Risk of Death among HIV Co-Infected Multidrug Resistant Tuberculosis Patients, Compared To Mortality in the General Population of South Africa

Abstract

Background Even though highly effective drugs are available in South Africa, multidrug resistant tuberculosis (MDR-TB) patients with HIV infection have higher mortality compared to HIV-uninfected MDR-TB patients. This trend has been observed in similar countries with high HIV prevalence. This study sought to determine excess mortality attributable to HIV among MDR-TB patients in South Africa using relative survival methods. Methods Data available were from a cohort of 2079 MDR-TB patients enrolled in a Standardized Programmatic Management of MDR-TB from 2000 to 2004 in South Africa. A Poisson-based model adjusted for age, gender, year of diagnosis, TB history, and resistance to ethambutol, anti-TB injectable drugs and fluoroquinolones antibiotics was constructed to assess the excess mortality among HIV co-infected MDR-TB patients. Excess hazard ratios (EHRs) were used to describe the effect of the predictors on net mortality, controlling for the general mortality in the South African population. Results Death was recorded on 1619 patients, of whom 367 (22.7%) had died within 2 years. Out of the 1413 patients that tested for HIV infection, 554 (39.2%) tested positive. Excess mortality was higher in HIV infected, compared to HIV uninfected, MDR-TB patients (adjusted excess hazard ratio, 5.6 [95% CI, 3.2–9.7]); in patients whose TB isolates’ resistance to ethambutol and kanamycin was unknown (3.7 [2.1–6.2] and 4.87 [1.9–13.3], respectively) vs. known. There were no differences in excess mortality between age and gender of the patient, year of diagnosis and TB history. Conclusion Adjusting for some important predictors, MDR-TB patients with HIV infection experienced higher excess mortality compared to HIV-uninfected MDR-TB patients, after accounting for the general mortality in South Africa. An appropriate, though complex method has produced predictor effect estimates similar to those obtained from classical methods. Thus, the use of relative survival methods should be encouraged in the analysis of causespecific mortality, when ascertainment of cause of death is inaccurate or unknown.

Outcomes of HIV-infected versus HIV-non-infected patients treated for drug-resistance tuberculosis: Multicenter cohort study

“…Treatment success rate in this cohort is higher than the 50% reported by WHO [1]. The higher success rate in HIV-positive patients are not consistent with what is usually observed in the TB drug susceptible population, where success rates are lower among HIV-positive due to higher death rate [15]. We also report a high case fatality rate among HIV-positive patients for both MDR and PDR-TB patients, likely to be attributable to HIV as already shown in previous studies [16][17][18].…”

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

“…The steady rise in mortality in TB patients over the years 2003 to 2009 is variously attributed to migration [15] and high levels of HIV co-infected multidrug-resistant TB [16]. The marked decline in the mortality trend after 2009 can possibly be attributed to the progressive evolving of clinical eligibility requirements for HIV co-infected TB cases to access antiretroviral treatment (ART) [17], as well as heightened political attention and international support and civil society mobilisation around TB and HIV, including the launch of a national HIV/TB campaign in 2011 [4, 18].…”

Predictors of mortality in a cohort of tuberculosis/HIV co-infected patients in Southwest Ethiopia

“…Previous studies have focused mainly on the survival rates of general HIV patients, giving less attention to TB/HIV co-infected patients [12–15]. A few studies in Ethiopia have analysed factors associated with mortality in HIV-infected TB patients [16, 17] and some studies [18, 19] took into account drug susceptibility patterns of Mycobacterium tuberculosis outside Ethiopia. However, these studies assessed the mortality rates of HIV positive and negative patients on anti-TB treatment.…”