Incidence and mortality of tuberculosis before and after initiation of antiretroviral therapy: an HIV cohort study in India

Abstract

IntroductionIndia has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.MethodsWe describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.ResultsA total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1–23.6) in the pre-ART group and 17.8% (95% CI, 16.3–19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economical conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9–32.6) in pre-ART TB and 34.9% (95% CI, 31–39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.ConclusionsThe high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.

Patching the gaps towards the 90–90–90 targets: outcomes of Nigerian children receiving antiretroviral treatment who are co‐infected with tuberculosis

“…In contrast, our study did not find significant differences in severe immunosuppression between TB-co-infected and non-infected children. The association between low CD4 count and TB among adult ART patients has also shown mixed results, with some studies showing stronger association and others weaker [ 22 , 27 ].…”

Frequent HIV Testing: Impact on HIV Risk Among Chinese Men Who Have Sex with Men

“…Restricted cubic spline with four knots was applied to fit the non-linear association between frequency of HIV testing and odds of HIV infection in the whole study sample. 35,36 Three models were applied to identify and adjust for potential confounding variables. First, we used direct acyclic graphs (DAG) to evaluate and a priori select potential confounders to adjust in the multivariable model (Model A).…”

Factores asociados a sobrevida en pacientes con co-infección VIH-TBC en el Servicio de Infectología del Hospital Nacional Arzobispo Loayza, Perú, durante los años 2004-2012

“…Antes de la instauración del tratamiento anti-retroviral, la prevalencia de co-infección VIH-TBC se presentaba de manera frecuente. Estudios internacionales reportaron cifras de 33% de pacientes co-infectados durante los años 1993-1994 25 . En el Perú, Lama reportó hallazgos similares durante los años 1986-1993 (co-infección VIH-TBC de 33,8%) 16 .…”

“…La mortalidad secundaria a la co-infección ha disminuido considerablemente desde el inicio de la administración de TARGA 27 , observándose estos cambios en Perú desde mayo del 2004 9 . Estudios reportan que, en áreas endémicas de TBC, el uso de TARGA está asociado a una significante reducción de la tasa de incidencia de adquirir TBC, disminuyendo de 31,7/100 a 11,4/100 por año 25 . En Perú, el TARGA se fundamenta en tres fármacos base: efavirenz, nevirapina o inhibidor de la proteasa (lopinavir, atazanavir o saquinavir) reforzados con ritonavir, sumado a dos inhibidores nucleósidos de la transcriptasa reversa.…”

“…Las alteraciones nutricionales en pacientes con TBC, infección por VIH o co-infección, son variadas y la demanda energética conlleva a diversos estados nutricionales, los cuales pueden verse reflejados en el peso del paciente. Además, se dice que la pérdida de peso > 10% está asociada a menor sobrevida; por este motivo, se recomienda evaluar el peso de forma rutinaria en cada evaluación médica 25 . En este estudio se encontró que la variable peso es un factor protector, concluyendo que por cada kg más de peso, el paciente presenta 4% menos riesgo de morir, lo que refuerza la idea de que la ganancia ponderal está relacionada con sobrevida.…”