High mortality in tuberculosis patients despite HIV interventions in Swaziland

Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini

OBJECTIVES

Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years.

METHODS

Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths.

RESULTS

Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population.

CONCLUSIONS

TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.

Burden of HIV and treatment outcomes among TB patients in rural Kenya: a 9-year longitudinal study

BACKGROUND

Although tuberculosis (TB) patients coinfected with HIV are at risk of poor treatment outcomes, there is paucity of data on changing trends of TB/HIV co-infection and their treatment outcomes. This study aims to estimate the burden of TB/HIV co-infection over time, describe the treatment available to TB/HIV patients and estimate the effect of TB/HIV co-infection on TB treatment outcomes.

METHODS

This was a retrospective data analyses from TB surveillance in two counties in Kenya (Nyeri and Kilifi): 2012‒2020. All TB patients aged ≥ 18 years were included. The main exposure was HIV status categorised as infected, negative or unknown status. World Health Organization TB treatment outcomes were explored; cured, treatment complete, failed treatment, defaulted/lost-to-follow-up, died and transferred out. Time at risk was from date of starting TB treatment to six months later/date of the event and Cox proportion with shared frailties models were used to estimate effects of TB/HIV co-infection on TB treatment outcomes.

RESULTS

The study includes 27,285 patients, median (IQR) 37 (29‒49) years old and 64% male. 23,986 (88%) were new TB cases and 91% were started on 2RHZE/4RH anti-TB regimen. Overall, 7879 (29%, 95% 28‒30%) were HIV infected. The proportion of HIV infected patient was 32% in 2012 and declined to 24% in 2020 (trend P-value = 0.01). Uptake of ARTs (95%) and cotrimoxazole prophylaxis (99%) was high. Overall, 84% patients completed six months TB treatment, 2084 (7.6%) died, 4.3% LTFU, 0.9% treatment failure and 2.8% transferred out. HIV status was associated with lower odds of completing TB treatment: infected Vs negative (aOR 0.56 (95%CI 0.52‒0.61) and unknown vs negative (aOR 0.57 (95%CI 0.44‒0.73). Both HIV infected and unknown status were associated with higher hazard of death: (aHR 2.40 (95%CI 2.18‒2.63) and 1.93 (95%CI 1.44‒2.56)) respectively and defaulting treatment/LTFU: aHR 1.16 (95%CI 1.01‒1.32) and 1.55 (95%CI 1.02‒2.35)) respectively. HIV status had no effect on hazard of transferring out and treatment failure.

CONCLUSION

The overall burden of TB/HIV coinfection was within previous pooled estimate. Our findings support the need for systematic HIV testing as those with unknown status had similar TB treatment outcomes as the HIV infected.

The Impact of the COVID-19 Pandemic on Tuberculosis Case Notification and Treatment Outcomes in Eswatini

Objectives: We investigated the impact of COVID-19 on tuberculosis (TB) case notification and treatment outcomes in Eswatini.

Methods: A comparative retrospective cohort study was conducted using TB data from eight facilities. An interrupted time series analysis, using segmented Poisson regression was done to assess the impact of COVID-19 on TB case notification comparing period before (December 2018-February 2020, n = 1,560) and during the pandemic (March 2020–May 2021, n = 840). Case notification was defined as number of TB cases registered in the TB treatment register. Treatment outcomes was result assigned to patients at the end of treatment according to WHO rules.

Results: There was a significant decrease in TB case notification (IRR 0.71, 95% CI: 0.60–0.83) and a significant increase in death rate among registrants during the pandemic (21.3%) compared to pre-pandemic (10.8%, p < 0.01). Logistic regression indicated higher odds of unfavorable outcomes (death, lost-to-follow-up, and not evaluated) during the pandemic than pre-pandemic (aOR 2.91, 95% CI: 2.17–3.89).

Conclusion: COVID-19 negatively impacted TB services in Eswatini. Eswatini should invest in strategies to safe-guard the health system against similar pandemics.

Standard precautions for preventing Tuberculosis and HIV: Compliance of Eswatini university student nurses

Tuberculosis and Human Immunodeficiency Virus are among the top ten causes of death globally. To prevent the spread of these infections, health workers and student nurses should comply to infection prevention and control measures called standard precautions. The aim of this study is to assess compliance of Eswatini university student nurses regarding standard precautions for preventing Tuberculosis and Human Immunodeficiency Virus. A non-experimental quantitative approach was used to conduct a survey on all senior student nurses of Eswatini University using questionnaires. IBM SPSS Statistics version 26 software was used to analyse the data. Results from this study showed that out of the 105 student nurses who were asked only 51.4% (n = 54) said they always used personal protective equipment. However, they did comply well on disposing sharps as 92.4% (n = 97) reported that they always used designated containers. There is a need for close supervision of student nurses in the clinical area. The researcher recommends that clinical facilitator should always accompany student nurses in the clinical area and that preceptors should be exempted from other nursing duties when there are student nurses in the hospitals so that they can mentor the students.

Early or deferred initiation of efavirenz during rifampicin-based TB therapy has no significant effect on CYP3A induction in TB-HIV infected patients

Background and Purpose

In TB‐HIV co‐infection, prompt initiation of TB therapy is recommended but anti‐retroviral treatment (ART) is often delayed due to potential drug–drug interactions between rifampicin and efavirenz. In a longitudinal cohort study, we evaluated the effects of efavirenz/rifampicin co‐treatment and time of ART initiation on CYP3A induction.

Experimental Approach

Treatment‐naïve TB‐HIV co‐infected patients (n = 102) were randomized to efavirenz‐based‐ART after 4 (n = 69) or 8 weeks (n = 33) of commencing rifampicin‐based anti‐TB therapy. HIV patients without TB (n = 94) receiving efavirenz‐based‐ART only were enrolled as control. Plasma 4β‐hydroxycholesterol/cholesterol (4β‐OHC/Chol) ratio, an endogenous biomarker for CYP3A activity, was determined at baseline, at 4 and 16 weeks of ART.

Key Results

In patients treated with efavirenz only, median 4β‐OHC/Chol ratios increased from baseline by 269% and 275% after 4 and 16 weeks of ART, respectively. In TB‐HIV patients, rifampicin only therapy for 4 and 8 weeks increased median 4β‐OHC/Chol ratios from baseline by 378% and 576% respectively. After efavirenz/rifampicin co‐treatment, 4β‐OHC/Chol ratios increased by 560% of baseline (4 weeks) and 456% of baseline (16 weeks). Neither time of ART initiation, sex, genotype nor efavirenz plasma concentration were significant predictors of 4β‐OHC/Chol ratios after 4 weeks of efavirenz/rifampicin co‐treatment.

Conclusion and Implications

Rifampicin induced CYP3A more potently than efavirenz, with maximum induction occurring within the first 4 weeks of rifampicin therapy. We provide pharmacological evidence that early (4 weeks) or deferred (8 weeks) ART initiation during anti‐TB therapy has no significant effect on CYP3A induction.

LINKED ARTICLES

This article is part of a themed issue on Oxysterols, Lifelong Health and Therapeutics. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.16/issuetoc

Human immunodeficiency virus-associated tuberculosis care in Botswana: evidence from a real-world setting

BACKGROUND

Tuberculosis (TB) is among the world's top public health challenges and the leading killer of people with HIV, yet is a treatable disease. This study aimed to assess, in a real-world setting, the implementation of antiretroviral therapy (ART) and Cotrimoxazole preventive therapy (CPT) policy, specific interventions proven to benefit patients in HIV-associated TB care.

METHODS

This retrospective cohort study was conducted in Botswana in the Serowe/Palapye district, a largely urban district with a high burden of HIV-associated TB with a high case fatality, at Segkoma and Palapye hospitals and their feeder clinics. Between 1 January 2013 and 31 December 2013, confirmed HIV-positive patients aged ≥15 years with a confirmed TB diagnosis and medical record available were included in the analysis. The Kaplan-Meier method was used to compare time to death for the group of patients on ART and the group of patients not on ART during TB treatment. Cox proportional hazard regression was undertaken to identify predictors of mortality.

RESULTS

Of the 300 patients included in the study, 217 (72%) were ART experienced at TB diagnosis. Of these, 86 (40%) had TB within 3 months following ART initiation. Of the 83 (28%) patients who were ART-naïve at TB diagnosis, 40 (48%) were commenced on ART during TB treatment, with 24 (60%) patients commencing within 4 weeks following TB treatment initiation. The overall ART uptake was 84%, while cotrimoxazole preventive therapy uptake was 100%. There were 45 deaths (15%), ART-experienced patients during TB treatment accounted for 30 deaths (30/257; 14%), while those who were not ART-experienced during TB treatment accounted for 15 deaths (15/43; 35%). There was a significant difference in survival time between patients with no ART use during TB treatment and those with ART use during TB treatment (log rank p < 0.001). Patients with no ART use during TB treatment were more likely to die within the first 2 months.

CONCLUSION

The implementation of CPT policy is a substantial success. Strengthening the implementation of ART policy could improve survival among HIV-associated TB patients.

Decreased risk of HIV-associated TB during antiretroviral therapy expansion in rural Eswatini from 2009 to 2016: a cohort and population-based analysis

Objectives

This paper assesses patient‐ and population‐level trends in TB notifications during rapid expansion of antiretroviral therapy in Eswatini which has an extremely high incidence of both TB and HIV.

Methods

Patient‐ and population‐level predictors and rates of HIV‐associated TB were examined in the Shiselweni region in Eswatini from 2009 to 2016. Annual population‐level denominators obtained from projected census data and prevalence estimates obtained from population‐based surveys were combined with individual‐level TB treatment data. Patient‐ and population‐level predictors of HIV‐associated TB were assessed with multivariate logistic and multivariate negative binomial regression models.

Results

Of 11 328 TB cases, 71.4% were HIV co‐infected and 51.8% were women. TB notifications decreased fivefold between 2009 and 2016, from 1341 to 269 cases per 100 000 person‐years. The decline was sixfold in PLHIV vs. threefold in the HIV‐negative population. Main patient‐level predictors of HIV‐associated TB were recurrent TB treatment (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI]: 1.19–1.65), negative (aOR 1.31, 1.15–1.49) and missing (aOR 1.30, 1.11–1.53) bacteriological status and diagnosis at secondary healthcare level (aOR 1.18, 1.06–1.33). Compared with 2009, the probability of TB decreased for all years from 2011 (aOR 0.69, 0.58–0.83) to 2016 (aOR 0.54, 0.43–0.69). The most pronounced population‐level predictor of TB was HIV‐positive status (adjusted incidence risk ratio 19.47, 14.89–25.46).

Conclusions

This high HIV‐TB prevalence setting experienced a rapid decline in TB notifications, most pronounced in PLHIV. Achievements in HIV‐TB programming were likely contributing factors.

Hyperglycemia and Risk of All-cause Mortality Among People Living With HIV With and Without Tuberculosis Disease in Myanmar (2011-2017)

Background

There is limited empirical evidence on the relationship between hyperglycemia, tuberculosis (TB) comorbidity, and mortality in the context of HIV. We assessed whether hyperglycemia at enrollment in HIV care was associated with increased risk of all-cause mortality and whether this relationship was different among patients with and without TB disease.

Methods

We conducted a retrospective analysis of adult (≥15 years) HIV-positive patients enrolled into HIV care between 2011 and 2016 who had random blood glucose (RBG) measurements at enrollment. We used hazards regression to estimate associations between RBG and rate of all-cause mortality.

Results

Of 25 851 patients, 43% were female, and the median age was 36 years. At registration, the median CD4 count (interquartile range [IQR]) was 162 (68-310) cell/mm³, the median RBG level (IQR) was 88 (75-106) mg/dL, and 6.2% (95% confidence interval [CI], 6.0%-6.5%) had hyperglycemia (RBG ≥140 mg/dL). Overall 29% of patients had TB disease, and 15% died during the study period. The adjusted hazard of death among patients with hyperglycemia was significantly higher (adjusted hazard ratio [aHR], 1.2; 95% CI, 1.1-1.4) than among those with normoglycemia without TB disease, but not among patients with TB disease (aHR, 1.0; 95% CI, 0.8-1.2). Using 4 categories of RBG and restricted cubic spline regression, aHRs for death were significantly increased in patients with RBG of 110-140 mg/dL (categorical model: aHR, 1.3; 95% CI, 1.2-1.4; restricted spline: aHR, 1.1; 95% CI, 1.0-1.1) compared with those with RBG <110 mg/dL.

Conclusions

Our findings highlight an urgent need to evaluate hyperglycemia screening and diagnostic algorithms and to ultimately establish glycemic targets for PLHIV with and without TB disease.

Risk factors for mortality in TB patients: a 10-year electronic record review in a South African province

Background

Since 1990, reduction of tuberculosis (TB) mortality has been lower in South Africa than in other high-burden countries in Africa. This research investigated the influence of routinely captured demographic and clinical or programme variables on death in TB patients in the Free State Province.

Methods

A retrospective review of case information captured in the Electronic TB register (ETR.net) over the years 2003 to 2012 was conducted. Extracted data were subjected to descriptive and logistic regression analyses. The outcome variable was defined as all registered TB cases with ‘died’ as the recorded outcome. The variables associated with increased or decreased odds of dying in TB patients were established. The univariate and adjusted odds ratios (OR and AOR) together with their corresponding 95% confidence intervals (CI) were estimated, taking the clustering effect of the districts into account.

Results

Of the 190,472 TB cases included in the analysis, 30,991 (16.3%) had ‘died’ as the recorded treatment outcome. The proportion of TB patients that died increased from 15.1% in 2003 to 17.8% in 2009, before declining to 15.4% in 2012. The odds of dying was incrementally higher in the older age groups: 8–17 years (AOR: 2.0; CI: 1.5–2.7), 18–49 years (AOR: 5.8; CI: 4.0–8.4), 50–64 years (AOR: 7.7; CI: 4.6–12.7), and ≥65 years (AOR: 14.4; CI: 10.3–20.2). Other factors associated with increased odds of mortality included: HIV co-infection (males – AOR: 2.4; CI: 2.1–2.8; females – AOR: 1.9; CI: 1.7–2.1) or unknown HIV status (males – AOR: 2.8; CI: 2.5–3.1; females – AOR: 2.4; CI: 2.2–2.6), having a negative (AOR: 1.4; CI: 1.3–1.6) or a missing (AOR: 2.1; CI: 1.4–3.2) pre-treatment sputum smear result, and being a retreatment case (AOR: 1.3; CI: 1.2–1.4).

Conclusions

Although mortality in TB patients in the Free State has been falling since 2009, it remained high at more than 15% in 2012. Appropriately targeted treatment and care for the identified high-risk groups could be considered.

Health systems in the Republic of Congo: challenges and opportunities for implementing tuberculosis and HIV collaborative service, research, and training activities

The Republic of Congo is on the World Health Organization (WHO) list of 'high burden' countries for tuberculosis (TB) and HIV. TB is the leading cause of death among HIV-infected patients in the Republic of Congo. In this viewpoint, the available data on TB and HIV in the Republic of Congo are reviewed, and the gaps and bottlenecks that the National TB Control Program (NTCP) faces are discussed. Furthermore, priority requirements for developing and implementing TB and HIV collaborative service activities are identified. HIV and TB control programs operate as distinct entities with separate case management plans. The implementation of collaborative TB/HIV activities to evaluate and monitor the management of TB/HIV co-infected individuals remains inefficient in most regions, and these activities are sometimes non-existent. This reveals major challenges that require definition in order to improve the delivery of healthcare. The NTCP lacks adequate resources for optimal implementation of control measures of TB and HIV compliance and outcomes. The importance of aligning and integrating TB and HIV treatment services (including follow-up) and adherence support services through coordinated and collaborative efforts between individual TB and HIV programs is discussed. Aligning and integrating TB and HIV treatment services through coordinated and collaborative efforts between individual TB and HIV programs is required. However, the WHO recommendations are generic, and health services in the Republic of Congo need to tailor their TB and HIV programs according to the availability of resources and operational feasibility. This will also open opportunities for synergizing collaborative TB/HIV research and training activities, which should be prioritized by the donors supporting the TB/HIV programs.