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

Survival and predictors of mortality after completion of TB treatment among people living with HIV: a 5-year analytical cohort

BACKGROUND

After completion of TB treatment patients may remain at risk of co-morbidity and mortality. We determined the survival and predictors of all-cause mortality after completing TB treatment among ART-experienced patients.

METHODS

This was a retrospective cohort analysis of all ART experienced patients who completed TB treatment at a specialist HIV clinic in Uganda, between 2009 and 2014. The patients were followed for five years after TB treatment. We determined the cumulative probability of death, and predictors of mortality using Kaplan-Meier methods and Cox proportional hazard models, respectively.

RESULTS

A total 1,287 patients completed TB treatment between 2009 and 2014, of which 1,111 were included in the analysis. At TB treatment completion, the median age was 36 years (IQR: 31-42), 563 (50.7%) were males, and median CD4 cell count was 235 cells/mL (IQR: 139-366). The person-time at risk was 4410.60 person-years. The all-cause mortality rate was 15.42 (95% CI: 12.14-19.59) per 1000 person-years. The probability of death at five years was 6.9% (95%CI: 5.5- 8.8). In the multivariable analysis, CD4 count < 200 cells/mL was a predictor of all-cause mortality (aHR = 1.81, 95%CI:1.06-3.11, p = 0.03) alongside history of retreatment (aHR = 2.12, 95%CI: 1.16-3.85, p = 0.01).

CONCLUSION

Survival post TB treatment in ART experienced PLHIV is reasonably good. Most deaths occur within two years after TB treatment completion. Patients with a low CD4 count and those with a history of retreatment have an increased risk of mortality which underscores the need for TB prophylaxis, detailed assessment, and close monitoring after completion of TB treatment.

Transmission modeling to infer tuberculosis incidence prevalence and mortality in settings with generalized HIV epidemics

Tuberculosis (TB) killed more people globally than any other single pathogen over the past decade. Where surveillance is weak, estimating TB burden estimates uses modeling. In many African countries, increases in HIV prevalence and antiretroviral therapy have driven dynamic TB epidemics, complicating estimation of burden, trends, and potential intervention impact. We therefore develop a novel age-structured TB transmission model incorporating evolving demographic, HIV and antiretroviral therapy effects, and calibrate to TB prevalence and notification data from 12 African countries. We use Bayesian methods to include uncertainty for all TB model parameters, and estimate age-specific annual risks of TB infection, finding up to 16.0%/year in adults, and the proportion of TB incidence from recent (re)infection, finding a mean across countries of 34%. Rapid reduction of the unacceptably high burden of TB in high HIV prevalence settings will require interventions addressing progression as well as transmission.

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.

Health economic analyses of latent tuberculosis infection screening and preventive treatment among people living with HIV in lower tuberculosis incidence settings: a systematic review

Introduction: In lower tuberculosis (TB) incidence countries (<100 cases/100,000/year), screening and preventive treatment (PT) for latent TB infection (LTBI) among people living with HIV (PLWH) is often recommended, yet guidelines advising which groups to prioritise for screening can be contradictory and implementation patchy. Evidence of LTBI screening cost-effectiveness may improve uptake and health outcomes at reasonable cost. Methods: Our systematic review assessed cost-effectiveness estimates of LTBI screening/PT strategies among PLWH in lower TB incidence countries to identify model-driving inputs and methodological differences. Databases were searched 1980-2020. Studies including health economic evaluation of LTBI screening of PLWH in lower TB incidence countries (<100 cases/100,000/year) were included. Results: Of 2,644 articles screened, nine studies were included. Cost-effectiveness estimates of LTBI screening/PT for PLWH varied widely, with universal screening/PT found highly cost-effective by some studies, while only targeting to high-risk groups (such as those from mid/high TB incidence countries) deemed cost-effective by others. Cost-effectiveness of strategies screening all PLWH from studies published in the past five years varied from US$2828 to US$144,929/quality-adjusted life-year gained (2018 prices). Study quality varied, with inconsistent reporting of methods and results limiting comparability of studies. Cost-effectiveness varied markedly by screening guideline, with British HIV Association guidelines more cost-effective than NICE guidelines in the UK. Discussion: Cost-effectiveness studies of LTBI screening/PT for PLWH in lower TB incidence settings are scarce, with large variations in methods and assumptions used, target populations and screening/PT strategies evaluated. The limited evidence suggests LTBI screening/PT may be cost-effective for some PLWH groups but further research is required, particularly on strategies targeting screening/PT to PLWH at higher risk. Standardisation of model descriptions and results reporting could facilitate reliable comparisons between studies, particularly to identify those factors driving the wide disparity between cost-effectiveness estimates. Registration: PROSPERO CRD42020166338 (18/03/2020).

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.

Population-Based Geospatial and Molecular Epidemiologic Study of Tuberculosis Transmission Dynamics, Botswana, 2012-2016

Tuberculosis (TB) elimination requires interrupting transmission of Mycobacterium tuberculosis. We used a multidisciplinary approach to describe TB transmission in 2 sociodemographically distinct districts in Botswana (Kopanyo Study). During August 2012-March 2016, all patients who had TB were enrolled, their sputum samples were cultured, and M. tuberculosis isolates were genotyped by using 24-locus mycobacterial interspersed repetitive units-variable number of tandem repeats. Of 5,515 TB patients, 4,331 (79%) were enrolled. Annualized TB incidence varied by geography (range 66-1,140 TB patients/100,000 persons). A total of 1,796 patient isolates had valid genotyping results and residential geocoordinates; 780 (41%) patients were involved in a localized TB transmission event. Residence in areas with a high burden of TB, age <24 years, being a current smoker, and unemployment were factors associated with localized transmission events. Patients with known HIV-positive status had lower odds of being involved in localized transmission.

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.

Antiretroviral Long-Term Efficacy and Resistance of Lopinavir/Ritonavir Plus Lamivudine in HIV-1-Infected Treatment-Naïve Patients (ALTERLL): 144-Week Results of a Randomized, Open-Label, Non-Inferiority Study From Guangdong, China

Dual therapy with lopinavir/ritonavir (LPV/r) plus lamivudine (3TC) has been demonstrated to be non-inferior to the triple drug regimen including LPV/r plus two nucleoside reverse transcriptase inhibitors (NRTIs) in 48-week studies. However, little is known about the long-term efficacy and drug resistance of this simplified strategy. A randomized, controlled, open-label, non-inferiority trial (ALTERLL) was conducted to assess the efficacy, drug resistance, and safety of dual therapy with LPV/r plus 3TC (DT group), compared with the first-line triple-therapy regimen containing tenofovir (TDF), 3TC plus efavirenz (EFV) (TT group) in antiretroviral therapy (ART)-naïve HIV-1-infected adults in Guangdong, China. The primary endpoint was the proportion of patients with plasma HIV-1 RNA < 50 copies/ml at week 144. Between March 1 and December 31, 2015, a total of 196 patients (from 274 patients screened) were included and randomly assigned to either the DT group (n = 99) or the TT group (n = 97). In the primary intention-to-treat (ITT) analysis at week 144, 95 patients (96%) in the DT group and 93 patients (95.9%) in the TT group achieved virological inhibition with plasma HIV-1 RNA <50 copies/ml (difference: 0.1%; 95% CI, -4.6-4.7%), meeting the criteria for non-inferiority. The DT group did not show significant differences in the mean increase in CD4+ cell count (247.0 vs. 204.5 cells/mm3; p = 0.074) or the CD4/CD8 ratio (0.47 vs. 0.49; p = 0.947) from baseline, or the inflammatory biomarker levels through week 144 compared with the TT group. For the subgroup analysis, baseline high viremia (HIV-1 RNA > 100,000 copies/ml) and genotype BC did not affect the primary endpoint or the mean increase in CD4+ cell count or CD4/CD8 ratio from baseline at week 144. However, in patients with genotype AE, the DT group showed a higher mean increase in CD4+ cell count from baseline through 144 weeks than the TT group (308.7 vs. 209.4 cells/mm3; p = 0.038). No secondary HIV resistance was observed in either group. Moreover, no severe adverse event (SAE) or death was observed in any group. Nonetheless, more patients in the TT group (6.1%) discontinued the assigned regimen than those in the DT group (1%) due to adverse events. Dual therapy with LPV/r plus 3TC manifests long-term non-inferior therapeutic efficacy, low drug resistance, good safety, and tolerability compared with the first-line triple-therapy regimen in Guangdong, China, indicating dual therapy is a viable alternative in resource-limited areas. Clinical Trial Registration: [http://www.chictr.org.cn], identifier [ChiCTR1900024611].

Health economic analyses of latent tuberculosis infection screening and preventive treatment among people living with HIV in lower tuberculosis incidence settings: a systematic review

Introduction: In lower tuberculosis (TB) incidence countries (<100 cases/100,000/year), screening and preventive treatment (PT) for latent TB infection (LTBI) among people living with HIV (PLWH) is often recommended, yet guidelines advising which groups to prioritise for screening can be contradictory and implementation patchy. Evidence of LTBI screening cost-effectiveness may improve uptake and health outcomes at reasonable cost. Methods: Our systematic review assessed cost-effectiveness estimates of LTBI screening/PT strategies among PLWH in lower TB incidence countries to identify model-driving inputs and methodological differences. Databases were searched 1980-2020. Studies including health economic evaluation of LTBI screening of PLWH in lower TB incidence countries (<100 cases/100,000/year) were included. Study quality was assessed using the CHEERS checklist. Results: Of 2,644 articles screened, nine studies were included. Cost-effectiveness estimates of LTBI screening/PT for PLWH varied widely, with universal screening/PT found highly cost-effective by some studies, while only targeting to high-risk groups (such as those from mid/high TB incidence countries) deemed cost-effective by others. Cost-effectiveness of strategies screening all PLWH from studies published in the past five years varied from US$2828 to US$144,929/quality-adjusted life-year gained (2018 prices). Study quality varied, with inconsistent reporting of methods and results limiting comparability of studies. Cost-effectiveness varied markedly by screening guideline, with British HIV Association guidelines more cost-effective than NICE guidelines in the UK. Discussion: Cost-effectiveness studies of LTBI screening/PT for PLWH in lower TB incidence settings are scarce, with large variations in methods and assumptions used, target populations and screening/PT strategies evaluated. The limited evidence suggests LTBI screening/PT may be cost-effective for some PLWH groups but further research is required, particularly on strategies targeting screening/PT to PLWH at higher risk. Standardisation of model descriptions and results reporting could facilitate reliable comparisons between studies, particularly to identify those factors driving the wide disparity between cost-effectiveness estimates. Registration: PROSPERO CRD42020166338 (18/03/2020).

HIV-associated tuberculosis

Tuberculosis (TB) remains a leading cause of morbidity and mortality among people living with HIV. HIV-associated TB disproportionally affects African countries, particularly vulnerable groups at risk for both TB and HIV. Currently available TB diagnostics perform poorly in people living with HIV; however, new diagnostics such as Xpert Ultra and lateral flow urine lipoarabinomannan assays can greatly facilitate diagnosis of TB in people living with HIV. TB preventive treatment has been underutilized despite its proven benefits independent of antiretroviral therapy (ART). Shorter regimens using rifapentine can support increased availability and scale-up. Mortality is high in people with HIV-associated TB, and timely initiation of ART is critical. Programs should provide decentralized and integrated TB and HIV care in settings with high burden of both diseases to improve access to services that diagnose TB and HIV as early as possible. The new prevention and diagnosis tools recently recommended by WHO offer an immense opportunity to advance our fight against HIV-associated TB. They should be made widely available and scaled up rapidly supported by adequate funding with robust monitoring of the uptake to advance global TB elimination.

Potential impact of tuberculosis vaccines in China, South Africa, and India

More effective tuberculosis vaccines are needed to help reach World Health Organization tuberculosis elimination goals. Insufficient evidence exists on the potential impact of future tuberculosis vaccines with varying characteristics and in different epidemiological settings. To inform vaccine development decision making, we modeled the impact of hypothetical tuberculosis vaccines in three high-burden countries. We calibrated Mycobacterium tuberculosis (M.tb) transmission models to age-stratified demographic and epidemiological data from China, South Africa, and India. We varied vaccine efficacy to prevent infection or disease, effective in persons M.tb uninfected or infected, and duration of protection. We modeled routine early-adolescent vaccination and 10-yearly mass campaigns from 2025. We estimated median percentage population-level tuberculosis incidence rate reduction (IRR) in 2050 compared to a no new vaccine scenario. In all settings, results suggested vaccines preventing disease in M.tb-infected populations would have greatest impact by 2050 (10-year, 70% efficacy against disease, IRR 51%, 52%, and 54% in China, South Africa, and India, respectively). Vaccines preventing reinfection delivered lower potential impact (IRR 1, 12, and 17%). Intermediate impact was predicted for vaccines effective only in uninfected populations, if preventing infection (IRR 21, 37, and 50%) or disease (IRR 19, 36, and 51%), with greater impact in higher-transmission settings. Tuberculosis vaccines have the potential to deliver substantial population-level impact. For prioritizing impact by 2050, vaccine development should focus on preventing disease in M.tb-infected populations. Preventing infection or disease in uninfected populations may be useful in higher transmission settings. As vaccine impact depended on epidemiology, different development strategies may be required.

Cost-effectiveness of a 12 country-intervention to scale up short course TB preventive therapy among people living with HIV

INTRODUCTION

In 2017, the Aurum Institute, with support from Unitaid, launched an initiative to expand short-course therapy for the prevention of tuberculosis (TB) in 12 high-burden countries. This study aimed to investigate the importance of "catalytic" effects beyond the original project timeframe when estimating cost-effectiveness of such large investments.

METHODS

We estimated the cost-effectiveness of the IMPAACT4TB (I4TB) initiative from a health system perspective, using a 10-year time horizon. We first conservatively estimated costs using a "top-down" approach considering only the direct health benefits of providing TB preventive therapy to people initiating antiretroviral therapy (ART) through I4TB activities. We then re-estimated the incremental cost-effectiveness of I4TB incorporating the costs and health benefits of potential catalytic effects beyond the program itself.

RESULTS

We estimated that TB preventive therapy through the I4TB initiative alone would prevent 14 201 cases of active TB and 1562 TB deaths over 10 years with an up-front investment of $52.5 million; the estimated incremental cost-effectiveness was $1580 per disability-adjusted life year (DALY) averted. If this initiative could achieve its desired catalytic effects, an additional 375 648 cases and 41 321 deaths could be averted, at an incremental cost of $546 million and cost-effectiveness of $713 per DALY averted.

CONCLUSIONS

Our findings provide donors with reasonable evidence of value for money to support investment in short-course TB preventive therapy for people initiating ART in high-burden settings. Our study also illustrates the importance of considering long-term secondary ("catalytic") effects when evaluating the cost-effectiveness of large-scale initiatives designed to change a global policy landscape.

Mortality and risk of tuberculosis among people living with HIV in whom TB was initially ruled out

Tuberculosis (TB) misdiagnosis remains a public health concern, especially among people living with HIV (PLHIV), given the high mortality associated with missed TB diagnoses. The main objective of this study was to describe the all-cause mortality, TB incidence rates and their associated risk factors in a cohort of PLHIV with presumptive TB in whom TB was initially ruled out. We retrospectively followed a cohort of PLHIV with presumptive TB over a 2 year-period in a rural district in Southern Mozambique. During the study period 382 PLHIV were followed-up. Mortality rate was 6.8/100 person-years (PYs) (95% CI 5.2-9.2) and TB incidence rate was 5.4/100 PYs (95% CI 3.9-7.5). Thirty-six percent of deaths and 43% of TB incident cases occurred in the first 12 months of the follow up. Mortality and TB incidence rates in the 2-year period after TB was initially ruled out was very high. The TB diagnostic work-up and linkage to HIV care should be strengthened to decrease TB burden and all-cause mortality among PLHIV with presumptive TB.

Pharmacokinetic study of two different rifabutin doses co-administered with lopinavir/ritonavir in African HIV and tuberculosis co-infected adult patients

Background

This study aimed to assess the pharmacokinetic profile of 150 mg rifabutin (RBT) taken every other day (every 48 h) versus 300 mg RBT taken every other day (E.O.D), both in combination with lopinavir/ritonavir (LPV/r), in adult patients with human immunodeficiency virus (HIV) and tuberculosis (TB) co-infection.

Methods

This is a two-arm, open-label, pharmacokinetic, randomised study conducted in Burkina Faso between May 2013 and December 2015. Enrolled patients were randomised to receive either 150 mg RBT EOD (arm A, 9 subjects) or 300 mg RBT EOD (arm B, 7 subjects), both associated with LPV/r taken twice daily. RBT plasma concentrations were evaluated after 2 weeks of combined HIV and TB treatment. Samples were collected just before drug ingestion and at 1, 2, 3, 4, 6, 8, and 12 h after drug ingestion to measure plasma drug concentration using an HPLC-MS/MS assay.

Results

The Cmax and AUC_0–12h medians in arm A (Cmax = 296 ng/mL, IQR: 205–45; AUC_0–12h = 2528 ng.h/mL, IQR: 1684–2735) were lower than those in arm B (Cmax = 600 ng/mL, IQR: 403–717; AUC_0–12h = 4042.5 ng.h/mL, IQR: 3469–5761), with a statistically significant difference in AUC_0–12h (p = 0.044) but not in Cmax (p = 0.313). No significant differences were observed in Tmax (3 h versus 4 h). Five patients had a Cmax below the plasma therapeutic limit (< 300 ng/mL) in the 150 mg RBT arm, while the Cmax was above this threshold for all patients in the 300 mg RBT arm. Additionally, at 48 h after drug ingestion, all patients had a mycobacterial minimum inhibitory concentration (MIC) above the limit (> 64 ng/mL) in the 300 mg RBT arm, while 4/9 patients had such values in the 150 mg RBT arm.

Conclusion

This study confirmed that the 150 mg dose of rifabutin ingested EOD in combination with LPV/r is inadequate and could lead to selection of rifamycin-resistant mycobacteria.

Trial registration

PACTR201310000629390, 28th October 2013.

Systematic or Test-Guided Treatment for Tuberculosis in HIV-Infected Adults

BACKGROUND

In regions with high burdens of tuberculosis and human immunodeficiency virus (HIV), many HIV-infected adults begin antiretroviral therapy (ART) when they are already severely immunocompromised. Mortality after ART initiation is high in these patients, and tuberculosis and invasive bacterial diseases are common causes of death.

METHODS

We conducted a 48-week trial of empirical treatment for tuberculosis as compared with treatment guided by testing in HIV-infected adults who had not previously received ART and had CD4+ T-cell counts below 100 cells per cubic millimeter. Patients recruited in Ivory Coast, Uganda, Cambodia, and Vietnam were randomly assigned in a 1:1 ratio to undergo screening (Xpert MTB/RIF test, urinary lipoarabinomannan test, and chest radiography) to determine whether treatment for tuberculosis should be started or to receive systematic empirical treatment with rifampin, isoniazid, ethambutol, and pyrazinamide daily for 2 months, followed by rifampin and isoniazid daily for 4 months. The primary end point was a composite of death from any cause or invasive bacterial disease within 24 weeks (primary analysis) or within 48 weeks after randomization.

RESULTS

A total of 522 patients in the systematic-treatment group and 525 in the guided-treatment group were included in the analyses. At week 24, the rate of death from any cause or invasive bacterial disease (calculated as the number of first events per 100 patient-years) was 19.4 with systematic treatment and 20.3 with guided treatment (adjusted hazard ratio, 0.95; 95% confidence interval [CI], 0.63 to 1.44). At week 48, the corresponding rates were 12.8 and 13.3 (adjusted hazard ratio, 0.97 [95% CI, 0.67 to 1.40]). At week 24, the probability of tuberculosis was lower with systematic treatment than with guided treatment (3.0% vs. 17.9%; adjusted hazard ratio, 0.15; 95% CI, 0.09 to 0.26), but the probability of grade 3 or 4 drug-related adverse events was higher with systematic treatment (17.4% vs. 7.2%; adjusted hazard ratio 2.57; 95% CI, 1.75 to 3.78). Serious adverse events were more common with systematic treatment.

CONCLUSIONS

Among severely immunosuppressed adults with HIV infection who had not previously received ART, systematic treatment for tuberculosis was not superior to test-guided treatment in reducing the rate of death or invasive bacterial disease over 24 or 48 weeks and was associated with more grade 3 or 4 adverse events. (Funded by the Agence Nationale de Recherches sur le Sida et les Hépatites Virales; STATIS ANRS 12290 ClinicalTrials.gov number, NCT02057796.).

Two-drug vs. three-drug combinations for HIV-1: Do we have enough data to make the switch?

Three-drug combination antiretroviral therapy (ART) became available in 1996, dramatically improving the prognosis of people living with HIV. The clinical benefits of ART are due to the sustained viral load suppression and CD4 T cell gains. Major drawbacks of the first ART regimens were adverse events, and high pill burden, which led to the reduction of drug adherence resulting in frequent treatment discontinuations and the development of drug resistance. Due to increased viral potency of new antiretroviral drugs consideration of a two-drug combination therapy repositioning occurred in an effort to reduce adverse events, drug-drug interactions and cost, while maintaining a sustained antiviral effect. Various combinations of two-drug regimens have been studied, and non-inferiority compared to a three-drug regimen has been shown only for some of them. In addition, a two-drug combination regimen may not be suitable for every patient, especially those who are pregnant, those with tuberculosis or coexisting HBV infection. Furthermore no information has been generated concerning the secondary transmission of HIV from patients who have undetectable plasma viral load on two-drug regimens. Additional studies of two-drug combinations are also necessary to evaluate the debated existence of low viral replication in tissues and on immune activation. While there is no urgent need to routinely switch patients to two-drug combination therapy, due to the availability of drug combinations without significant toxicities, dual regimens represent a suitable option that deserve long-term evaluation before being introduced to clinical practice.

Delays in HIV and TB diagnosis and treatment initiation in co-infected patients in Colombia

We investigated the delays in the diagnosis of tuberculosis and/or HIV, their treatment initiation, and factors associated with each delay. All drug-susceptible tuberculosis cases diagnosed in 2014 and 2015 in Colombia, with a confirmed diagnosis of HIV were included. A total of 1909 patients were registered with tuberculosis/HIV co-infection. Seventy-nine percent of patients were men, 50% had sputum smear-negative tuberculosis, culture was done in 50% of cases, 68.5% had <200 CD4 cell count at diagnosis, and 35% had concurrent tuberculosis/HIV diagnosis. Delays in the tuberculosis diagnosis were identified in 54.8% of the patients, and delays in tuberculosis and HIV treatment initiation in 41.8% and 27.4%, respectively. The risk factors associated with delay in tuberculosis diagnosis were age between 15–34 and ≥45 years, and those patients who received tuberculin skin test. The risk factor associated with antiretroviral therapy initiation delay was previously-treated tuberculosis patients after failure. It is necessary to implement strategies for early detection and treatment initiation of HIV and to use rapid test for tuberculosis diagnosis in this population.

Survival model analysis of tuberculosis treatment among patients with human immunodeficiency virus coinfection

Background

Tuberculosis (TB) with human immunodeficiency virus (HIV) coinfection is the highest clinical epidemiology and public health issue. Despite many programs established to tackle the epidemic, TB target controls have not been reached. One of the many factors attributed to the failure in TB treatment is HIV coinfection. The aim of this study is to assess the survival rate of HIV infection among TB patients and the risk factors of death among the TB patients with HIV coinfection during the retro of directly observed treatment, short-course (DOTS) program.

Methods

This study is a retrospective cohort conducted to compare the survivorship between TB/HIV patients for 8 months DOTS. Death among TB patients was considered as failures and those defaulted or survived were censored. The Cox proportional-hazards regression and log-linear model were used to establish the hazard ratio (HR) of death for each variable at baseline and estimate the risk factors effect among TB patients.

Results

The findings revealed that 50% of death from TB/HIV patients were from HIV coinfection (advanced HR = 2.01, 95% confidence interval = 1.13-3.17). The risk of death was significantly higher in HIV-positive TB patients (P = 0.000) during the extension care phase. TB/HIV-positive patients on antiretroviral therapy have decreased survival rate (log-rank test = 14.88, df = 2, P = 0.0001). The probability of TB patients surviving is significantly decreased in HIV positive with some factors such as age, weight, smoking, and alcohol found significant.

Conclusion

The probability of survival in HIV-positive TB patients was significantly lower during the TB treatment. Weight loss, age, alcohol, smoking, and pregnancy were showed to affect the survival probability of TB/HIV patients' coinfection significantly.

Tuberculosis: a focused review for the emergency medicine clinician

INTRODUCTION

Tuberculosis (TB) is a common disease worldwide, affecting nearly one-third of the world's population. While TB has decreased in frequency in the United States, it remains an important infection to diagnose and treat.

OBJECTIVE

This narrative review discusses the evaluation and management of tuberculosis, with an emphasis on those factors most relevant for the emergency clinician.

DISCUSSION

TB is caused by Mycobacterium tuberculosis and is highly communicable through aerosolized particles. A minority of patients will develop symptomatic, primary disease. Most patients will overcome the initial infection or develop a latent infection, which can reactivate. Immunocompromised states increase the risk of primary and reactivation TB. Symptoms include fever, prolonged cough, weight loss, and hemoptysis. Initial diagnosis often includes a chest X-ray, followed by serial sputum cultures. If the patient has a normal immune system and a normal X-ray, active TB can be excluded. Newer tests, including nucleic acid amplification testing, can rapidly diagnose active TB with high sensitivity. Treatment for primary and reactivation TB differs from latent TB. Extrapulmonary forms can occur in a significant proportion of patients and involve a range of different organ systems. Patients with human immunodeficiency virus are high-risk and require specific considerations.

CONCLUSIONS

TB is a disease associated with significant morbidity and mortality. The emergency clinician must consider TB in the appropriate setting, based on history and examination. Accurate diagnosis and rapid therapy can improve patient outcomes and reduce the spread of this communicable disease.

Factors associated with mortality in persons co-infected with tuberculosis and HIV in Suriname: a retrospective cohort study

Objective.

To identify socio-demographic and clinical factors associated with mortality among persons with tuberculosis (TB) and TB/HIV co-infection in Suriname.

Methods.

This was a retrospective cohort study using data from the national TB and HIV databases for 2010 – 2015. The survival probability of TB and TB/HIV co-infected patients was analyzed using the Kaplan-Meier estimates and the log-rank test. A Cox proportional hazard model was applied.

Results.

The study showed that HIV-seropositivity (aHR: 2.08, 95%CI: 1.48 – 2.92) and older age (aHR: 5.84, 95%CI: 3.00 – 11.4) are statistically associated with higher mortality. For the TB/HIV co-infected patients, TB treatment (aHR: 0.43, 95%CI: 0.35 – 0.53) reduces the risk of death. Similarly, HIV treatment started within 56 days (aHR: 0.15, 95%CI: 0.12 – 0.19) and delayed (aHR: 0.25, 95%CI: 0.13 – 0.47) result in less hazard for mortality; Directly-Observed Treatment (aOR: 0.16, 95%CI: 0.09 – 0.29) further reduces the risk.

Conclusions.

The Ministry of Health of Suriname should develop strategies for early case-finding in key populations, such as for HIV and TB in men 60 years of age and older. Implementation of Isoniazid Preventive Therapy for HIV should be pursued. Scaling up TB and HIV treatment, preferably through supervision, are essential to reducing the TB/HIV mortality.

Treatment outcomes and antiretroviral uptake in multidrug-resistant tuberculosis and HIV co-infected patients in Sub Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) in HIV endemic settings is a major threat to public health. MDR-TB is a substantial and underreported problem in Sub-Saharan Africa (SSA), with recognised cases projected to increase with advancement in diagnostic technology. There is paucity of review evidence on treatment outcomes and antiretroviral (ART) uptake among MDR-TB patients with HIV in SSA. To address this gap a review of treatment outcomes in HIV patients co-infected with MDR-TB in the SSA region was undertaken.

METHODS

Three databases (Medline, Web of Science, CINHAL), Union on Lung Heath conference proceedings and grey literature were searched for publications between January 2004 and May 2018. Records were assessed for eligibility and data extracted. Random effect meta-analysis was conducted using STATA and Cochrane's review manager.

RESULTS

A total of 271 publications were identified of which nine fulfilled the inclusion criteria. Data was collected from 3368 MDR-TB and HIV co-infected patients from four SSA countries; South Africa (6), Lesotho (1), Botswana (1) and Ethiopia (1). The most common outcome was cure (34.9% cured in the pooled analysis), this was followed by death (18.1% in pooled analysis). ART uptake was high, at 83% in the pooled analysis. Cure ranged from 28.6 to 54.7% among patients on ART and from 22.2 to 57.7%  among those not on ART medication. MDR-TB and HIV co-infected patients were less likely to be successfully treated than HIV negative MDR-TB patients (Risk Ratio = 0.87, 95% CI 0.97, 0.96).

CONCLUSION

Treatment outcomes for MDR-TB and HIV co-infected patients do not vary widely from those reported globally. However, treatment success was lower among HIV positive MDR-TB patients compared to HIV negative MDR-TB patients. Prompt antiretroviral initiation and interventions to improve treatment adherence are necessary.

Mortality during treatment for tuberculosis; a review of surveillance data in a rural county in Kenya

Background

Globally in 2016, 1.7 million people died of Tuberculosis (TB). This study aimed to estimate all-cause mortality rate, identify features associated with mortality and describe trend in mortality rate from treatment initiation.

Method

A 5-year (2012–2016) retrospective analysis of electronic TB surveillance data from Kilifi County, Kenya. The outcome was all-cause mortality within 180 days after starting TB treatment. The risk factors examined were demographic and clinical features at the time of starting anti-TB treatment. We performed survival analysis with time at risk defined from day of starting TB treatment to time of death, lost-to-follow-up or completing treatment. To account for ‘lost-to-follow-up’ we used competing risk analysis method to examine risk factors for all-cause mortality.

Results

10,717 patients receiving TB treatment, median (IQR) age 33 (24–45) years were analyzed; 3,163 (30%) were HIV infected. Overall, 585 (5.5%) patients died; mortality rate of 12.2 (95% CI 11.3–13.3) deaths per 100 person-years (PY). Mortality rate increased from 7.8 (95% CI 6.4–9.5) in 2012 to 17.7 (95% CI 14.9–21.1) in 2016 per 100PY (P_trend<0.0001). 449/585 (77%) of the deaths occurred within the first three months after starting TB treatment. The median time to death (IQR) declined from 87 (40–100) days in 2012 to 46 (18–83) days in 2016 (P_trend = 0·04). Mortality rate per 100PY was 7.3 (95% CI 6.5–7.8) and 23.1 (95% CI 20.8–25.7) among HIV-uninfected and HIV-infected patients respectively. Age, being a female, extrapulmonary TB, being undernourished, HIV infected and year of diagnosis were significantly associated with mortality.

Conclusions

We found most deaths occurred within three months and an increasing mortality rate during the time under review among patients on TB treatment. Our results therefore warrant further investigation to explore host, disease or health system factors that may explain this trend.

Impact of HIV on spontaneous spondylodiscitis

AIMS

HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients' CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them.

PATIENTS AND METHODS

Between January 2014 and December 2015, 63 consecutive cases of spontaneous spondylodiscitis were identified from a single-centre, prospectively maintained database. Demographics, presenting symptoms, blood results, HIV status, bacteriology, imaging, and procedure undertaken were reviewed and comparisons made of TB, non-TB, and HIV groups. There were 63 patients (22 male, 41 female) with a mean age of 42.0 years (11 to 78; sd 15.0).

RESULTS

In total, 53 patients had tuberculous, nine bacterial, and one cryptococcal spondylodiscitis. There were 29 HIV-positive patients, 29 HIV-negative patients, and five patients with unknown HIV status. The local incidence of TB spondylodiscitis was 1.54/100 000 and that of non-TB spondylodiscitis was 0.29/100 000 per annum. TB patients were younger with similar clinical presentation and infective markers, but were more likely to have a paraspinal abscess. They were also less likely to have a hyperintense disc on MRI. There was no difference between the two HIV groups.

CONCLUSION

In areas of endemic TB and HIV, TB remains the most common cause of spondylodiscitis at five times the rate of non-tuberculous causes. HIV managed with HAART increases the rate of infection but does not influence the bacteriology unless there is a low CD4. There was little to differentiate the groups. TB /HIV co-infected patients were younger than non-TB and HIV-negative patients. Non-TB patients were more likely to have disc hyperintensity on MRI and TB patients were more likely to have abscess formation, but as both groups exhibited these features, neither was diagnostic. Culture confirmation remains necessary. Cite this article: Bone Joint J 2019;101-B:617-620.

Isoniazid Preventive Therapy for People With HIV Who Are Heavy Alcohol Drinkers in High TB-/HIV-Burden Countries: A Risk-Benefit Analysis

BACKGROUND

Isoniazid preventive therapy (IPT) reduces mortality among people living with HIV (PLHIV) and is recommended for those without active tuberculosis (TB) symptoms. Heavy alcohol use, however, is contraindicated for liver toxicity concerns. We evaluated the risks and benefits of IPT at antiretroviral therapy (ART) initiation to ART alone for PLHIV who are heavy drinkers in 3 high TB-/HIV-burden countries.

METHODS

We developed a Markov simulation model to compare ART alone to ART with either 6 or 36 months of IPT for heavy drinking PLHIV enrolling in care in Brazil, India, and Uganda. Outcomes included nonfatal toxicity, fatal toxicity, life expectancy, TB cases, and TB death.

RESULTS

In this simulation, 6 months of IPT + ART (IPT6) extended life expectancy over both ART alone and 36 months of IPT + ART (IPT36) in India and Uganda, but ART alone dominated in Brazil in 51.5% of simulations. Toxicity occurred in 160/1000 persons on IPT6 and 415/1000 persons on IPT36, with fatal toxicity in 8/1000 on IPT6 and 21/1000 on IPT36. Sensitivity analyses favored IPT6 in India and Uganda with high toxicity thresholds.

CONCLUSIONS

The benefits of IPT for heavy drinkers outweighed its risks in India and Uganda when given for a 6-month course. The toxicity/efficacy trade-off was less in Brazil where TB incidence is lower. IPT6 resulted in fatal toxicity in 8/1000 people, whereas even higher toxicities of IPT36 negated its benefits in all countries. Data to better characterize IPT toxicity among HIV-infected drinkers are needed to improve guidance.

Macrodetermined racial inequalities in diagnostic testing among tuberculosis patients in Brazil

OBJECTIVES

To estimate the association between tuberculosis (TB) patients' race and patients' access to diagnostic testing in Brazil. In addition, we evaluated if the associations could be explained by a geographic codistribution between racial groups and diagnostic testing.

STUDY DESIGN

It is a cross-sectional study based on secondary data from a national surveillance system of new TB cases diagnosed in 2015.

METHODS

We evaluated the association between TB patients' race (independent variable) and the HIV testing and TB mycobacterial culture providing (dependent variables) with logistic regression models. We used multilevel models to consider different geopolitical levels (region, state and municipality). In addition, we used conditional logistic regressions matched by health-care unit. All models were adjusted by individual covariates associated with the outcomes.

RESULTS

Compared with non-Afro-Brazilian patients, Afro-Brazilian patients had significantly lower odds to have had HIV testing [odds ratio (OR): 0.72; 95% confidence interval (CI): 0.69-0.75] and mycobacterial culture performed (OR: 0.74; 95% CI: 0.71-0.77). However, these statistically significant negative associations between Afro-Brazilian racial category and testing disappeared when patients were considered as nested in geopolitical contexts or matched for health-care unit.

CONCLUSIONS

Afro-Brazilian TB patients had lower probability to have HIV test and mycobacterial culture performed. However, these associations seem to be macrodeterminated by the geographic distribution of both racial groups and diagnostic testing. Our findings can support the formulation of public policies aiming to mitigate regional disparities as a strategy to improve racial equity in access to healthcare. The approach presented can be applied in a range of scenarios to identify disparities, localize its source and support decision-making.

Tuberculosis burden on AIDS in Brazil: A study using linked databases

Objectives

To estimate the burden of tuberculosis (TB) in reported AIDS cases, to compare the characteristics of TB/HIV subjects with those without TB and to evaluate survival with or without TB in Brazil.

Methods

The data source was the linked database between AIDS (2011–2014) and TB (2011–2014) databases from the Notifiable Diseases Information System (SINAN). The sociodemographic, clinical, laboratory results and use of antiretroviral therapy (ART) data were compared by TB occurrence or not. Survival probability was estimated using the Kaplan-Meier method and associated factors were sought using Cox regression.

Results

The proportion of TB diagnosed from 2011 to 2014 among AIDS cases reported between 2006 and 2014 was 6.3%. Subjects coinfected with TB were predominantly male, older, with lower schooling, with lower CD4 count, higher viral load, and higher proportion of ART initiation than those without TB. 57.5% were diagnosed with HIV before TB, 38.2% as concurrent TB/HIV and 4.3% with TB before HIV. 16,466 reported TB cases were not found in the AIDS database, although registered as HIV-infected in the SINAN TB database between 2011 and 2014. Median survival for PLHIV was 581 days, with 582 for those without TB, significantly higher than 547 for those with TB (log-rank teste, p = 0,001). In the Cox multivariate analysis, male gender [aHR = 1.27 (CI 95% 1.22–1.33)], older age [aHR = 1.020 (CI 95% 1.019–1.022)] and TB coinfection [aHR = 1.97 (CI 95% 1.88–2.07)] were positively associated with adjusted hazard of death, whereas CD4 count 200–499 cells [aHR = 0.21 (CI 95% 0.20–0.22)] and receiving ART [aHR = 0.2 2(CI 95% 0.21–0.23)] reduced the risk of death.

Conclusions

HIV-infected subjects should be screened for TB at care entry, to minimize diagnosis and treatment delays when active TB is present or to increase the odds of being offered latent TB infection therapy to prevent TB. On the other hand, TB cases should be promptly tested for HIV. All those will contribute to reduce mortality among people living with AIDS.

Opportunistic diseases diminish the clinical benefit of immediate antiretroviral therapy in HIV-tuberculosis co-infected adults with low CD4+ cell counts

INTRODUCTION

HIV-tuberculosis (TB) co-infection remains an important cause of mortality in sub-Saharan Africa. Clinical trials have reported early (within 2 weeks of TB therapy) antiretroviral therapy (ART) reduces mortality among HIV-TB co-infected research participants with low CD4 cell counts, but this has not been consistently observed. We aimed to evaluate the current WHO recommendations for ART in HIV-TB co-infected patients on mortality in routine clinical settings.

METHODS

We compared two cohorts before (2008-2010) and after (2012-2013) policy change on ART timing after TB and examined the effectiveness of early versus delayed ART on mortality in HIV-TB co-infected participants with CD4 cell count 100 cells/μl or less. We used inverse probability censoring-weighted Cox models on baseline characteristics to balance the study arms and generated hazard ratios for mortality.

RESULTS

Of 356 participants with CD4 cell counts 100 cells/μl or less, 180 were in the delayed ART cohorts whereas 176 were in the early ART cohorts. Their median age (32.5 versus 32 years) and baseline CD4 cell counts (26.5 versus 26 cells/μl) respectively were similar. There was no difference in mortality rates of both cohorts. The risk of death increased in participants with a positive Cryptococcal antigen (CrAg) test in both the early ART cohort (aHR = 2.6, 95% CI 1.0-6.8; P = 0.045) and the delayed ART cohort (aHR = 4.2, 95% CI 1.9-9.0; P < 0.001 CONCLUSION:: Early ART in patients with HIV-TB co-infection was not associated with reduced risk of mortality in routine care. Asymptomatic Cryptococcal antigenaemia increased the risk of mortality in both cohorts.

Workability of patients with HIV/AIDS in Northern Vietnam: a societal perspective on the impact of treatment program

In Vietnam, the antiretroviral therapy (ART) program has been widely scaled up across the country since 2005, and now covers treatment for about half the HIV population. However, limited data exist about the workability and productivity outcome of ART in Vietnam. We aim to assess the employment status and work productivity among HIV patients taking ART in Northern Vietnam. A cross-sectional study was conducted in Hanoi and Nam Dinh with 1133 participants taking ART at the selected clinics. The Work Productivity and Activity Impairment Questionnaire: General Health (WPAI-GH) was applied. We found that 23% of patients with HIV/AIDS reported overall work productivity loss, and 12% had activity impairment. Among those having a job, their monthly income, however, was significantly lower than national averages 2806 thousand VND vs. 4120 thousand VND). The average education level of participants was low, with only 41.61% having greater than secondary education. Health problems and lower CD4 cell counts decreased workability of the patients while having a more dependent family, being a smoker or having a later HIV stage was associated with being less likely to have a job. The rate of employment among HIV/AIDS patients in this study was high however incomes were substantially lower than average. This could be due to low education levels or social stigma regarding these patients. Vocational education programs and public awareness could empower the patients economically. Similarly, a number of social and behavioral problems were associated with decreasing the working rate and productivity. Addressing these health issues may improve productivity among patients.

HIV and TB co-infection in the ART era: CD4 count distributions and TB case fatality in Cape Town

BACKGROUND

In Cape Town, the roll-out of antiretroviral therapy (ART) has increased over the last decade with an estimated coverage of 63% of HIV- positive patients in 2013. The influence of ART on the characteristics of the population of HIV-positive patients presenting to the primary care TB programme is unknown. In this study, we examined trends in CD4 count distribution, ART usage and treatment outcomes among HIV-positive TB patients in Cape Town from 2009 to 2013.

METHODS

Data from the electronic TB register on all newly registered drug-sensitive TB patients ≥18 years were analyzed retrospectively. Descriptive statistics were used to compare baseline characteristics, the CD4 count distribution and TB treatment outcomes both by year of treatment and ART status at the start of TB treatment. Survival analyses were used to assess the change in mortality risk during TB treatment over time, stratified by ART status at start of TB treatment.

RESULTS

118,989 patients were treated over 5 years. HIV prevalence among TB patients decreased from 50.9% in 2009 to 49.0% in 2013. The absolute number of HIV-positive TB cases declined by 13.2% between 2010 and 2013. More patients entered the TB programme on ART in 2013 compared to 2009 (30.0% vs 9.9%). Among these, the CD4 count distribution showed a year by year shift to higher CD4 counts. In 2013, over 75% of ART-naïve TB patients still had a CD4 count < 350 cells/mm3. ART initiation among ART-naive patients increased from 37.0 to 77.7% and TB case fatality declined from 7.4 to 5.2% (p < 0.001). In multivariate analysis a decrease in TB mortality was most strongly associated with CD4 count (Adjusted HR 0.82 per increase of 50 cells/mm3, 95% CI: 0.81-0.83, p < 001) and the initiation of ART during TB treatment (Adjusted HR 0.39, 95% CI: 0.35-0.42, p < 0.001).

CONCLUSION

Comprehensive changes in the ART and TB treatment programmes resulted in incremental increases in ART coverage for HIV-positive TB patients and a subsequent decrease in TB case fatality due to increased ART uptake in HIV-positive ART-naïve patients. However TB still remained a major presenting opportunistic infection with the majority of cases occurring at low CD4 counts.

Risk factors for extrapulmonary dissemination of tuberculosis and associated mortality during treatment for extrapulmonary tuberculosis

Many environmental, host, and microbial characteristics have been recognized as risk factors for dissemination of extrapulmonary tuberculosis (EPTB). However, there are few population-based studies investigating the association between the primary sites of tuberculosis (TB) infection and mortality during TB treatment. De-identified population-based surveillance data of confirmed TB patients reported from 2009 to 2015 in Texas, USA, were analyzed. Regression analyses were used to determine the risk factors for EPTB, as well as its subsite distribution and mortality. We analyzed 7007 patients with exclusively pulmonary TB, 1259 patients with exclusively EPTB, and 894 EPTB patients with reported concomitant pulmonary involvement. Age ≥45 years, female gender, human immunodeficiency virus (HIV)-positive status, and end-stage renal disease (ESRD) were associated with EPTB. ESRD was associated with the most clinical presentations of EPTB other than meningeal and genitourinary TB. Patients age ≥45 years had a disproportionately high rate of bone TB, while foreign-born patients had increased pleural TB and HIV+ patients had increased meningeal TB. Age ≥45 years, HIV+ status, excessive alcohol use within the past 12 months, ESRD, and abnormal chest radiographs were independent risk factors for EPTB mortality during TB treatment. The epidemiologic risk factors identified by multivariate analyses provide new information that may be useful to health professionals in managing patients with EPTB.

Antiretroviral Therapy in HIV-Infected Children With Tuberculosis: A Systematic Review

BACKGROUND

Tuberculosis (TB) is the major cause of mortality in HIV-infected children globally. Current guidelines about the management of antiretroviral therapy in children with TB are based on a limited number of nonrandomized studies involving small numbers of participants. The aim of the study was to systematically retrieve and critically appraise available evidence on the efficacy and safety of different antiretroviral regimens in children with HIV infection who are receiving treatment for active TB.

METHODS

We conducted a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Records were retrieved through March 2016 from Medline, Embase and manual screening of key conference proceedings. Four specific research questions assessing available treatment options were defined.

RESULTS

Although 4 independent searches were conducted (1 for each Population, Intervention, Comparator, Outcomes question), results were elaborated and interpreted together because of significant overlap among the retrieved records. Six observational studies were selected for qualitative synthesis while meta-analysis could not be performed.

CONCLUSION

Evidence for optimal treatment options for HIV/TB coinfected children is limited. As the global community strives to reach the fast-track HIV treatment targets and eliminate childhood TB deaths, it must ensure that coinfected children are included in key treatment studies and expand this neglected but crucial area of research.

Biomarkers Associated with Death After Initiating Treatment for Tuberculosis and HIV in Patients with Very Low CD4 Cells

Background

The risk of short-term death for treatment naive patients dually infected with Mycobacterium tuberculosis and HIV may be reduced by early anti-retroviral therapy. Of those dying, mechanisms responsible for fatal outcomes are unclear. We hypothesized that greater malnutrition and/or inflammation when initiating treatment are associated with an increased risk for death.

Methods

We utilized a retrospective case-cohort design among participants of the ACTG A5221 study who had baseline CD4 < 50 cells/mm³. The case-cohort sample consisted of 51 randomly selected participants, whose stored plasma was tested for C-reactive protein, cytokines, chemokines, and nutritional markers. Cox proportional hazards models were used to assess the association of nutritional, inflammatory, and immunomodulatory markers for survival.

Results

The case-cohort sample was similar to the 282 participants within the parent cohort with CD4 <50 cells/mm³. In the case cohort, 7 (14%) had BMI < 16.5 (kg/m²) and 17 (33%) had BMI 16.5-18.5(kg/m²). Risk of death was increased per 1 IQR width higher of log₁₀ transformed level of C-reactive protein (adjusted hazard ratio (aHR) = 3.42 [95% CI = 1.33-8.80], P = 0.011), interferon gamma (aHR = 2.46 [CI = 1.02-5.90], P = 0.044), MCP-3 (3.67 [CI = 1.08-12.42], P = 0.037), and with IL-15 (aHR = 2.75 [CI = 1.08-6.98], P = 0.033) and IL-17 (aHR = 3.99 [CI = -1.06-15.07], P = 0.041). BMI, albumin, hemoglobin, and leptin levels were not associated with risk of death.

Conclusions

Unlike patients only infected with M. tuberculosis for whom malnutrition and low BMI increase the risk of death, this relationship was not evident in our dually infected patients. Risk of death was associated with significant increases in markers of global inflammation along with soluble biomarkers of innate and adaptive immunity.

Common Variation in NLRP3 Is Associated With Early Death and Elevated Inflammasome Biomarkers Among Advanced HIV/TB Co-infected Patients in Botswana

Background

Elevated inflammation is associated with early mortality among HIV/tuberculosis (TB) patients starting antiretroviral therapy (ART); however, the sources of immune activation are unclear. We hypothesized that common variation in innate immune genes contributes to excessive inflammation linked to death. As single nucleotide polymorphisms (SNPs) in inflammasome pathway genes can increase risk for inflammatory diseases, we investigated their association with early mortality among a previously described cohort of HIV/TB patients initiating ART in Botswana.

Methods

We genotyped 8 SNPs within 5 inflammasome pathway genes and determined their association with death. For adjusted analyses, we used a logistic regression model. For SNPs associated with mortality, we explored their relationship with levels of systemic inflammatory markers using a linear regression model.

Results

Ninety-four patients in the parent study had samples for genetic analysis. Of these, 82 (87%) were survivors and 12 (13%) died within 6 months of starting ART. In a logistic regression model, NLRP3 rs10754558 was independently associated with a 4.1-fold increased odds of death (95% confidence interval, 1.04–16.5). In adjusted linear regression models, the NLRP3 rs10754558-G allele was linked to elevated IL-18 at baseline (Beta, 0.23; SE, 0.10; P = .033) and week 4 post-ART (Beta, 0.24; SE, 0.11; P = .026). This allele was associated with increased MCP-1 at baseline (Beta, 0.24; SE, 0.10; P = .02) and IL-10 (Beta, 0.27; SE, 0.11; P = .013) at week 4 post-ART.

Conclusion

The NLRP3 rs10754558-G SNP is associated with an increased risk for early mortality in HIV/TB patients initiating ART. These patients may benefit from therapies that decrease inflammasome-mediated inflammation.

Comorbidities and treatment outcomes in multidrug resistant tuberculosis: a systematic review and meta-analysis

Little is known about the impact of comorbidities on multidrug resistant (MDR) and extensively drug resistant (XDR) tuberculosis (TB) treatment outcomes. We aimed to examine the effect of human immunodeficiency virus (HIV), diabetes, chronic kidney disease (CKD), alcohol misuse, and smoking on MDR/XDRTB treatment outcomes. We searched MEDLINE, EMBASE, Cochrane Central Registrar and Cochrane Database of Systematic Reviews as per PRISMA guidelines. Eligible studies were identified and treatment outcome data were extracted. We performed a meta-analysis to generate a pooled relative risk (RR) for unsuccessful outcome in MDR/XDRTB treatment by co-morbidity. From 2457 studies identified, 48 reported on 18,257 participants, which were included in the final analysis. Median study population was 235 (range 60-1768). Pooled RR of unsuccessful outcome was higher in people living with HIV (RR = 1.41 [95%CI: 1.15-1.73]) and in people with alcohol misuse (RR = 1.45 [95%CI: 1.21-1.74]). Outcomes were similar in people with diabetes or in people that smoked. Data was insufficient to examine outcomes in exclusive XDRTB or CKD cohorts. In this systematic review and meta-analysis, alcohol misuse and HIV were associated with higher pooled OR of an unsuccessful outcome in MDR/XDRTB treatment. Further research is required to understand the role of comorbidities in driving unsuccessful treatment outcomes.

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.

Mortality in Severe Human Immunodeficiency Virus-Tuberculosis Associates With Innate Immune Activation and Dysfunction of Monocytes

Background

Case fatality rates among hospitalized patients diagnosed with human immunodeficiency virus (HIV)-associated tuberculosis remain high, and tuberculosis mycobacteremia is common. Our aim was to define the nature of innate immune responses associated with 12-week mortality in this population.

Methods

This prospective cohort study was conducted at Khayelitsha Hospital, Cape Town, South Africa. Hospitalized HIV-infected tuberculosis patients with CD4 counts <350 cells/µL were included; tuberculosis blood cultures were performed in all. Ambulatory HIV-infected patients without active tuberculosis were recruited as controls. Whole blood was stimulated with Escherichia coli derived lipopolysaccharide, heat-killed Streptococcus pneumoniae, and Mycobacterium tuberculosis. Biomarkers of inflammation and sepsis, intracellular (flow cytometry) and secreted cytokines (Luminex), were assessed for associations with 12-week mortality using Cox proportional hazard models. Second, we investigated associations of these immune markers with tuberculosis mycobacteremia.

Results

Sixty patients were included (median CD4 count 53 cells/µL (interquartile range [IQR], 22-132); 16 (27%) died after a median of 12 (IQR, 0-24) days. Thirty-one (52%) grew M. tuberculosis on blood culture. Mortality was associated with higher concentrations of procalcitonin, activation of the innate immune system (% CD16+CD14+ monocytes, interleukin-6, tumour necrosis factor-ɑ and colony-stimulating factor 3), and antiinflammatory markers (increased interleukin-1 receptor antagonist and lower monocyte and neutrophil responses to bacterial stimuli). Tuberculosis mycobacteremia was not associated with mortality, nor with biomarkers of sepsis.

Conclusions

Twelve-week mortality was associated with greater pro- and antiinflammatory alterations of the innate immune system, similar to those reported in severe bacterial sepsis.

Towards an ideal antiretroviral regimen for the global HIV epidemic

Currently, immediate initiation of antiretroviral therapy (ART) is recommended for all individuals with HIV infection. However, among the 37 million people estimated to be living with HIV/AIDS, only 17 million are actively on treatment. Optimal use of ART among HIV-infected and at-risk individuals reduces morbidity, mortality, transmission and acquisition of HIV infection. ART regimen choices are affected by factors such as economic differences between resource-rich and low- and middle-income countries (LIMC), drug availability, and considerations for use in special populations. Ideal ART regimens combine high efficacy, high tolerability, low toxicity, low pill burden, affordability and global availability. Here, we highlight five aspects to be considered when thinking of an ideal global ART regimen: (1) the co-administration with other medications especially tuberculosis treatment; (2) treatment for specific populations such as women, children, adolescents, older people and acutely infected individuals; (3) efficacy; (4) safety, tolerability and convenience; and (5) affordability and global access for all PLWH.

Hemostatic Changes Associated With Increased Mortality Rates in Hospitalized Patients With HIV-Associated Tuberculosis: A Prospective Cohort Study

Background

Mortality rates remain high for human immunodeficiency virus (HIV)-associated tuberculosis, and our knowledge of contributing mechanisms is limited. We aimed to determine whether hemostatic changes in HIV-tuberculosis were associated with mortality or decreased survival time and the contribution of mycobacteremia to these effects.

Methods

We conducted a prospective study in Khayelitsha, South Africa, in hospitalized HIV-infected patients with CD4 cell counts <350/µL and microbiologically proved tuberculosis. HIV-infected outpatients without tuberculosis served as controls. Plasma biomarkers reflecting activation of procoagulation and anticoagulation, fibrinolysis, endothelial cell activation, matricellular protein release, and tissue damage were measured at admission. Cox proportional hazard models were used to assess variables associated with 12-week mortality rates.

Results

Of 59 patients with HIV-tuberculosis, 16 (27%) died after a median of 12 days (interquartile range, 0-24 days); 29 (64%) of the 45 not receiving anticoagulants fulfilled criteria for disseminated intravascular coagulation. Decreased survival time was associated with higher concentrations of markers of fibrinolysis, endothelial activation, matricellular protein release, and tissue damage and with decreased concentrations for markers of anticoagulation. In patients who died, coagulation factors involved in the common pathway were depleted (factor II, V, X), which corresponded to increased plasma clotting times. Mycobacteremia modestly influenced hemostatic changes without affecting mortality.

Conclusions

Patients with severe HIV-tuberculosis display a hypercoagulable state and activation of the endothelium, which is associated with mortality.

Human Immunodeficiency Virus Infection, Antiretroviral Therapy, and Liver Pathology

The improvement in antiretroviral therapy has significantly impacted the lives of people living with human immunodeficiency virus (HIV). In high-income countries, HIV deaths are predominated by liver disease consequent to viral hepatitis coinfection, alcohol, and nonalcoholic fatty liver disease. Published liver pathology findings have shifted from being predominated by opportunistic infections to the metabolic effects of HIV and antiretroviral therapy as well as drug-induced liver injuries. Differences remain between high-income and low-income countries, where opportunistic infections and immune reconstitution syndromes, dominate findings.

The cursed duet today: Tuberculosis and HIV-coinfection

The tuberculosis (TB) and HIV syndemic continues to rage and are a major public health concern worldwide. This deadly association raises complexity and represent a significant barrier towards TB elimination. TB continues to be the leading cause of death amongst HIV-infected people. This paper reports the challenges that lay ahead and outlines some of the current and future strategies that may be able to address this co-epidemic efficiently. Improved diagnostics, cheaper and more effective drugs, shorter treatment regimens for both drug-sensitive and drug-resistant TB are discussed. Also, special topics on drug interactions, TB-IRIS and TB relapse are also described. Notwithstanding the defeats and meagre investments, diagnosis and management of the two diseases have seen significant and unexpected improvements of late. On the HIV side, expansion of ART coverage, development of new updated guidelines aimed at the universal treatment of those infected, and the increasing availability of newer, more efficacious and less toxic drugs are an essential element to controlling the two epidemics. On the TB side, diagnosis of MDR-TB is becoming easier and faster thanks to the new PCR-based technologies, new anti-TB drugs active against both sensitive and resistant strains (i.e. bedaquiline and delamanid) have been developed and a few more are in the pipeline, new regimens (cheaper, shorter and/or more effective) have been introduced (such as the "Bangladesh regimen") or are being tested for MDR-TB and drug-sensitive-TB. However, still more resources will be required to implement an integrated approach, install new diagnostic tests, and develop simpler and shorter treatment regimens.

Addressing tuberculosis patients' medical and socio-economic needs: a comprehensive programmatic approach

OBJECTIVE

For a cohort of patients with tuberculosis in Carabayllo, Peru, we describe the prevalence of medical comorbidities and socio-economic needs, the efforts required by a comprehensive support programme ('TB Cero') to address them and the success of this programme in linking patients to care.

METHODS

Patients diagnosed with tuberculosis in Carabayllo underwent evaluations for HIV, diabetes, mental health and unmet basic needs. For patients initiating treatment during 14 September, 2015-15 May, 2016, we abstracted data from evaluation forms and a support request system. We calculated the prevalence of medical comorbidities and the need for socio-economic support at the time of tuberculosis diagnosis, as well as the proportion of patients successfully linked to care or support.

RESULTS

Of 192 patients, 83 (43%) had at least one medical comorbidity other than tuberculosis. These included eight (4%) patients with HIV, 12 (6%) with diabetes and 62 (32%) deemed at risk for a mental health condition. Of patients who required follow-up for a comorbidity, 100% initiated antiretroviral therapy, 71% attended endocrinology consultations and 66% attended psychology consultations. Of 126 (65%) patients who completed the socio-economic evaluation, 58 (46%) reported already receiving food baskets from the municipality, and 79 (63%) were given additional support, most commonly food vouchers and assistance in accessing health care.

CONCLUSION

Carabayllo tuberculosis patients face many challenges in addition to tuberculosis. A collaborative, comprehensive treatment support programme can achieve high rates of linkage to care for these needs.

Co-infections of tuberculosis, hepatitis B or C viruses in a cohort of people living with HIV/AIDS in China: predictors and sequelae

The co-infection of viral hepatitis and tuberculosis (TB) among people living with HIV/AIDS (PLWHA) makes the syndemic of HIV even worse as there is higher mortality and morbidity among PLWHA with co-infections compared to people with HIV mono-infection. In the current study, we explored predictors and sequelae among a group of Chinese PLWHA to guide future program strategies and enhance the repertoire of action for both preventative and clinical purposes. Between October 2012 and August 2013, we conducted a cross-sectional study in Guangxi Autonomous Region (Guangxi) of China. With an overall participation rate of 90%, we finally recruited 3002 patients with 2987 (99.5%) completed the survey and were included in the data analysis. We employed both predictive and explanatory modeling strategies to explore predictors and sequelae of co-infections among PLWHA. The overall prevalence of co-infection was 15.6% with 4.4% of HBV, 5.4% of HCV and 4.8% of TB, respectively. Predictors of co-infections included history of injecting drugs or drinking alcohol, sharing needles, having sex with sex workers or casual partners, higher viral loads and lower CD4 counts. Meanwhile, co-infections were associated with various physical and psychological problems among PLWHA. As an entangled phenomenon, co-infections among PLWHA produce continuous and shifting scenarios, which add complexity to clinic, epidemiological and political ways of dealing with health risks among PLWHA in China. Exploring predictors and sequelae can help to prevent and manage co-infection comorbidities among PLWHA.

Intimate partner violence and challenges facing women living with HIV/AIDS in accessing antiretroviral treatment at Singida Regional Hospital, central Tanzania

BACKGROUND

Human immunodeficiency virus (HIV) remains a global public health problem. Sub-Saharan Africa is the region most affected by HIV/AIDS in the world. Globally, and in Tanzania in particular, women are more affected by HIV/AIDS than men. Tanzania has been reported to be among the countries with the highest burden of intimate partner violence (IPV). This study explored the challenges facing women living with HIV/AIDS (LWHA) attending the care and treatment clinic (CTC) in Singida Regional Hospital in Tanzania.

DESIGN

A qualitative study was performed in which data were collected through in-depth interviews with 35 women LWHA who also experienced IPV. Content analysis was used to analyse the data.

RESULTS

The study findings showed that women LWHA experienced challenges from their male partners in the form of lack of fare to attend CTC, delayed attendance to CTC, verbal threats and intimidation, mistrust partner resulting in changed antiretroviral (ARV) dosing time. Also, systemic challenges such as malfunction of CD4 count testing apparatus contributed to mistrust from their male partners which led to IPV.

CONCLUSION

In this study, women LWHA experienced IPV challenges that resulted in poor adherence to ARV medication and CTC attendance, as well as insufficient time to collect ARV medication. It is recommended that the government address systemic challenges faced by women LWHA, introduce multiple approaches to address the needs of women LWHA experiencing IPV, and develop strong policies to prevent IPV against women in Tanzania, regardless of their HIV status.

Assessing the impact of defining a global priority research agenda to address HIV-associated tuberculosis

OBJECTIVES

In 2010, the WHO issued 77 priority research questions (PRQs) to address HIV-associated TB. Objective of the this study was to assess the impact of defining the research agenda in stimulating and directing research around priority research questions.

METHODS

We used number and type of scientific publications as a proxy to quantitatively assess the impact of research agenda setting. We conducted 77 single systematic reviews - one for every PRQ - building 77 different search strategies using PRQs' keywords. Multivariate logistic regression models were applied to assess the quantity and quality of research produced over time and accounting for selected covariates.

RESULTS

In 2009-2015, PRQs were addressed by 1631 publications (median: 11 studies published per PRQ, range 1-96). The most published area was 'Intensified TB case finding' (median: 23 studies/PRQ, range: 2-74). The majority (62.1%, n = 1013) were published as original studies, and more than half (58%, n = 585) were conducted in the African region. Original studies' publication increased over the study period (P trend = <0.001). They focused more on the 'Intensified TB case finding' (OR = 2.17, 95% CI: 1.56-2.93) and 'Drug-resistant TB and HIV infection' (OR = 2.12, 95% CI: 1.47-3.06) areas than non-original studies. Original studies were published in journals of lower impact factor and received a smaller number of citations than non-original studies (OR = 0.54, 95% CI: 0.42-0.69).

CONCLUSION

The generation of evidence to address PRQs has increased over time particularly in selected fields. Setting a priority research agenda for HIV-associated TB might have positively influenced the direction and the conduct of research and contributed to the global response to such a major threat to health.

Bipolar I and II Disorders; A Systematic Review and Meta-Analysis on Differences in Comorbid Obsessive-Compulsive Disorder

CONTEXT

More than half of the bipolar disorder (BD) cases have an additional diagnosis; one of the most difficult to manage is obsessive-compulsive disorder (OCD). Although some authors recently investigated the co-occurrence of anxiety and BD, the topic remains insufficiently studied. The current study aimed to investigate differences in comorbid OCD between BD-I and BD-II.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was conducted on the prevalence and predictors of comorbid BD-I/BD-II and OCD. Relevant papers published until June 30, 2015 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

RESULTS

Fourteen articles met the inclusion criteria. The pooled prevalence of BD-I in OCD was 3.9% (95% confidence interval (CI), 2.4 to 6.4, I2 = 83%, Q = 56) while that of BD-II in OCD was 13.5% (95% CI, 9.3 to 19.3, I2 = 89%, Q = 91). The pooled prevalence of OCD in BD-I was 21.7 (95% CI, 4.8 to 60.3, I2 = 84%, Q = 95). With regard to OCD-BD predictors, mean age and rate of males did not predict the prevalence of BD-I (β = 0.0731, 95% CI, -0.1097 to 0.256, z = 0.78; β = 0.035, 95% CI, -0.2356 to 0.1656, z = 0.34) and BD-II (β = 0.0577, 95% CI, -0.1942 to 0.0788, z = 0.83; β = -0.0317, 95% CI, -0.1483 to 0.085, z = 0.53) in OCD. The mean age explained some of the observed heterogeneity (R2 = 0.13; R2 = 0.08).

CONCLUSIONS

This first systematic review and meta-analysis of the prevalence and predictors of comorbid BD-I/BD-II and OCD suggests that BD-OCD comorbidity is a common condition in psychiatry. However, the available evidence does not allow to assess whether BD-I or BD-II are more common in patients with OCD.

Timing of antiretroviral therapy and TB treatment outcomes in patients with TB-HIV in Myanmar

SETTING

Integrated HIV Care programme, Mandalay, Myanmar.

OBJECTIVES

To determine time to starting antiretroviral treatment (ART) in relation to anti-tuberculosis treatment (ATT) and its association with TB treatment outcomes in patients co-infected with tuberculosis (TB) and the human immunodeficiency virus (HIV) enrolled from 2011 to 2014.

DESIGN

Retrospective cohort study.

RESULTS

Of 1708 TB-HIV patients, 1565 (92%) started ATT first and 143 (8%) started ART first. Treatment outcomes were missing for 226 patients and were thus not included. In those starting ATT first, the median time to starting ART was 8.6 weeks. ART was initiated after 8 weeks in 830 (53%) patients. Unsuccessful outcome was found in 7%, with anaemia being an independent predictor. In patients starting ART first, the median time to starting ATT was 21.6 weeks. ATT was initiated within 3 months in 56 (39%) patients. Unsuccessful outcome was found in 12%, and in 20% of those starting ATT within 3 months. Patients with CD4 count <100/mm(3) had a four times higher risk of an unsuccessful outcome.

CONCLUSIONS

Timing of ART in relation to ATT was not an independent risk factor for unsuccessful outcome. Extensive screening for TB with rapid and sensitive diagnostic tests in HIV-infected persons and close monitoring of anaemia and immunosuppression are recommended to further improve TB treatment outcomes among patients with TB-HIV.

Impact of HIV infection on treatment outcome of tuberculosis in Europe

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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