Tuberculosis in human immunodeficiency virus infected Ugandan children starting on antiretroviral therapy

Abstract

Objective To identify the incidence of tuberculosis (TB) in HIV-infected children in a resource-limited setting prior to and after antiretroviral therapy (ART) initiation. A secondary objective was to assess the impact of TB screening by Tuberculin skin testing (TST) and clinical history. Methods A retrospective cohort study of 1806 HIV-infected children and adolescents initiating ART from 2003 through July 1, 2006 in Kampala, Uganda. A TB screening program was instituted clinic-wide in January 2006. Results 311 (17.2%) HIV-infected children had with TB diagnosed among 171 diagnosed pre-ART and among 140 post-ART initiation. During the first 100 days of ART, risk of a new TB diagnosis was 2.7 fold higher compared to the pre-ART period (RR 2.7; 95% CI: 2.1 to 3.5; P<.001). After 100 days of ART, the TB incidence rate decreased below pre-ART levels (RR 0.41; 95% CI: 0.30 to 0.54; P=.002). After TB screening was instituted in 2006, the proportion of new TB cases diagnosed after starting ART decreased by 70% (95% CI: 51 to 82%; P<.001), abating the early excess risk. Conclusions TB is common among African children and adolescents initiating ART in Sub-Saharan Africa. More aggressive screening for active TB prior to starting ART can diminish the rate of TB during immune reconstitution. Future studies are needed to determine optimal screening practice for HIV-infected children.

Prevalence of and risk factors for pulmonary tuberculosis among newly diagnosed HIV-1 infected Nigerian children

“…But this alone cannot explain our observed overall high prevalence, since a Ugandan study reported a lower prevalence compared to our study, 9.5%, although the majority of diagnoses (80%) were based on clinical features and chest radiograph, like in our study. 5 Nevertheless, our observed annual prevalence of co-infection was decreasing, with the rate in 2012 of 6.1% comparable to that of the Ugandan study (9.5%) reported in 2011. 5 The diagnosis of PTB in children remains challenging, partly due to the inability of children <8 years to generate a productive sputum specimen 17 and because of their paucibacillary nature.…”

“…5 Nevertheless, our observed annual prevalence of co-infection was decreasing, with the rate in 2012 of 6.1% comparable to that of the Ugandan study (9.5%) reported in 2011. 5 The diagnosis of PTB in children remains challenging, partly due to the inability of children <8 years to generate a productive sputum specimen 17 and because of their paucibacillary nature. 18 The majority (70%) of our study subjects were children <5 years of age.…”

“…[26][27][28][29][30] Also, co-infection with HIV and TB increases the risk of death with or without ART. 5,28,29 A limitation of this study was our inability to routinely provide bacteriological confirmation of PTB in most cases, resulting in a possible overestimation of the number of PTB cases and hence a higher prevalence of PTB-HIV coinfection. However, it is well-recognized that bacteriological confirmation is often difficult in pediatric populations.…”

“…This finding is consistent with those of other studies in African children. 4,5,23 Severe immunosuppression in TB-HIV co-infection has largely been attributed to CD4+ T-cell depletion. 24,25 Severe immunosuppression in children with HIV mono-infection or HIV-TB co-infection has been associated with poor clinical outcomes and increased mortality with or without ART.…”

“…3 Data on the incidence or prevalence of and risk factors for TB among children newly diagnosed with HIV in sub-Saharan Africa are scarce. [3][4][5][6] In Nigeria, the prevalence of pulmonary TB (PTB) in HIV-infected children and the predisposing risk factors are poorly described. Therefore, such a description would be useful in highlighting the burden of PTB-HIV co-infection in children, and in developing prevention strategies to protect HIV infected children from co-infection with M. tuberculosis.…”