The complex relationship between human immunodeficiency virus infection and death in adults being treated for tuberculosis in Cape Town, South Africa

Preventing tuberculosis with community-based care in an HIV-endemic setting: a modelling analysis

INTRODUCTION

Antiretroviral therapy (ART) and tuberculosis preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase the uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men.

METHODS

We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programmes during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e. ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for 10 years. We projected the number of TB cases, deaths and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated programme costs and incremental cost-effectiveness ratios from the provider perspective.

RESULTS

If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3%-34.1%) and TB mortality by 34.6% (range 24.8%-42.2%) after 10 years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9%-36.0%) and TB mortality by 36.0% (range 26.9%-43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates, with a projected 54 more deaths annually among men than women (range 11-103) after 10 years of community-based care versus 109 (range 41-182) in standard care. Over 10 years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709-$1012).

CONCLUSIONS

By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.

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

Background

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

Methods

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

Results

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

Conclusions

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

The impact of COVID-19 pandemic on reported tuberculosis incidence and mortality in China: An interrupted time series analysis

Background

The reported number of cases and deaths from common infectious diseases can change during major public health crises. We explored whether the coronavirus disease 2019 (COVID-19) had an impact on tuberculosis (TB) incidence and mortality in China based on routinely reported TB data.

Methods

We used TB data used from the monthly national notifiable infectious disease reports in China from January 2015 to January 2023. Based on an interrupted time series (ITS) design, we applied Poisson and negative binomial regression models to assess the changes of reported TB incidence and mortality before and during the COVID-19 pandemic.

Results

We found a significant and immediate decrease in the levels of both reported TB incidence (relative risk (RR) = 0.887; 95% confidence interval (CI) = 0.810-0.973) and mortality (RR = 0.448; 95% CI = 0.351-0.572) at the start of COVID-19 outbreak. During the pandemic, the slope of reported incidence decreased significantly (RR = 0.994; 95% CI = 0.989-0.999), while the slope of reported mortality increased sharply (RR = 1.032; 95% CI = 1.022-1.041) owing to an abrupt rise in reported mortality after January 2022.

Conclusions

Both TB incidence and mortality decreased immediately at the start of the COVID-19 pandemic. Over a longer period, the COVID-19 pandemic had contributed to a sustained and more significant decrease in reported incidence, and a delayed but sharp increase in reported mortality.

Preventing tuberculosis with community-based care in an HIV-endemic setting: a modeling analysis

Introduction

Antiretroviral therapy (ART) and TB preventive treatment (TPT) both prevent tuberculosis (TB) disease and deaths among people living with HIV. Differentiated care models, including community-based care, can increase uptake of ART and TPT to prevent TB in settings with a high burden of HIV-associated TB, particularly among men.

Methods

We developed a gender-stratified dynamic model of TB and HIV transmission and disease progression among 100,000 adults ages 15-59 in KwaZulu-Natal, South Africa. We drew model parameters from a community-based ART initiation and resupply trial in sub-Saharan Africa (Delivery Optimization for Antiretroviral Therapy, DO ART) and other scientific literature. We simulated the impacts of community-based ART and TPT care programs during 2018-2027, assuming that community-based ART and TPT care were scaled up to similar levels as in the DO ART trial (i.e., ART coverage increasing from 49% to 82% among men and from 69% to 83% among women) and sustained for ten years. We projected the number of TB cases, deaths, and disability-adjusted life years (DALYs) averted relative to standard, clinic-based care. We calculated program costs and incremental cost-effectiveness ratios from the provider perspective.

Results

If community-based ART care could be implemented with similar effectiveness to the DO ART trial, increased ART coverage could reduce TB incidence by 27.0% (range 21.3% - 34.1%) and TB mortality by 36.0% (range 26.9% - 43.8%) after ten years. Increasing both ART and TPT uptake through community-based ART with TPT care could reduce TB incidence by 29.7% (range 23.9% - 36.0%) and TB mortality by 36.0% (range 26.9% - 43.8%). Community-based ART with TPT care reduced gender disparities in TB mortality rates by reducing TB mortality among men by a projected 39.8% (range 32.2% - 46.3%) and by 30.9% (range 25.3% - 36.5%) among women. Over ten years, the mean cost per DALY averted by community-based ART with TPT care was $846 USD (range $709 - $1,012).

Conclusions

By substantially increasing coverage of ART and TPT, community-based care for people living with HIV could reduce TB incidence and mortality in settings with high burdens of HIV-associated TB and reduce TB gender disparities.

A systematic review of risk factors for mortality among tuberculosis patients in South Africa

BACKGROUND

Tuberculosis (TB)-associated mortality in South Africa remains high. This review aimed to systematically assess risk factors associated with death during TB treatment in South African patients.

METHODS

We conducted a systematic review of TB research articles published between 2010 and 2018. We searched BioMed Central (BMC), PubMed®, EBSCOhost, Cochrane, and SCOPUS for publications between January 2010 and December 2018. Searches were conducted between August 2019 and October 2019. We included randomised control trials (RCTs), case control, cross sectional, retrospective, and prospective cohort studies where TB mortality was a primary endpoint and effect measure estimates were provided for risk factors for TB mortality during TB treatment. Due to heterogeneity in effect measures and risk factors evaluated, a formal meta-analysis of risk factors for TB mortality was not appropriate. A random effects meta-analysis was used to estimate case fatality ratios (CFRs) for all studies and for specific subgroups so that these could be compared. Quality assessments were performed using the Newcastle-Ottawa scale or the Cochrane Risk of Bias Tool.

RESULTS

We identified 1995 titles for screening, 24 publications met our inclusion criteria (one cross-sectional study, 2 RCTs, and 21 cohort studies). Twenty-two studies reported on adults (n = 12561) and two were restricted to children < 15 years of age (n = 696). The CFR estimated for all studies was 26.4% (CI 18.1-34.7, n = 13257 ); 37.5% (CI 24.8-50.3, n = 5149) for drug-resistant (DR) TB; 12.5% (CI 1.1-23.9, n = 1935) for drug-susceptible (DS) TB; 15.6% (CI 8.1-23.2, n = 6173) for studies in which drug susceptibility was mixed or not specified; 21.3% (CI 15.3-27.3, n = 7375) for people living with HIV/AIDS (PLHIV); 19.2% (CI 7.7-30.7, n = 1691) in HIV-negative TB patients; and 6.8% (CI 4.9-8.7, n = 696) in paediatric studies. The main risk factors associated with TB mortality were HIV infection, prior TB treatment, DR-TB, and lower body weight at TB diagnosis.

CONCLUSIONS

In South Africa, overall mortality during TB treatment remains high, people with DR-TB have an elevated risk of mortality during TB treatment and interventions to mitigate high mortality are needed. In addition, better prospective data on TB mortality are needed, especially amongst vulnerable sub-populations including young children, adolescents, pregnant women, and people with co-morbidities other than HIV. Limitations included a lack of prospective studies and RCTs and a high degree of heterogeneity in risk factors and comparator variables.

SYSTEMATIC REVIEW REGISTRATION

The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018108622. This study was funded by the Bill and Melinda Gates Foundation (Investment ID OPP1173131) via the South African TB Think Tank.

Mortality during tuberculosis treatment in South Africa using an 8-year analysis of the national tuberculosis treatment register

In 2011, the South African HIV treatment eligibility criteria were expanded to allow all tuberculosis (TB) patients lifelong ART. The impact of this change on TB mortality in South Africa is not known. We evaluated mortality in all adults (≥ 15 years old) treated for drug-susceptible TB in South Africa between 2009 and 2016. Using a Cox regression model, we quantified risk factors for mortality during TB treatment and present standardised mortality ratios (SMR) stratified by year, age, sex, and HIV status. During the study period, 8.6% (219,618/2,551,058) of adults on TB treatment died. Older age, male sex, previous TB treatment and HIV infection (with or without the use of ART) were associated with increased hazard of mortality. There was a 19% reduction in hazard of mortality amongst all TB patients between 2009 and 2016 (adjusted hazard ratio: 0.81 95%CI 0.80-0.83). The highest SMR was in 15-24-year-old women, more than double that of men (42.3 in 2016). Between 2009 and 2016, the SMR for HIV-positive TB patients increased, from 9.0 to 19.6 in women, and 7.0 to 10.6 in men. In South Africa, case fatality during TB treatment is decreasing and further interventions to address specific risk factors for TB mortality are required. Young women (15-24-year-olds) with TB experience a disproportionate burden of mortality and interventions targeting this age-group are needed.

Early mortality in tuberculosis patients initially lost to follow up following diagnosis in provincial hospitals and primary health care facilities in Western Cape, South Africa

In South Africa, low tuberculosis (TB) treatment coverage and high TB case fatality remain important challenges. Following TB diagnosis, patients must link with a primary health care (PHC) facility for initiation or continuation of antituberculosis treatment and TB registration. We aimed to evaluate mortality among TB patients who did not link to a TB treatment facility for TB treatment within 30 days of their TB diagnosis, i.e. who were “initial loss to follow-up (ILTFU)” in Cape Town, South Africa. We prospectively included all patients with a routine laboratory or clinical diagnosis of TB made at PHC or hospital level in Khayelitsha and Tygerberg sub-districts in Cape Town, using routine TB data from an integrated provincial health data centre between October 2018 and March 2020. Overall, 74% (10,208/13,736) of TB patients were diagnosed at PHC facilities and ILTFU was 20.0% (2,742/13,736). Of ILTFU patients, 17.1% (468/2,742) died, with 69.7% (326/468) of deaths occurring within 30 days of diagnosis. Most ILTFU deaths (85.5%; 400/468) occurred in patients diagnosed in hospital. Multivariable logistic regression identified increasing age, HIV positive status, and hospital-based TB diagnosis (higher in the absence of TB treatment initiation and being ILTFU) as predictors of mortality. Although hospitals account for a modest proportion of diagnosed TB patients they have high TB-associated mortality. A hospital-based TB diagnosis is a critical opportunity to identify those at high risk of early and overall mortality. Interventions to diagnose TB before hospital admission, improve linkage to TB treatment following diagnosis, and reduce mortality in hospital-diagnosed TB patients should be prioritised.

Time and risk factors for death among smear-positive pulmonary tuberculosis patients in the Health District of commune VI of Bamako, Mali, 2016

Background

The End Tuberculosis (TB) Strategy aims to achieve 90% reduction of deaths due to TB by 2030, compared with 2015. Mortality due to tuberculosis in Mali was 13 per 100,000 inhabitants in 2014 and 11 per 100,000 inhabitants in 2017. Risk factors for death are not known. The objective of this study was to determine the time and risk factors for death in pulmonary TB patients with positive microscopy.

Methods

We conducted a retrospective cohort study from October to December 2016 in Commune VI of Bamako. Smear positive cases pulmonary tuberculosis from 2011 to 2015 were included. We reviewed the treatment registers and collected sociodemographic, clinical, biological and therapeutic data. Median time to death and hazard ratio (HR) were estimated by the Kaplan-Meier method and a Cox regression model, respectively.

Results

In total, we analysed 1362 smear positive cases of pulmonary TB including 104 (8%) HIV positive and 90 (7%) deaths. The mean age was 36 ± 13 years, the sex ratio of males to females was 2:1. Among the deaths, 48 (53%) occurred during the first 2 months of treatment. Age ≥ 45 years (HR 2.09 95% CI [1.35–3.23]), weight <  40 kg (HR 2.20 95% CI [1.89–5.42]), HIV unknown status (HR 1.96, 95% CI [1.04–3.67]) and HIV-positive (HR 7.10 95% CI [3.53–14.26]) were significantly associated with death.

Conclusions

The median time to death was 2 months from the start of treatment. Independent risk factors for death were age ≥ 45 years, weight <  40 kg, unknown and positive HIV status. We recommend close monitoring of patients over 45 years, HIV testing in those with unknown status, an adequate care for positive HIV status, as well as a nutritional support for those with weight below 40 kg during the intensive phase of TB treatment.

Reported health, lifestyle and clinical manifestations associated with HIV status in people from rural and urban communities in the Free State Province, South Africa

BACKGROUND

HIV infection impacts heavily on the infected individual's overall health status.

AIM

To determine significant health, lifestyle (smoking and alcohol use) and independent clinical manifestations associated with HIV status in rural and urban communities.

METHODS

Adults aged between 25 and 64 years completed a questionnaire in a structured interview with each participant. Blood specimens were analysed in an accredited laboratory using standard techniques and controls. Anthropometric measurements were determined using standardised methods.

RESULTS

Of the 567 rural participants, 97 (17.1%) were HIV-infected, and 172 (40.6%) of the 424 urban participants. More than half of HIV-infected rural participants used alcohol and more than 40% smoked. Median body mass index (BMI) of HIV-infected participants was lower than that of uninfected participants. Significantly more HIV-infected participants reported experiencing cough (rural), skin rash (urban), diarrhoea (rural and urban), vomiting (rural), loss of appetite (urban) and involuntary weight loss (rural). Significantly more HIV-uninfected participants reported diabetes mellitus (urban) and high blood pressure (rural and urban). In rural areas, HIV infection was positively associated with losing weight involuntarily (odds ratio 1.86), ever being diagnosed with tuberculosis (TB) (odds ratio 2.50) and being on TB treatment (odds ratio 3.29). In the urban sample, HIV infection was positively associated with having diarrhoea (odds ratio 2.04) and ever being diagnosed with TB (odds ratio 2.49).

CONCLUSION

Involuntary weight loss and diarrhoea were most likely to predict the presence of HIV. In addition, present or past diagnosis of TB increased the odds of being HIV-infected. Information related to diarrhoea, weight loss and TB is easy to obtain from patients and should prompt healthcare workers to screen for HIV.

Development and validation of a prognostic score during tuberculosis treatment

BACKGROUND

Death under care is a major challenge for tuberculosis (TB) treatment programs. We derived and validated a simple score to predict mortality during tuberculosis treatment in high endemicity areas.

METHODS

We used data for patients aged ≥15 years, diagnosed and treated for tuberculosis at the Yaounde Jamot Hospital between January 2012 and December 2013. Baseline characteristics associated with mortality were investigated using logistic regressions. A simple prognosis score (CABI) was constructed with regression coefficients for predictors in the final model. Internal validation used bootstrap resampling procedures. Models discrimination was assessed using c-statistics and calibration assessed via calibration plots and the Hosmer and Lemeshwow (H-L) statistics. The optimal score was based on the Youden's index.

RESULTS

A total of 2250 patients (men 57.2%) with a mean age of 35.8 years were included; among whom 213 deaths (cumulative incidence 9.5%) were recorded. Clinical form of tuberculosis (C), age (A, years), adjusted body mass index (B, BMI, kg/m²) and status for HIV (Human immunodefiency virus) infection (I) were significant predictors in the final model (p < 0.0001) which was of the form Death risk = 1/(1 + e ^{- (-1.3120 + 0.0474 ∗ age - 0.1866 ∗ BMI + 1.1637 (if smear negative TB) + 0.5418(if extra - pulmonary TB) + 1.3820(if HIV+))}). The c-statistic was 0.812 in the derivation sample and 0.808 after correction for optimism. The calibration was good [H-Lχ² = 6.44 (p = 0.60)]. The optimal absolute risk threshold was 4.8%, corresponding to a sensitivity of 81% and specificity of 67%.

CONCLUSIONS

The preliminary promising findings from this study require confirmation through independent external validation studies. If confirmed, the model derived could facilitate the stratification of TB patients for mortality risk and implementation of additional monitoring and management measures in vulnerable patients.