Comparison of trends in tuberculosis incidence among adults living with HIV and adults without HIV--Kenya, 1998-2012

Incidence of self-reported tuberculosis treatment with community-wide universal testing and treatment for HIV and tuberculosis screening in Zambia and South Africa: A planned analysis of the HPTN 071 (PopART) cluster-randomised trial

BACKGROUND

HIV is a potent risk factor for tuberculosis (TB). Therefore, community-wide universal testing and treatment for HIV (UTT) could contribute to TB control, but evidence for this is limited. Community-wide TB screening can decrease population-level TB prevalence. Combining UTT with TB screening could therefore significantly impact TB control in sub-Saharan Africa, but to our knowledge there is no evidence for this combined approach.

METHODS AND FINDINGS

HPTN 071 (PopART) was a community-randomised trial conducted between November 2013 to July 2018; 21 Zambian and South African communities (with a total population of approximately 1 million individuals) were randomised to arms A (community-wide UTT and TB screening), B (community-wide universal HIV testing with treatment following national guidelines and TB screening), or C (standard-of-care). In a cohort of randomly selected adults (18 to 44 years) enrolled between 2013 and 2015 from all 21 communities (total size 38,474; 27,139 [71%] female; 8,004 [21%] HIV positive) and followed-up annually for 36 months to measure the population-level impact of the interventions, data on self-reported TB treatment in the previous 12 months (self-reported TB) were collected by trained research assistants and recorded using a structured questionnaire at each study visit. In this prespecified analysis of the trial, self-reported TB incidence rates were measured by calendar year between 2014 and 2017/2018. A p-value ≤0.05 on hypothesis testing was defined as reaching statistical significance. Between January 2014 and July 2018, 38,287 individuals were followed-up: 494 self-reported TB during 104,877 person-years. Overall incidence rates were similar across all arms in 2014 and 2015 (0.33 to 0.46/100 person-years). In 2016 incidence rates were lower in arm A compared to C overall (adjusted rate ratio [aRR] 0.48 [95% confidence interval (95% CI) 0.28 to 0.81; p = 0.01]), with statistical significance reached. In 2017/2018, while incidence rates were lower in arm A compared to C, statistical significance was not reached (aRR 0.58 [95% CI 0.27 to 1.22; p = 0.13]). Among people living with HIV (PLHIV) incidence rates were lower in arm A compared to C in 2016 (RR 0.56 [95% CI 0.29 to 1.08; p = 0.08]) and 2017/2018 (RR 0.50 [95% CI 0.26 to 0.95; p = 0.04]); statistical significance was only reached in 2017/2018. Incidence rates in arms B and C were similar, overall and among PLHIV. Among HIV-negative individuals, there were too few events for cross-arm comparisons. Study limitations include the use of self-report which may have been subject to under-reporting, limited covariate adjustment due to the small number of events, and high losses to follow-up over time.

CONCLUSIONS

In this study, community-wide UTT and TB screening resulted in substantially lower TB incidence among PLHIV at population-level, compared to standard-of-care, with statistical significance reached in the final study year. There was also some evidence this translated to a decrease in self-reported TB incidence overall in the population. Reduction in arm A but not B suggests UTT drove the observed effect. Our data support the role of UTT in TB control, in addition to HIV control, in high TB/HIV burden settings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01900977.

Expression and epitope prediction of MPT64 recombinant proteins from clinical isolates of Mycobacterium tuberculosis as immunoserodiagnostic candidates

Background and Aim: The success in the handling and prevention of tuberculosis (TB) cases is highly dependent on their rapid detection, monitoring, and treatment. The efficacy of the Bacille Calmette–Guerin (BCG) vaccine is inconclusive in eastern Indonesia. The RV1980c gene of Mycobacterium tuberculosis encodes an antigenic protein that is considered to be a virulence factor, as it can stimulate the immune response in patients with TB. This study aimed to study the expression and epitope indicator of MPT64 recombinant proteins from clinical isolates of M. tuberculosis as immunoserodiagnostic candidates for pET SUMO plasmids from clinical isolates as candidates for serodiagnostic tests and recombinant vaccines. Materials and Methods: The polymerase chain reaction (PCR) product of the RV1980c gene was inserted into the SUMO pET plasmid, which was then transformed into Escherichia coli BL21 (DE3) cells and expressed in Luria Bertani media induced by 1.0 M IPTG. Subsequently, sequencing was performed and the results were analyzed using the ClustalW and National Center for Biotechnology Information BLAST software. The T-cell epitope prognosis was then explained by GENETYX version 8.0., for the prediction of B-cell epitope, as assessed using an Immune Epitope Database analysis. Results: The PCR product of the RV1980c gene had a length of 619 bp. Moreover, SDS–polyacrylamide gel electrophoresis and Western blotting revealed that the protein encoded by the Rv1980c gene weighed 36 kDa. We gained nine specific T-cell epitopes according to Iad Pattern position and eight epitopes according to Rothbard/Taylor Pattern Position; furthermore, we detected five B-cell epitopes in the RV1980c gene. Conclusion: The MPT64 protein encoded by the RV1980c gene carries epitopes that are realized by lymphocytes and represent potential immunoserodiagnostic candidates in diagnostic immunology.

Methods for conducting trends analysis: roadmap for comparing outcomes from three national HIV Population-based household surveys in Kenya (2007, 2012, and 2018)

BACKGROUND

For assessing the HIV epidemic in Kenya, a series of independent HIV indicator household-based surveys of similar design can be used to investigate the trends in key indicators relevant to HIV prevention and control and to describe geographic and sociodemographic disparities, assess the impact of interventions, and develop strategies. We developed methods and tools to facilitate a robust analysis of trends across three national household-based surveys conducted in Kenya in 2007, 2012, and 2018.

METHODS

We used data from the 2007 and 2012 Kenya AIDS Indicator surveys (KAIS 2007 and KAIS 2012) and the 2018 Kenya Population-based HIV Impact Assessment (KENPHIA 2018). To assess the design and other variables of interest from each study, variables were recoded to ensure that they had equivalent meanings across the three surveys. After assessing weighting procedures for comparability, we used the KAIS 2012 nonresponse weighting procedure to revise normalized KENPHIA weights. Analyses were restricted to geographic areas covered by all three surveys. The revised analysis files were then merged into a single file for pooled analysis. We assessed distributions of age, sex, household wealth, and urban/rural status to identify unexpected changes between surveys. To demonstrate how a trend analysis can be carried out, we used continuous, binary, and time-to-event variables as examples. Specifically, temporal trends in age at first sex and having received an HIV test in the last 12 months were used to demonstrate the proposed analytical approach. These were assessed with respondent-specific variables (age, sex, level of education, and marital status) and household variables (place of residence and wealth index). All analyses were conducted in SAS 9.4, but analysis files were created in Stata and R format to support additional analyses.

RESULTS

This study demonstrates trends in selected indicators to illustrate the approach that can be used in similar settings. The incidence of early sexual debut decreased from 11.63 (95% CI: 10.95-12.34) per 1,000 person-years at risk in 2007 to 10.45 (95% CI: 9.75-11.2) per 1,000 person-years at risk in 2012 and to 9.58 (95% CI: 9.08-10.1) per 1,000 person-years at risk in 2018. HIV-testing rates increased from 12.6% (95% CI: 11.6%-13.6%) in 2007 to 56.1% (95% CI: 54.6%-57.6%) in 2012 but decreased slightly to 55.6% [95% CI: 54.6%-56.6%) in 2018. The decrease in incidence of early sexual debut could be convincingly demonstrated between 2007 and 2012 but not between 2012 and 2018. Similarly, there was virtually no difference between HIV Testing rates in 2012 and 2018.

CONCLUSIONS

Our approach can be used to support trend comparisons for variables in HIV surveys in low-income settings. Independent national household surveys can be assessed for comparability, adjusted as appropriate, and used to estimate trends in key indicators. Analyzing trends over time can not only provide insights into Kenya's progress toward HIV epidemic control but also identify gaps.

Role of community-based active case finding in screening tuberculosis in Yunnan province of China

Background

The barriers to access diagnosis and receive treatment, in addition to insufficient case identification and reporting, lead to tuberculosis (TB) spreads in communities, especially among hard-to-reach populations. This study evaluated a community-based active case finding (ACF) strategy for the detection of tuberculosis cases among high-risk groups and general population in China between 2013 and 2015.

Methods

This retrospective cohort study conducted an ACF in ten communities of Dongchuan County, located in northeast Yunnan Province between 2013 and 2015; and compared to 136 communities that had passive case finding (PCF). The algorithm for ACF was: 1) screen for TB symptoms among community enrolled residents by home visits, 2) those with positive symptoms along with defined high-risk groups underwent chest X-ray (CXR), followed by sputum microscopy confirmation. TB incidence proportion and the number needed to screen (NNS) to detect one case were calculated to evaluate the ACF strategy compared to PCF, chi-square test was applied to compare the incidence proportion of TB cases’ demography and the characteristics for detected cases under different strategies. Thereafter, the incidence rate ratio (IRR) and multiple Fisher’s exact test were applied to compare the incidence proportion between general population and high-risk groups. Patient and diagnostic delays for ACF and PCF were compared by Wilcoxon rank sum test.

Results

A total of 97 521 enrolled residents were visited with the ACF cumulatively, 12.3% were defined as high-risk groups or had TB symptoms. Sixty-six new TB patients were detected by ACF. There was no significant difference between the cumulative TB incidence proportion for ACF (67.7/100000 population) and the prevalence for PCF (62.6/100000 population) during 2013 to 2015, though the incidence proportion in ACF communities decreased after three rounds active screening, concurrent with the remained stable prevalence in PCF communities. The cumulative NNS were 34, 39 and 29 in HIV/AIDS infected individuals, people with positive TB symptoms and history of previous TB, respectively, compared to 1478 in the general population. The median patient delay under ACF was 1 day (Interquartile range, IQR: 0–27) compared to PCF with 30 days (IQR: 14–61).

Conclusions

This study confirmed that massive ACF was not effective in general population in a moderate TB prevalence setting. The priority should be the definition and targeting of high-risk groups in the community before the screening process is launched. The shorter time interval of ACF between TB symptoms onset and linkage to healthcare service may decrease the risk of TB community transmission. Furthermore, integrated ACF strategy in the National Project of Basic Public Health Service may have long term public health impact.

Bayesian modeling of spatiotemporal patterns of TB-HIV co-infection risk in Kenya

Background

Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) diseases are globally acknowledged as a public health challenge that exhibits adverse bidirectional relations due to the co-epidemic overlap. To understand the co-infection burden we used the case notification data to generate spatiotemporal maps that described the distribution and exposure hypotheses for further epidemiologic investigations in areas with unusual case notification levels.

Methods

We analyzed the TB and TB-HIV case notification data from the Kenya national TB control program aggregated for forty-seven counties over a seven-year period (2012–2018). Using spatiotemporal poisson regression models within the Integrated Nested Laplace Approach (INLA) paradygm, we modeled the risk of TB-HIV co-infection. Six competing models with varying space-time formulations were compared to determine the best fit model. We then assessed the geographic patterns and temporal trends of coinfection risk by mapping the posterior marginal from the best fit model.

Results

Of the total 608,312 TB case notifications, 194,129 were HIV co-infected. The proportion of TB-HIV co-infection was higher in females (39.7%) than in males (27.0%). A significant share of the co-infection was among adults aged 35 to 44 years (46.7%) and 45 to 54 years (42.1%). Based on the Bayesian Defiance Information (DIC) and the effective number of parameters (pD) comparisons, the spatiotemporal model allowing space-time interaction was the best in explaining the geographical variations in TB-HIV coinfection. The model results suggested that the risk of TB-HIV coinfection was influenced by infrastructure index (Relative risk (RR) = 5.75, Credible Interval (Cr.I) = (1.65, 19.89)) and gender ratio (RR = 5.81e⁻⁰⁴, Cr. I = (1.06e⁻⁰⁴, 3.18e⁻⁰³). The lowest and highest temporal relative risks were in the years 2016 at 0.9 and 2012 at 1.07 respectively. The spatial pattern presented an increased co-infection risk in a number of counties. For the spatiotemporal interaction, only a few counties had a relative risk greater than 1 that varied in different years.

Conclusions

We identified elevated risk areas for TB/HIV co-infection and fluctuating temporal trends which could be because of improved TB case detection or surveillance bias caused by spatial heterogeneity in the co-infection dynamics. Focused interventions and continuous TB-HIV surveillance will ensure adequate resource allocation and significant reduction of HIV burden amongst TB patients.

Space-time clustering of recently-diagnosed tuberculosis and impact of ART scale-up: Evidence from an HIV hyper-endemic rural South African population

In HIV hyperendemic sub-Saharan African communities, particularly in southern Africa, the likelihood of achieving the Sustainable Development Goal of ending the tuberculosis (TB) epidemic by 2030 is low, due to lack of cost-effective and practical interventions in population settings. We used one of Africa’s largest population-based prospective cohorts from rural KwaZulu-Natal Province, South Africa, to measure the spatial variations in the prevalence of recently-diagnosed TB disease, and to quantify the impact of community coverage of antiretroviral therapy (ART) on recently-diagnosed TB disease. We collected data on TB disease episodes from a population-based sample of 41,812 adult individuals between 2009 and 2015. Spatial clusters (‘hotspots’) of recently-diagnosed TB were identified using a space-time scan statistic. Multilevel logistic regression models were fitted to investigate the relationship between community ART coverage and recently-diagnosed TB. Spatial clusters of recently-diagnosed TB were identified in a region characterized by a high prevalence of HIV and population movement. Every percentage increase in ART coverage was associated with a 2% decrease in the odds of recently-diagnosed TB (aOR = 0.98, 95% CI:0.97–0.99). We identified for the first time the clear occurrence of recently-diagnosed TB hotspots, and quantified potential benefit of increased community ART coverage in lowering tuberculosis, highlighting the need to prioritize the expansion of such effective population interventions targeting high-risk areas.

Initiation and completion rates of isoniazid preventive therapy among people living with HIV in Far-Western Region of Nepal: a retrospective cohort study

OBJECTIVES

Isoniazid preventive therapy (IPT), for people living with HIV (PLHIV) is the proven and recommended intervention to avert tuberculosis (TB). In 2015, Nepal implemented 6 months of IPT for all PLHIV registered for HIV care in antiretroviral therapy (ART) centres. After programmatic implementation, there has been no systematic assessment of IPT initiation and completion rates among PLHIV. We aimed to assess IPT initiation and completion rates in the Far-Western Region (FWR) of Nepal.

DESIGN

We conducted a retrospective cohort study using secondary data extracted from registers maintained at ART centres.

SETTING

All 11 ART centres in the FWR of Nepal.

PARTICIPANTS

All PLHIV registered for care between January 2016 and December 2017 in 11 ART centres.

PRIMARY OUTCOME MEASURES

IPT initiation and completion rates were summarised as percentages with 95% CI. Independent association between patient characteristics and non-initiation of IPT was assessed using cluster-adjusted generalised linear model (log binomial regression) and adjusted relative risk (RR) with 95% CI was calculated.

RESULT

Of the 492 PLHIV included, 477 (97.0%) did not have active TB at registration. Among 477 without active TB, 141 (29.8%, 95% CI 25.7% to 34.1%) had been initiated on IPT and 85 (17.8%) were initiated within 3 months of registration. Of 141 initiated on IPT, 133 (94.3%, 95% CI 89.1% to 97.5%) had completed 6 months of IPT. Being more than 60 years of age (RR-1.3, 95% CI 1.1 to 1.7), migrant worker (RR-1.3, 95% CI 1.1 to 1.4) and not being initiated on ART (RR-1.4, 95% CI 1.1 to 1.8) were significantly associated with IPT initiation.

CONCLUSIONS

In FWR of Nepal, three out of 10 eligible PLHIV had received IPT. Among those who have received IPT, the completion rate was good. The HIV care programme needs to explore the potential reasons for this low coverage and take context specific corrective action to fix this gap.

Epidemiology of Pediatric Tuberculosis in Kenya and Risk Factors for Mortality during Treatment: A National Retrospective Cohort Study

OBJECTIVES

To describe the epidemiology of childhood tuberculosis (TB) in Kenya, assess the magnitude of TB/human immunodeficiency virus (HIV) co-infection and identify risk factors for mortality during TB treatment.

STUDY DESIGN

We conducted a retrospective analysis of the Kenyan national TB program data for patients enrolled from 2013 through 2015. A total of 23 753 children aged less than 15 years were included in the analysis. Survival analysis was performed with censorship at 9 months and mortality was the main outcome. We used Cox proportional hazards regression for assessing risk factors for mortality.

RESULTS

Childhood TB accounted for 9% (n = 24 216) of all patients with TB; 98% of the notified children (n = 23 753) were included in the analysis. TB/HIV co-infection was 28% (n = 6112). Most TB cases (71%; n = 16 969) were detected through self-referral. Treatment was successful in 90% (n = 19 088) and 4% (n = 1058) died. Independent risk factors for mortality included being HIV infected but not on antiretroviral therapy (adjusted hazard ratio [aHR], 4.84; 95% CI, 3.59-6.51), being HIV infected and on antiretroviral therapy (aHR, 3.69; 95% CI, 3.14-4.35), children aged less than 5 years (aHR, 1.25; 95% CI, 1.08-1.44), and being diagnosed with smear negative pulmonary disease (aHR, 1.68; 95% CI, 1.27-2.24).

CONCLUSIONS

Most childhood TB cases in Kenya were detected through passive case finding. TB/HIV co-infection is high among children on treatment for TB, and HIV is associated with an increased risk of death. There is a need to intensify active case finding among children. TB prevention interventions among HIV-infected children, early diagnosis of HIV, and early antiretroviral therapy initiation among children on TB treatment should be strengthened.

Assessing the impact of antiretroviral therapy on tuberculosis notification rates among people with HIV: a descriptive analysis of 23 countries in sub-Saharan Africa, 2010-2015

BACKGROUND

HIV is a major driver of the tuberculosis epidemic in sub-Saharan Africa. The population-level impact of antiretroviral therapy (ART) scale-up on tuberculosis rates in this region has not been well studied. We conducted a descriptive analysis to examine evidence of population-level effect of ART on tuberculosis by comparing trends in estimated tuberculosis notification rates, by HIV status, for countries in sub-Saharan Africa.

METHODS

We estimated annual tuberculosis notification rates, stratified by HIV status during 2010-2015 using data from WHO, the Joint United Nations Programme on HIV/AIDS, and the United Nations Population Division. Countries were included in this analysis if they had ≥4 years of HIV prevalence estimates and ≥ 75% of tuberculosis patients with known HIV status. We compared tuberculosis notification rates among people living with HIV (PLHIV) and people without HIV via Wilcoxon rank sum test.

RESULTS

Among 23 included countries, the median annual average change in tuberculosis notification rates among PLHIV during 2010-2015 was -5.7% (IQR -6.9 to -1.7%), compared to a median change of -2.3% (IQR -4.2 to -0.1%) among people without HIV (p-value = 0.0099). Among 11 countries with higher ART coverage, the median annual average change in TB notification rates among PLHIV was -6.8% (IQR -7.6 to -5.7%) compared to a median change of -2.1% (IQR -6.0 to 0.7%) for PLHIV in 12 countries with lower ART coverage (p = 0.0106).

CONCLUSION

Tuberculosis notification rates declined more among PLHIV than people without HIV, and have declined more in countries with higher ART coverage. These results are consistent with a population-level effect of ART on decreasing TB incidence among PLHIV. To further reduce TB incidence among PLHIV, additional scale-up of ART as well as greater use of isoniazid preventive therapy and active case-finding will be necessary.

Spatial overlap links seemingly unconnected genotype-matched TB cases in rural Uganda

Introduction

Incomplete understanding of TB transmission dynamics in high HIV prevalence settings remains an obstacle for prevention. Understanding where transmission occurs could provide a platform for case finding and interrupting transmission.

Methods

From 2012–2015, we sought to recruit all adults starting TB treatment in a Ugandan community. Participants underwent household (HH) contact investigation, and provided names of social contacts, sites of work, healthcare and socializing, and two sputum samples. Mycobacterium tuberculosis culture-positive specimens underwent 24-loci MIRU-VNTR and spoligotyping. We sought to identify epidemiologic links between genotype-matched cases by analyzing social networks and mapping locations where cases reported spending ≥12 hours over the one-month pre-treatment. Sites of spatial overlap (≤100m) between genotype-matched cases were considered potential transmission sites. We analyzed social networks stratified by genotype clustering status, with cases linked by shared locations, and compared network density by location type between clustered vs. non-clustered cases.

Results

Of 173 adults with TB, 131 (76%) were enrolled, 108 provided sputum, and 84/131 (78%) were MTB culture-positive: 52% (66/131) tested HIV-positive. Of 118 adult HH contacts, 105 (89%) were screened and 3 (2.5%) diagnosed with active TB. Overall, 33 TB cases (39%) belonged to 15 distinct MTB genotype-matched clusters. Within each cluster, no cases shared a HH or reported shared non-HH contacts. In 6/15 (40%) clusters, potential epidemiologic links were identified by spatial overlap at specific locations: 5/6 involved health care settings. Genotype-clustered TB social networks had significantly greater network density based on shared clinics (p<0.001) and decreased density based on shared marketplaces (p<0.001), compared to non-clustered networks.

Conclusions

In this molecular epidemiologic study, links between MTB genotype-matched cases were only identifiable via shared locations, healthcare locations in particular, rather than named contacts. This suggests most transmission is occurring between casual contacts, and emphasizes the need for improved infection control in healthcare settings in rural Africa.

Reduction of HIV-associated excess mortality by antiretroviral treatment among tuberculosis patients in Kenya

Background

Mortality from TB continues to be a global public health challenge. TB ranks alongside Human Immunodeficiency Virus (HIV) as the leading infectious causes of death globally. HIV is a major driver of TB related morbidity and mortality while TB is the leading cause of mortality among people living with HIV/AIDS. We sought to determine excess mortality associated with HIV and the effect of antiretroviral therapy on reducing mortality among tuberculosis patients in Kenya.

Methods

We conducted a retrospective analysis of Kenya national tuberculosis program data of patients enrolled from 2013 through 2014. We used direct standardization to obtain standardized mortality ratios for tuberculosis patients compared with the general population. We calculated the population attributable fraction of tuberculosis deaths due to HIV based on the standardized mortality ratio for deaths among TB patients with HIV compared to TB patients without HIV. We used Cox proportional hazards regression for assessing risk factors for mortality.

Results

Of 162,014 patients included in the analysis, 6% died. Mortality was 10.6 (95% CI: 10.4–10.8) times higher among TB patients than the general population; 42% of deaths were attributable to HIV infection. Patients with HIV who were not receiving ART had an over four-fold risk of death compared to patients without HIV (aHR = 4.2, 95% CI 3.9–4.6). In contrast, patients with HIV who were receiving ART had only 2.6 times the risk of death (aHR = 2.6, 95% CI 2.5–2.7).

Conclusion

HIV was a significant contributor to TB-associated deaths in Kenya. Mortality among HIV-infected individuals was higher among those not on ART than those on ART. Early initiation of ART among HIV infected people (a “test and treat” approach) should further reduce TB-associated deaths.

Vaccine research and development: tuberculosis as a global health threat

One of the aims of the World Health Organisation (WHO) Millennium Development Goals (MDG) is to reduce the number of cases of tuberculosis (TB) infection by the year 2015. However, 9 million new cases were reported in 2013, with an estimated 480,000 new cases of multi-drug resistant tuberculosis (MDR-TB) globally. Bacille Calmette-Guérin (BCG) is the most available and currently used candidate vaccine against tuberculosis; it prevents childhood TB, but its effectiveness against pulmonary TB in adults and adolescents is disputed. To achieve the goal of the WHO MDG, the need for a new improved vaccine is of primary importance. This review highlights several articles that have reported vaccine development. There are about 16 TB vaccines in different phases of clinical trials at the time of writing, which include recombinant peptide/protein, live-attenuated and recombinant live-attenuated, protein/adjuvant, viral-vectored, and immunotherapeutic vaccine. Further studies in reverse vaccinology and massive campaigns on vaccination are needed in order to achieve the target for TB eradication by 2050.

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

Background

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

Methods

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

Results

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

Conclusion

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

Scale-up of ART in Malawi has reduced case notification rates in HIV-positive and HIV-negative tuberculosis

Setting: For 30 years, Malawi has experienced a dual epidemic of human immunodeficiency virus (HIV) infection and tuberculosis (TB) that has recently begun to be attenuated by the scale-up of antiretroviral therapy (ART). Objective: To report on the correlation between ART scale-up and annual national TB case notification rates (CNR) in Malawi, stratified by HIV-positive and HIV-negative status, from 2005 to 2015. Design: A retrospective descriptive ecological study using aggregate data from national reports. Results: From 2005 to 2015, ART was scaled up in Malawi from 28 470 to 618 488 total patients, with population coverage increasing from 2.4% to 52.2%. During this time, annual TB notifications declined by 35%, from 26 344 to 17 104, and the TB CNR per 100 000 population declined by 49%, from 206 to 105. HIV testing uptake increased from 51% to 92%. In known HIV-positive TB patients, the CNR decreased from a high of 1247/100 000 to 710/100 000, a 43% decrease. In known HIV-negative TB patients, the CNR also decreased, from a high of 66/100 000 to 49/100 000, a 26% decrease. Conclusion: TB case notifications have continued to decline in association with ART scale-up, with the decline seen more in HIV-positive than HIV-negative TB. These findings have programmatic implications for national TB control efforts.

Implementation and Operational Research: Declining Tuberculosis Incidence Among People Receiving HIV Care and Treatment Services in East Africa, 2007-2012

BACKGROUND

Antiretroviral therapy (ART) reduces the risk of Tuberculosis (TB) among people living with HIV (PLWH). With ART scale-up in sub-Saharan Africa over the past decade, incidence of TB among PLWH engaged in HIV care is predicted to decline.

METHODS

We conducted a retrospective analysis of routine clinical data from 168,330 PLWH receiving care at 35 facilities in Kenya, Tanzania, and Uganda during 2003-2012, participating in the East African region of the International Epidemiologic Databases to Evaluate AIDS. Temporal trends in facility-based annual TB incidence rates (per 100,000 person years) among PLWH and country-specific standardized TB incidence ratios using annual population-level TB incidence data from the World Health Organization were computed between 2007 and 2012. We examined patient-level and facility-level factors associated with incident TB using multivariable Cox models.

RESULTS

Overall, TB incidence rates among PLWH in care declined 5-fold between 2007 and 2012 from 5960 to 985 per 100,000 person years [P = 0.0003] (Kenya: 7552 to 1115 [P = 0.0007]; Tanzania: 7153 to 635 [P = 0.0025]; Uganda: 3204 to 242 [P = 0.018]). Standardized TB incidence ratios significantly decreased in the 3 countries, indicating a narrowing gap between incidence rates among PLWH and the general population. We observed lower hazards of incident TB among PLWH on ART and/or isoniazid preventive therapy and receiving care in facilities offering TB treatment onsite.

CONCLUSIONS

Annual TB incidence rates among PLWH significantly declined during ART scale-up but remained higher than the general population. Increasing access to ART and isoniazid preventive therapy and co-location of HIV and TB treatment may further reduce TB incidence among PLWH.

Association Analysis of Interleukin-17 Gene Polymorphisms with the Risk Susceptibility to Tuberculosis

BACKGROUND

Recently, many institutions have investigated the associations of interleukin-17 (IL17) polymorphisms with tuberculosis (TB) susceptibility, while those results are inconsistent. The purpose of this meta-analysis is to comprehensively assess whether IL17A rs22275913, IL17F rs763780, and IL17A rs3748067 polymorphisms are correlated with TB risk.

METHODS

Electronic bibliographic databases were searched for case-control studies which potentially focused on the relationship between the aforementioned polymorphisms and TB risk on October 15th, 2015. Pooled odds ratios (OR) combined with 95 % confidence intervals (CI) were employed to assess the associations.

RESULTS

There was no significant association of IL-17A rs22275913 polymorphism with susceptibility to TB in Asians or Caucasians. For IL-17A rs3748067 polymorphism, significant associations were observed in Asian (T vs. C: OR 1.461, 95 % CI 1.158-1.844, P = 0.001; TT vs. CC: OR 1.871, 95 % CI 1.140-3.069, P = 0.013; TT/TC vs. CC: OR 1.392 95 % CI 1.062-1.825, P = 0.017; TT vs.

TC/CC

OR 1.820, 95 % CI 1.111-2.981, P = 0.017). For IL-17F rs763780, we detected the significant associations under allele contrast, heterozygote, dominant and recessive models (C vs. T: OR 1.571, 95 % CI 1.352-1.824, P = 0.000; CT vs. TT: OR 1.624, 95 % CI 1.346-1.958, P = 0.000; CT/TT vs. TT: OR 1.639, 95 % CI 1.381-1.946, P = 0.000, respectively). The corresponding results were also detected in Asian populations (C vs. T: OR 1.068, 95 % CI 1.380-1.875, P = 0.000; CT vs. TT: OR 1.689, 95 % CI 1.390-2.053, P = 0.000; CT/TT vs. TT: OR 1.695, 95 % CI 1.420-2.023, P = 0.000), while there were no significant associations in Caucasian.

CONCLUSION

IL-17F rs763780 allele C and IL-17A rs3748067 allele C may be involved in the susceptibility to TB in Asian populations. There were no significant associations between IL-17A rs22275913 polymorphism and risk of TB.

Temporal trends in TB notification rates during ART scale-up in Cape Town: an ecological analysis

INTRODUCTION

Although antiretroviral therapy (ART) reduces individual tuberculosis (TB) risk by two-thirds, the population-level impact remains uncertain. Cape Town reports high TB notification rates associated with endemic HIV. We examined population trends in TB notification rates during a 10-year period of expanding ART.

METHODS

Annual Cape Town TB notifications were used as numerators and mid-year Cape Town populations as denominators. HIV-stratified population was calculated using overall HIV prevalence estimates from the Actuarial Society of South Africa AIDS and Demographic model. ART provision numbers from Western Cape government reports were used to calculate overall ART coverage. We calculated rates per 100,000 population over time, overall and stratified by HIV status. Rates per 100,000 total population were also calculated by ART use at treatment initiation. Absolute numbers of notifications were compared by age and sub-district. Changes over time were described related to ART provision in the city as a whole (ART coverage) and by sub-district (numbers on ART).

RESULTS

From 2003 to 2013, Cape Town's population grew from 3.1 to 3.7 million inhabitants, and estimated HIV prevalence increased from 3.6 to 5.2%. ART coverage increased from 0 to 63% in 2013. TB notification rates declined by 16% (95% confidence interval (CI), 14-17%) from a 2008 peak (851/100,000) to a 2013 nadir (713/100,000). Decreases were higher among the HIV-positive (21% (95% CI, 19-23%)) than the HIV-negative (9% (95% CI, 7-11%)) population. The number of HIV-positive TB notifications decreased mainly among 0- to 4- and 20- to 34-year-olds. Total population rates on ART at TB treatment initiation increased over time but levelled off in 2013. Overall median CD4 counts increased from 146 cells/µl (interquartile range (IQR), 66, 264) to 178 cells/µl (IQR 75, 330; p<0.001). Sub-district antenatal HIV seroprevalence differed (10-33%) as did numbers on ART (9-29 thousand). Across sub-districts, infant HIV-positive TB decreased consistently whereas adult decreases varied.

CONCLUSIONS

HIV-positive TB notification rates declined during a period of rapid scale-up of ART. Nevertheless, both HIV-positive and HIV-negative TB notification rates remained very high. Decreases among HIV positives were likely blunted by TB remaining a major entry to the ART programme and occurring after delayed ART initiation.