious diseases in developing countries compared with the developed world. The looming problem of antimicrobial resistance and relative lack of new anti-infective agents in development is an issue that will be faced by pediatric intensive care units throughout the world in the near future. Updated evidence-based guidelines have appeared for early treatment of septic shock in children, and on prevention and treatment of opportunistic infections in adults and adolescents with human immunodeficiency virus. In patients with measles, use of oral co-trimoxazole or amoxicillin reduces the risk of secondary bacterial infections of respiratory tract; however, the same may not be true for other systemic viral infections, such as influenza. In patients with acute bacterial meningitis, maintenance fluids-instead of restricted fluids-and use of glycerol may improve the outcomes; however, the role of dexamethasone in prevention of adverse outcome needs reevaluation. Intravenous use of botulism immune globulin decreases the length of hospital stay and mechanical ventilation. Pediatric patients with aspergillosis have radiologic findings distinct from those of adults and present more often with nodules, and only rarely with cavitation; early focal surgical resection may improve the survival of these patients.

Antiretroviral therapy for control of the HIV-associated tuberculosis epidemic in resource-limited settings

Great progress has been made over the past few years in HIV testing in patients who have tuberculosis (TB) and in the scale-up of antiretroviral therapy. More than 3 million people in resource-limited settings were estimated to have started antiretroviral therapy by the end of 2007 and 2 million of these were in sub-Saharan Africa. However, little is known about what impact this massive public health intervention will have on the HIV-associated TB epidemic or how antiretroviral therapy might be used to best effect TB control. This article provides an in-depth review of these issues.

HIV: treating tuberculosis

INTRODUCTION

In people infected with both HIV and Mycobacterium tuberculosis, the annual risk of developing active tuberculosis is 5% to 10% - more than 10 times the rate for HIV-negative people with M tuberculosis infection. Untreated, mortality from tuberculosis in people with HIV is likely to be high, and over 5% of people relapse after successful treatment.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of first-line treatments for tuberculosis in HIV-positive people? What are the effects of second-line treatments for tuberculosis in HIV-positive people? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 23 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: adjuvant immunotherapy (with corticosteroids, or Mycobacterium vaccae); antimycobacterial treatment combinations; conventional antituberculous treatment (short course, long course, including rifabutin [3 or 5 months], quinolones, or thiacetazone); directly observed therapy (short course); highly active antiretroviral treatment (early initiation or delayed initiation); rifampicin (3 months or less); secondary prophylaxis with antituberculous treatment; and unsupervised treatment.