Factors Impacting Early Mortality in Tuberculosis/HIV Patients: Differences between Subjects Naïve to and Previously Started on HAART

Abstract

BackgroundMortality among patients with tuberculosis (TB)/HIV is highest during the first few months of antituberculous therapy. The objective of this study was to assess the factors associated with early mortality among TB/HIV patients and whether these factors are similar for HAART naïve and those with prior HAART initiation.MethodsProspective cohort study including HIV patients with tuberculosis confirmed by culture, cared for at a referral center in Rio de Janeiro, Brazil. Multivariable Cox analysis was used to assess predictors of mortality within 3 months of antituberculous therapy.ResultsAmong 227 patients included, 90 (40%) started HAART before TB diagnosis. The median time to TB diagnosis after ARV initiation was 5.9 months (interquartile range [IQR] 3.0–8.9 months). Fourteen patients (6%) died within the first 3 months. Mortality was not different between patients previously started on HAART and those who were naïve to it. In the overall adjusted analysis, HAART use during TB treatment (hazard ratio [HR] = 0.21, 95% confidential interval [CI] = 0.06–0.72) and CD4 lymphocyte count >100 cells/mm3 (HR = 0.21, 95% CI = 0.04–0.99) were associated with lower mortality, while subjects with unknown baseline CD4 lymphocyte count (HR = 9.39, 95% CI = 2.56–34.5) had higher mortality. In subgroup analysis, among HAART naïve subjects, disseminated TB (HR = 5.32, 95% CI = 1.09–25.8) and unknown baseline CD4 lymphocyte count (HR = 13.2, 95% CI = 2.71–64.5) were associated with significantly higher mortality, while HAART (HR = 0.14, 95% CI = 0.03–0.69) predicted a better outcome. Among subjects previously started on HAART, mortality was significantly associated with duration of TB symptoms >120 days (HR = 6.15, 95% CI = 1.15–32.9).ConclusionsPredictors of early mortality among TB/HIV patients may vary according to the timing of HAART initiation. Among HAART naïve patients, mortality was influenced by baseline clinical severity, HAART use and, possibly, the quality of care preceding TB diagnosis. For patients with prior HAART initiation, longer delays in TB diagnosis predicted a significantly higher mortality.

Changes in the etiology, incidence and prognosis of acute lower respiratory track infections in human immunodeficiency virus patients

“…Early diagnosis of TB, as well as the use of HAART, improves prognosis, as its late onset in patients with a previously confirmed diagnosis of TB increases mortality; which highlights the importance of good immunological control in HIV patients. 6,8 TB in Spain may be more common in immigrants. In our study there were 2 patients from Pakistan and one from Eastern Europe, although the only patient that died was native.…”

“…4 Conversely, a reduction in the incidence of S. peumoniae invasive disease (bacteremia) has been observed. 5 Pulmonary tuberculosis (TBC) has always been a worldwide health problem with a great impact in the pre-HAART era, in HIV/AIDS population [6][7][8][9] even in the developed world. Nowadays, pulmonary tuberculosis develops in HIV patients with relatively good immunological control and its incidence has become close to that of the immunocompetent population of the same geographical area.…”

Mortality among adults living with HIV treated for tuberculosis based on positive, negative, or no bacteriologic test results for tuberculosis: the IeDEA consortium

“…Additionally, bacteriologic testing for extrapulmonary TB is less sensitive in general compared to pulmonary TB, extrapulmonary TB is more common in PLWH, certain extrapulmonary TB types (e.g. disseminated or meningitis) are associated with especially high mortality in PLWH, and extrapulmonary TB has been associated with delays in diagnosis [40, 42, 43, 49–52]. These features may also have influenced clinicians to forego bacteriologic testing and initiate empiric TB treatment among individuals that were already at increased risk of death.…”

“…This underscores the fundamental importance of early ART initiation and immune preservation on survival, regardless of the presence or result of TB bacteriologic testing, in resource-constrained settings. Advanced HIV immunosuppression is known to be a critical risk factor for TB-related mortality (including mortality ≥ 1 year after completion of TB therapy), and the scale-up of ART coverage has been associated with marked reductions in TB incidence and mortality in countries with high HIV and TB burdens [20, 21, 40, 41, 55–57].…”

Os determinantes da mortalidade por Tuberculose e TB-HIV no Sul do Brasil: Da abordagem espacial à análise de sobrevida

“…A curta sobrevida encontrada (menos de 1 mês) acena para a gravidade da doença no momento do diagnóstico, acenando sua ocorrência em uma fase muito tardia (SCHMALTZ et al, 2012;WAITT et al, 2011;); estes resultados suscitam reflexões acerca das medidas de controle adotadas, como o uso de anti-retroviral, DOTS e a busca ativa, se estão sendo efetivamente empregadas.…”