Effect of tuberculosis infection on mortality of HIV-infected patients in Northern Tanzania

Implementation of systematic screening for tuberculosis disease and tuberculosis preventive treatment among people living with HIV attending antiretroviral treatment clinics in Ghana: a national pilot study

OBJECTIVES

To assess the yield and cost of implementing systematic screening for tuberculosis (TB) disease among people living with HIV (PLHIV) and initiation of TB preventive treatment (TPT) in Ghana.

DESIGN

Prospective cohort study from August 2019 to December 2020.

SETTING

One hospital from each of Ghana's regions (10 total).

PARTICIPANTS

Any PLHIV already receiving or newly initiating antiretroviral treatment were eligible for inclusion.

INTERVENTIONS

All participants received TB symptom screening and chest radiography. Those with symptoms and/or an abnormal chest X-ray provided a sputum sample for microbiological testing. All without TB disease were offered TPT.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated the proportion diagnosed with TB disease and proportion initiating TPT. We used logistic regression to identify factors associated with TB disease diagnosis. We used microcosting to estimate the health system cost per person screened (2020 US$).

RESULTS

Of 12 916 PLHIV attending participating clinics, 2639 (20%) were enrolled in the study and screened for TB disease. Overall, 341/2639 (12.9%, 95% CI 11.7% to 14.3%) had TB symptoms and/or an abnormal chest X-ray; 50/2639 (1.9%; 95% CI 1.4% to 2.5%) were diagnosed with TB disease, 20% of which was subclinical. In multivariable analysis, only those newly initiating antiretroviral treatment were at increased odds of TB disease (adjusted OR 4.1, 95% CI 2.0 to 8.2). Among 2589 participants without TB, 2581/2589 (99.7%) initiated TPT. Overall, the average cost per person screened during the study was US$57.32.

CONCLUSION

In Ghana, systematic TB disease screening among PLHIV was of high yield and modest cost when combined with TPT. Our findings support WHO recommendations for routine TB disease screening among PLHIV.

Mechanisms and Cardiorenal Complications of Chronic Anemia in People with HIV

Chronic anemia is more prevalent in people living with HIV (PLWH) compared to the general population. The mechanisms that drive chronic anemia in HIV are multifaceted and include functional impairment of hematopoietic stem cells, dysregulation of erythropoietin production, and persistent immune activation. Chronic inflammation from HIV infection adversely affects erythropoiesis, erythrocyte lifespan, and erythropoietin response, leading to a heightened risk of co-infections such as tuberculosis, persistent severe anemia, and increased mortality. Additionally, chronic anemia exacerbates the progression of HIV-associated nephrotoxicity and contributes to cardiovascular risk through immune activation and inflammation. This review highlights the cardinal role of chronic inflammation as a link connecting persistent anemia and cardiovascular complications in PLWH, emphasizing the need for a universal understanding of these interconnected pathways for targeted interventions.

Factors Associated with the Effectiveness of Regimens for the Treatment of Tuberculosis in Patients Coinfected with HIV/AIDS: Cohort 2015 to 2019

(1) Background: Infection with the Human Immunodeficiency Virus (HIV) is a significant challenge for tuberculosis (TB) control, with increasing mortality rates worldwide. Moreover, the loss to follow-up is very high, with low adherence to treatment, resulting in unfavorable endpoints. This study aimed to analyze the effectiveness of TB treatment in patients coinfected with HIV/AIDS and its associated factors. (2) Methods: Patients coinfected with TB and HIV/AIDS at a Reference Hospital for infectious diseases were followed up for a maximum of one year from the start of TB treatment until cure or censorship (death, abandonment, and transfer) from 2015 to 2019. The Cox proportional model was used to identify risk factors for effectiveness. (3) Results: Of the 244 patients included in the cohort, 58.2% (142/244) had no treatment effectiveness, 12.3% (30/244) died, and 11.1% (27/244) abandoned treatment. Viral suppression at the onset of TB treatment (HR = 1.961, CI = 1.123-3.422), previous use of Antiretroviral Therapy (HR = 1.676, CI = 1.060-2.651), new cases (HR = 2.407, CI = 1.197-3.501), not using illicit drugs (HR = 1.763, CI = 1.141-2.723), and using the basic TB regimen (HR = 1.864, CI = 1.084-3.205) were significant variables per the multivariate Cox regression analysis. (4) Conclusion: TB treatment for most TB patients coinfected with HIV/AIDS was not effective. This study identified that an undetectable viral load at the beginning of the disease, previous use of ART, not using illicit drugs and not having previously taken anti-TB treatment are factors associated with successful TB treatment.

Landscape of TB Infection and Prevention among People Living with HIV

Tuberculosis (TB) is one of the leading causes of mortality in people living with HIV (PLHIV) and contributes to up to a third of deaths in this population. The World Health Organization guidelines aim to target early detection and treatment of TB among PLHIV, particularly in high-prevalence and low-resource settings. Prevention plays a key role in the fight against TB among PLHIV. This review explores TB screening tools available for PLHIV, including symptom-based screening, chest radiography, tuberculin skin tests, interferon gamma release assays, and serum biomarkers. We then review TB Preventive Treatment (TPT), shown to reduce the progression to active TB and mortality among PLHIV, and available TPT regimens. Last, we highlight policy-practice gaps and barriers to implementation as well as ongoing research needs to lower the burden of TB and HIV coinfection through preventive activities, innovative diagnostic tests, and cost-effectiveness studies.

Low transcriptomic of PTPRCv1 and CD3E is an independent predictor of mortality in HIV and tuberculosis co-infected patient

A comprehensive assessment of immunological profiles during HIV-TB co-infection is essential to predict mortality, and facilitate the development of effective diagnostic assays, therapeutic agents, and vaccines. Expression levels of 105 immune-related genes were measured at enrolment and 6th month follow-up from 9 deceased HIV and TB coinfected patients who died between 3 and 7th months follow-up and at enrolment, 6th and 18th month from 18 survived matched controls groups for 2 years. Focused gene expression profiling was assessed from peripheral whole blood using a dual-color Reverse-Transcription Multiplex Ligation-dependent Probe Amplification assay. Eleven of the 105 selected genes were differentially expressed between deceased individuals and survivor-matched controls at baseline. At baseline, IL4δ2 was significantly more highly expressed in the deceased group than survivor matched controls, whereas CD3E, IL7R, PTPRCv1, CCL4, GNLY, BCL2, CCL5, NOD1, TLR3, and NLRP13 had significantly lower expression levels in the deceased group compared to survivor matched controls. At baseline, a non-parametric receiver operator characteristic curve was conducted to determine the prediction of mortality of single genes identified CCL5, PTPRCv1, CD3E, and IL7R with Area under the Curve of 0.86, 0.86, 0.86, and 0.85 respectively. The expression of these genes in the survived control was increased at the end of TB treatment from that at baseline, while decreased in the deceased group. The expression of PTPRCv1, CD3E, CCL5, and IL7R host genes in peripheral blood of patients with TB-HIV coinfected can potentially be used as a predictor of mortality in the Ethiopian setting. Anti-TB treatment might be less likely to restore gene expression in the level expression of the deceased group. Therefore, other new therapeutics that can restore these genes (PTPRCv1, CD3E, IL7R, and CCL5) in the deceased groups at baseline might be needed to save lives.

Modeling Survival Time to Death Among TB and HIV Co-infected Adult Patients: an Institution-Based Retrospective Cohort Study

BACKGROUND

Tuberculosis is a serious health threat, particularly for people living with human immunodeficiency virus (HIV), and HIV-positive people are more likely than others to contract the disease. Globally, tuberculosis (TB) is one of the leading causes of death among people living with HIV. The purpose of the current study was to identify factors associated with survival rates of TB/HIV co-infected patients using survival models.

METHODS

A retrospective study was conducted on TB/HIV co-infected adult patients registered and under follow-up at Tepi General Hospital (TGH) and Mizan-Tepi University Teaching Hospital (MTUTH), southwest Ethiopia. All TB/HIV co-infection patients who were registered and under follow-up from 1st January 2015 through 1st January 2020 were considered. The global Schoenfeld test was used to test the proportional hazard (PH) assumption. Various accelerated failure time (AFT) models were compared to determine the best model for the time to death of TB/HIV co-infected patients' data set. Among the most commonly used accelerated failure time models (AFT models), the study used exponential, Weibull, log-logistic, and log-lognormal AFT models. AIC and BIC were used to compare the performance of fitted models. The data were analyzed with the statistical software R.

RESULTS

Of 363 TB/HIV co-infected patients followed for 60 months, 79 (21.8%) died, while the remaining 284 (78.2%) were censored. The overall median survival time was 15.6 months. The proportional hazard assumption was checked and it was violated. In comparison to other models, the lognormal AFT model performed better. The results of the multivariable lognormal AFT model showed that age, residence, substance use, educational status, clinical stages of the disease, cluster of differentiation 4 (CD4 count/mm³), functional status, cotrimoxazole prophylactic therapy use (CPT use), and INH were all found to be significant factors, while gender, illness other than TB, and disclosure of status were insignificant variables at 5% level of significance.

CONCLUSION

Current study results revealed that older age, substance use, advanced WHO clinical stages of the disease (stage IV), bedridden functional status, and CD4 less than 200 count/mm³ were significantly associated with shorter survival time to death of HIV/TB co-infected patients while having advanced educational status, being from urban residence, CPT use, and INH significantly increase the survival time to death of TB/HIV co-infected patients. Patients with TB/HIV co-infection should be given special attention based on these important factors to improve their health and prolong their lives. HIV-positive patients are more likely than others to contract the TB disease. The risk of death among TB/HIV co-infected patients was found to be high. Out of all patients, 79 (21.8%) died. Accelerated failure time models are good alternatives for scenario Cox proportional hazard assumptions not met.

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

Tuberculosis (TB) is the leading cause of death in people living with HIV (PLHIV) globally, causing 208,000 deaths in PLHIV in 2019. PLHIV have an 18-fold higher risk of TB, and HIV/TB mortality is highest in inpatient facilities, compared with primary care and community settings. Here we discuss challenges and potential mitigating solutions to address TB-related mortality in adults with HIV. Key factors that affect healthcare engagement are stigma, knowledge, and socioeconomic constraints, which are compounded in people with HIV/TB co-infection. Innovative approaches to improve healthcare engagement include optimizing HIV/TB care integration and interventions to reduce stigma. While early diagnosis of both HIV and TB can reduce mortality, barriers to early diagnosis of TB in PLHIV include difficulty producing sputum specimens, lower sensitivity of TB diagnostic tests in PLHIV, and higher rates of extra pulmonary TB. There is an urgent need to develop higher sensitivity biomarker-based tests that can be used for point-of-care diagnosis. Nonetheless, the implementation and scale-up of existing tests including molecular World Health Organization (WHO)-recommended diagnostic tests and urine lipoarabinomannan (LAM) should be optimized along with expanded TB screening with tools such as C-reactive protein and digital chest radiography. Decreased survival of PLHIV with TB disease is more likely with late HIV diagnosis and delayed start of antiretroviral (ART) treatment. The WHO now recommends starting ART within 2 weeks of initiating TB treatment in the majority of PLHIV, aside from those with TB meningitis. Dedicated TB treatment trials focused on PLHIV are needed, including interventions to improve TB meningitis outcomes given its high mortality, such as the use of intensified regimens using high-dose rifampin, new and repurposed drugs such as linezolid, and immunomodulatory therapy. Ultimately holistic, high-quality, person-centered care is needed for PLHIV with TB throughout the cascade of care, which should address biomedical, socioeconomic, and psychological barriers.

Impact of saturated treatments on HIV-TB dual epidemic as a consequence of COVID-19: optimal control with awareness and treatment

In this study, we propose an HIV-TB co-infection model by considering the treatment provision limitation induced by recent COVID-19 pandemic that impacts this dual epidemic immensely, assimilating the significance of educational attempts. We analyze the model and its submodels with single infections individually. We obtain the awareness-induced basic reproduction numbers and discuss the global stability of disease-free equilibrium when provision limitation is zero. We observe that the submodels exhibit forward as well as backward bifurcations under provision restriction. Further, we derive thresholds for resource limitations regulating the dynamical behavior of the systems while analyzing the stability of endemic equilibrium of the models with single infections. Sophisticated simulation approaches are implemented to discover the influences of provision-restricted medication and awareness on dual epidemic. Our findings convey the persistence of co-infection though the basic reproduction number is below unity, if the provision restriction remains uncurbed. An observable insight is that, in spite of having epidemic threshold less than unity and no limitation in TB treatment, co-infection relapses and persists in the population, when there is no awareness attempt. Numerical findings emphasize the urgent need of increased treatment accessibility and importance of awareness in the current situation. Moreover, an optimization problem incorporating treatment and awareness controls is formulated and solved to find the ideal strategy to manage HIV-TB co-epidemic that recommends to diminish the medical resource limitation to get the enormous impact in dominating the adversity caused by COVID-19.

Different diets and their effect on tuberculosis prevention in HIV patients

Introduction:

The relationship between nutrition and human immunodeficiency virus (HIV) infection, tuberculosis, and other infectious diseases is logically proven. Nutrition affects the immune system and the health of the organs. Inadequate dietary intake endangers the immune system, which itself increases susceptibility to disease and often culminates in active disease. The disease then reduces the body’s appetite and ability to absorb nutrients, and the cycle continues. Considering the importance of the role of nutrition in the health of acquired immune deficiency syndrome (AIDS) patients, this current review aimed to discuss the different diets and their effects on tuberculosis (TB) prevention in HIV patients.

Method and Materials:

The present study evaluates the important points related to AIDS and the prevention and treatment of this disease by considering the diet and known scientific cases during the last 10 years, in simple terms, the prevalence of this disease.

Result:

Articles were searched by valid databases in May 2021. The findings showed that in addition to malnutrition, the high prevalence of infectious diseases can have serious consequences for public health. Many people will be safe from getting infections if there are safe and effective interventions for many of these infectious diseases.

Conclusion:

Based on the information presented herein, it is clear that TB affects the nutritional status. Many patients with active TB experience severe weight loss, and many people with the symptoms show a lack of vitamins and minerals.

Pharmacodynamic biomarkers for quantifying the mycobacterial effect of high doses of rifampin in patients with rifampin-susceptible pulmonary tuberculosis

Background

Suboptimal drug exposure in patients with drug-susceptible tuberculosis (DS-TB) can drive treatment failure. Pharmacodynamics (PD) biomarkers such as the plasma TB drug-activity (TDA) assay may guide dose finding studies and predict microbiological outcomes differently than conventional indices.

Methods

A study was nested from phase 2b randomized double-blind controlled trial of Tanzanian patients who received a 600 mg, 900 mg, or 1200 mg with a standard dose for DS-TB. Serum at 6 weeks collected over 24-h at 2-h intervals was collected for rifampin area under the concentration–time curve relative to minimum inhibitory concentration (AUC_0-24/MIC) or peak concentration and MIC (C_max/MIC). TDA was the ratio of time-to-positive growth of the patient’s Mycobacterium tuberculosis isolates with and without coculture of patient’s plasma collected at C_max. Spearman’s rank correlation (r) between PD parameters and culture convention on both liquid and solid culture media.

Results

Among 10 patients, 600 mg (3), 900 mg (3), and 1200 mg (4) of rifampin dosages. The mean ± standard deviation (SD) of AUC_0-24/MIC for patients on 600 mg was 168 ± 159 mg·h/L, on 900 mg was 169 ± 166 mg·h/L, and on 1200 mg was 308 ± 238 mg·h/L. The mean-TDA (SD) was 2.56 (±0.75), 1.5 (±0.59), and 2.29 (±1.08) for patients on 600 mg, 900 mg, and 1200 mg rifampin doses, respectively. Higher TDA values correlated with faster time to culture convention on both liquid (r =–0.55, P = 0.099) and solid media (r =–0.65, P = 0.04).

Conclusions

TDA and rifampin AUC_0-24/MIC did not trend as expected with rifampin dose, but TDA better predicted the time to sputum culture conversion. TDA may provide additional discrimination in predicting treatment response for some regimens distinct from plasma exposure relative to MIC or mg/kg dose.

Association of sociodemographic and environmental factors with spatial distribution of tuberculosis cases in Gombak, Selangor, Malaysia

Tuberculosis (TB) cases have increased drastically over the last two decades and it remains as one of the deadliest infectious diseases in Malaysia. This cross-sectional study aimed to establish the spatial distribution of TB cases and its association with the sociodemographic and environmental factors in the Gombak district. The sociodemographic data of 3325 TB cases such as age, gender, race, nationality, country of origin, educational level, employment status, health care worker status, income status, residency, and smoking status from 1st January 2013 to 31st December 2017 in Gombak district were collected from the MyTB web and Tuberculosis Information System (TBIS) database at the Gombak District Health Office and Rawang Health Clinic. Environmental data consisting of air pollution such as air quality index (AQI), carbon monoxide (CO), nitrogen dioxide (NO₂), sulphur dioxide (SO₂), and particulate matter 10 (PM₁₀,) were obtained from the Department of Environment Malaysia from 1st July 2012 to 31st December 2017; whereas weather data such as rainfall were obtained from the Department of Irrigation and Drainage Malaysia and relative humidity, temperature, wind speed, and atmospheric pressure were obtained from the Malaysia Meteorological Department in the same period. Global Moran’s I, kernel density estimation, Getis-Ord Gi* statistics, and heat maps were applied to identify the spatial pattern of TB cases. Ordinary least squares (OLS) and geographically weighted regression (GWR) models were used to determine the spatial association of sociodemographic and environmental factors with the TB cases. Spatial autocorrelation analysis indicated that the cases was clustered (p<0.05) over the five-year period and year 2016 and 2017 while random pattern (p>0.05) was observed from year 2013 to 2015. Kernel density estimation identified the high-density regions while Getis-Ord Gi* statistics observed hotspot locations, whereby consistently located in the southwestern part of the study area. This could be attributed to the overcrowding of inmates in the Sungai Buloh prison located there. Sociodemographic factors such as gender, nationality, employment status, health care worker status, income status, residency, and smoking status as well as; environmental factors such as AQI (lag 1), CO (lag 2), NO₂ (lag 2), SO₂ (lag 1), PM₁₀ (lag 5), rainfall (lag 2), relative humidity (lag 4), temperature (lag 2), wind speed (lag 4), and atmospheric pressure (lag 6) were associated with TB cases (p<0.05). The GWR model based on the environmental factors i.e. GWR2 was the best model to determine the spatial distribution of TB cases based on the highest R² value i.e. 0.98. The maps of estimated local coefficients in GWR models confirmed that the effects of sociodemographic and environmental factors on TB cases spatially varied. This study highlighted the importance of spatial analysis to identify areas with a high TB burden based on its associated factors, which further helps in improving targeted surveillance.

Factors associated with survival in adult people living with HIV/AIDS (PLHAs) in Mumbai, India (2004-2019): A retrospective cohort study

Background:

Knowledge of factors that affect survival in People living with HIV/AIDS (PLHAs) on anti-retroviral therapy (ART) will help us develop and implement interventions to improve the clinical outcomes and survival in these individuals. The aim of this study was to estimate the survival in PLHAs on ART in the government ART programme in Mumbai, and the factors associated with survival in these individuals.

Methods:

It is a retrospective survival analysis of 28,345 adult PLHAs from 18 government ART centres in Mumbai (registration period 2004–2019). We estimated the mortality rates and their 95% confidence intervals [CIs], plotted the Kaplan Meier Survival curves, estimated incidence rate ratios (IRR) and hazard ratios (HR). There were done for the whole cohort and according to various demographic and clinical characteristics.

Results:

The mortality in PLHAs on ART was 9.04 per 1000 person years. The HR was significantly for those aged 50 years and more at the time of registration (HR: 3.01, 95% CI: 2.37, 3.83; P < 0.001), in those with baseline CD4 count of less than 200 higher hazard (HR: 1.83, 95% CI: 1.47, 2.27; P < 0.001), those with an adherence of 80–95% (HR; 5.58, 95% CI: 4.61, 6.75; P < 0.001) and adherence of <80% (HR: 9.37, 95% CI: 7.74, 11.33; P < 0.001). Furthermore, the hazard was significantly higher in those with TB compared those without TB (HR: 3.28, 95% CI: 2.87, 3.75; P < 0.001). Time from diagnosis (per month increase) to initiation of ART was not significantly associated with mortality.

Conclusions:

Increasing awareness about HIV testing and early detection of HIV in those who have high-risk behaviours, prompt diagnosis and management of TB among those infected, and developing and implementing strategies (such as enhanced counselling, telephone-based applications, messages, or reminders) to ensure ART adherence of more than 95% in those on ART will potentially help improve survival in PLHAs in India.