Prevalence, drug-induced hepatotoxicity, and mortality among patients multi-infected with HIV, tuberculosis, and hepatitis virus

Drug-Induced Liver Injury in Patients With Chronic Liver Disease

OBJECTIVE

Drug-induced liver injury (DILI) is a global problem and can develop from exposure to prescription or over-the-counter medications as well as herbal and dietary supplements. The diagnosis of DILI is clinically challenging, and liver injury can be severe leading to liver failure, death, or liver transplantation. Patients with underlying chronic liver diseases (CLD) may be at increased risk for DILI, which is associated with factors related to drug or liver disease.

METHODS

This review summarises current knowledge on the risk and outcomes of DILI in patients with CLD.

RESULTS

Patients with CLD may be at an increased risk for DILI. Additionally patients with underlying CLD are at risk for more severe liver injury and worse outcomes after DILI.

DISCUSSION

The risk for and poor outcomes from DILI are accentuated in patients with CLD and potentially leading to the worst-case scenario of acute-on-chronic liver failure. We highlight the key observations on DILI with a broad range of underlying liver diseases and the high-DILI risk agents implicated in those populations.

Risk factors associated with post-tuberculosis sequelae: a systematic review and meta-analysis

Background

Post-tuberculosis (TB) sequelae present a significant challenge in the management of TB survivors, often leading to persistent health issues even after successful treatment. Identifying risk factors associated with post-TB sequelae is important for improving outcomes and quality of life of TB survivors. This systematic review and meta-analysis aims to identify risk factors associated with long-term physical sequelae among TB survivors.

Methods

We systematically searched Medline, Embase, PROQUEST, and Scopus for studies on long-term physical sequelae among TB survivors up to December 12, 2023. The primary outcome of interest was to quantify risk factors of long-term physical sequelae (i.e., respiratory, hepatic, hearing, neurological, visual, renal, and musculoskeletal sequelae). We included all forms of TB patients who experienced long-term physical sequelae. We used narrative synthesis for risk factors reported once and random-effect meta-analysis for primary outcomes with two or more studies. Findings were presented with odds ratios (OR) and 95% confidence intervals (CI). Publication bias was assessed using funnel plots and Egger regression, and heterogeneity was examined with a Galbraith radial plot. The protocol was registered on Prospero (CRD42021250909).

Findings

A total of 73 articles from 28 countries representing 31,553 TB-treated patients were included in the narrative synthesis, with 64 of these studies included in the meta-analysis. Risk factors associated with post-TB lung sequelae include older age (OR = 1.62, 95% CI: 1.07-2.47), previous TB treatment history (OR = 3.43, 95% CI: 2.37-4.97), smoking (OR = 1.41, 95% CI: 1.09-1.83), alcohol consumption (OR = 1.84, 95% CI: 1.04-3.25), smear-positive pulmonary TB diagnosis (OR = 3.11, 95% CI: 1.77-6.44), and the presence of radiographic evidence of pulmonary lesions at the commencement of treatment (OR = 2.04, 95% CI: 1.07-3.87). Risk factors associated with post-TB liver injury included pre-existing hepatitis (OR = 2.41, 95% CI: 1.16-6.08), previous TB treatment (OR = 2.64, 95% CI: 1.22-6.67), hypo-albuminemia (OR = 2.10, 95% CI: 1.53-2.88), HIV co-infection (OR = 2.72, 95% CI: 1.66-4.46), and CD4 count <200 mm3 in HIV-infected individuals (OR = 2.03, 95%CI: 1.26-3.27). Risk factors associated with post-TB hearing loss include baseline hearing problems (OR = 1.72, 95% CI: 1.30-2.26), and HIV co-infection (OR = 3.02, 95% CI: 1.96-4.64).

Interpretation

This systematic review and meta-analysis found that long-term physical post-TB sequelae including respiratory, hepatic, and hearing impairment were associated with a range of socio-demographic, behavioral, and clinical factors. Identification of these risk factors will help to identify patients who will benefit from interventions to reduce the burden of suffering from post-TB treatment.

Funding

Healy Medical Research Raine Foundation, the Australian National Health and Medical Research Council, and Curtin University Higher Degree Research Scholarship fund the study.

Prevalence of Hepatitis B Virus, Human Immune Deficiency Virus and Associated Risk Factors Among Individuals with Presumptive Pulmonary Tuberculosis Attending at Saint Peter's Specialized Hospital, Addis Ababa, Ethiopia

Background

Hepatitis B virus (HBV), human immunodeficiency virus (HIV) and tuberculosis are the causes of widely spread infectious disease, especially in resource-limited countries. The extent of HBV infection and its contributing factors among people with suspected pulmonary tuberculosis (PTB) were not adequately addressed.

Objective

To assess the prevalence of HBV, HIV & their associated risk factors and the magnitude of TB among individuals with presumptive pulmonary tuberculosis attending at St. Peter's Specialized Hospital, Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted among 387 individuals with presumptive PTB from October to December 2020. A standard questionnaire was used to collect socio-demographic data and associated risk factors. Sputum samples were analyzed by GeneXpert, Florescent Microscopy and Ziehl-Nelson staining technique. HBsAg test was carried out using Murex Version 3 ELISA test kit from serum/Plasma samples, HIV testing was performed by rapid HIV test kits and data were analyzed using SPSS version 23.

Results

The mean age of study participants was 44.2 years. Overall, 14 (3.6%), 28 (7.2%) and 37 (9.6%) of them were positive for HBV, HIV & TB, respectively. Only single patient was HBV-HIV co-infected (0.3%). The TB-HIV co-infection was identified in 6 (1.6%). In multivariate analysis, being partner separated, alcohol consumption, body piercing and having multiple sexual partners were significantly associated with HBV infection. Having a spouse, who is divorced, widowed, sharing scissors, alcohol consumption and contact with multiple sexual partners also significantly associated with HIV infection.

Conclusion

This study showed that HBV, HIV and TB are still public health issues that need awareness and health education on the risky behaviors and transmission of HBV, HIV & TB among individuals with presumptive TB suspects. Further large-scale study is necessary.

Hepatitis B and C virus infections and associated factors among HIV-positive and HIV-negative tuberculosis patients in public health facilities, Northeast Ethiopia: A comparative cross-sectional study

Objective

Viral hepatitis, particularly hepatitis B virus and hepatitis C virus, is the leading cause of global liver-related morbidity and mortality. Concomitant infections of hepatitis B virus, hepatitis C virus, and tuberculosis are risks of hepatotoxicity and death due to antituberculosis therapy. Hepatitis and human immunodeficiency virus coinfection poses challenges in treating hepatotoxic patients and leads to mortality during antituberculosis treatment. Thus, this study aimed to determine the prevalence of hepatitis B virus and hepatitis C virus infections, and associated factors among human immunodeficiency virus-positive and human immunodeficiency virus-negative tuberculosis patients attending public health facilities, Northeast Ethiopia.

Methods

A comparative cross-sectional study was conducted among 229 tuberculosis patients from January 1 to April 30, 2021 in public health facilities' tuberculosis treatment centers. Study participants were selected using a consecutive sampling technique. Data on sociodemographic and other risk factors were collected using an interviewer-based pretested questionnaire by trained data collectors. Anti-hepatitis C virus and hepatitis B surface antigen were determined in serum using enzyme-linked immunosorbent assay. Data were entered and analyzed using SPSS version 22. Logistic regression analysis was computed, and then variables with a p value <0.05 were considered as statistically significant.

Result

The overall hepatitis virus infection among human immunodeficiency virus-positive and human immunodeficiency virus-negative tuberculosis patients was 14.03% and 8.14%, respectively. The prevalence of hepatitis B virus infection in human immunodeficiency virus positives and human immunodeficiency virus negatives was 10.5% and 6.4% and hepatitis C virus infection in human immunodeficiency virus positives and human immunodeficiency virus negatives was 3.5% and 1.75%, respectively. Hepatitis B virus and hepatitis C virus coinfections were not observed. Older age, history of problematic alcohol use, history of blood transfusion, ear-noise piercing, and history of multiple heterosexual partners were predictors for the hepatitis virus infection.

Conclusion

Hepatitis virus infection increases morbidity and mortality of tuberculosis patients. Therefore, screening tuberculosis patients for hepatitis virus infection is necessary to reduce the risk of antituberculosis complications.

Prevalence of hepatotoxicity among HIV-infected patients in Ethiopia: a systematic review and meta-analysis

Background

Globally, the human immunodeficiency virus has been recognized as a major public health concern. The direct toxicity of antiretroviral medicines or their active metabolites causes liver cell destruction by different mechanisms, inducing immune-mediated inflammation, oxidative stress, and other mechanisms. On the other hand, the virus itself also produces hepatotoxicity. Therefore, this systematic review and meta-analysis aimed to assess the pooled prevalence of hepatotoxicity among HIV-infected patients in Ethiopia.

Methods

PubMed, Science Direct, Cochrane Library, Web of Science, and ResearchGate databases were used to find relevant articles. As well, various professional associations were searched to retrieve grey literature. The Newcastle–Ottawa Quality Assessment Scale was used to assess the quality of recruited studies. The data were extracted using Microsoft Excel, and the meta-analysis was carried out using STATA 14 software. I2 and Cochran’s Q test were employed to assess the presence of heterogeneity between studies. A random effect model was used. The funnel plot and Egger’s statistics were used to assess publication bias. Moreover, subgroup analysis and sensitivity analysis were also done.

Results

The pooled prevalence of hepatotoxicity among HIV patients in Ethiopia was 25.45% (95% CI = 20.06–30.84%). There was high heterogeneity, with an I2 value of 93.7%. Subgroup analysis by HAART status showed a higher pooled prevalence of hepatotoxicity among HIV patients taking HAART (23.63%) than among HAART naive patients (7.29%). In subgroup analysis, the pooled prevalence of hepatotoxicity among HIV/Tb co-infected and HIV mono-infected patients was 26.3% and 17.94%, respectively.

Conclusion

The current systematic review and meta-analysis showed a high prevalence of hepatotoxicity among HIV-infected patients. Therefore, regular monitoring of hepatotoxicity among HIV-infected patients is required in order to avoid liver damage and other complications.

Systematic review registration PROSPERO (2022:CRD42022334704)

Prevalence of Hepatitis B Virus and Latent Tuberculosis Coinfection in the United States

CONTEXT

Underlying chronic hepatitis B virus (HBV) infection increases the risk of drug-induced liver injury (DILI) when receiving tuberculosis therapies. Prevalence of HBV and latent tuberculosis infection (LTBI) coinfection is not well reported and no studies have evaluated testing patterns for and prevalence of HBV-LTBI coinfection in the United States.

OBJECTIVE

To evaluate patterns of HBV and LTBI testing and prevalence of HBV-LTBI coinfection in the United States.

DESIGN

Retrospective cohort study.

SETTING

Quest Diagnostics clinical laboratory data, 2014-2020.

PATIENTS

Chronic HBV infection was defined as any combination of 2 positive HBV surface antigen, HBV e antigen, or detectable HBV DNA tests at least 6 months apart. LTBI was defined as a positive QuantiFERON-TB or T-SPOT.TB test without evidence of active tuberculosis infection.

MAIN OUTCOME MEASUREMENTS

Testing patterns for chronic HBV infection and LTBI and prevalence of HBV-LTBI coinfection were evaluated from 2016 through 2020 and stratified by age, sex, and race and ethnicity.

RESULTS

Among 89 259 patients with chronic HBV infection, 9508 (10.7%) were tested for LTBI, among whom prevalence of HBV-LTBI coinfection was 19.6%, more than twice the observed prevalence of LTBI in patients with no chronic HBV infection in our cohort. Among 394 817 LTBI patients, 127 414 (32.3%) were tested for HBV, among whom prevalence of HBV-LTBI coinfection was 1.5%, approximately 3 times higher than prevalence of HBV infection in patients with no LTBI. The HBV-LTBI coinfection prevalence was highest among Asian Americans and older individuals.

LIMITATIONS

The HBV-LTBI coinfection prevalence was likely underestimated because of suboptimal awareness and testing among at-risk populations.

CONCLUSION

Among US individuals with chronic HBV infection or LTBI, prevalence of HBV-LTBI coinfection is substantial and highlights the need of testing for HBV-LTBI coinfection to mitigate risk of DILI associated with tuberculosis medications in patients with chronic HBV infection.

Estimating Prevalence of Hepatitis B Virus Coinfection Among Adults With Tuberculosis: A Systematic Review With Meta-analysis

BACKGROUND

While patients with hepatitis B virus (HBV) infection and tuberculosis (TB) have similar risk factors, little is known regarding the prevalence of HBV and TB coinfection. We aim to evaluate the prevalence of HBV among patients with TB across world regions.

METHODS

We systematically reviewed the literature using PubMed from inception through September 1, 2019, to identify studies that provided data to calculate HBV coinfection prevalence among adults with TB infection. Prevalence estimates of HBV coinfection among TB patients were stratified by world regions and calculated using meta-analyses with random-effects models.

RESULTS

A total of 36 studies met inclusion criteria (4 from the Africa region, 6 from the Americas region, 5 from the Eastern Mediterranean region, 2 from European region, 6 from Southeast Asia region, and 13 from the Western Pacific region). On meta-analysis, overall pooled HBV coinfection prevalence among TB patients was 7.1%, but varied by world region. Region-specific pooled HBV prevalence among TB patients was highest in Africa region [11.4%, 95% confidence interval (CI): 3.45-19.31] and Western Pacific region (10.8%, 95% CI: 8.68-12.84), and was lowest in the Americas (2.2%, 95% CI: 0.78-3.53). Sensitivity analyses yielded similar HBV prevalence estimates across world regions.

CONCLUSIONS

In this meta-analysis, we observed HBV coinfection prevalence among TB patients to be 38% to 450% higher than published estimates from the Polaris group of region-specific overall HBV prevalence. Timely identification of HBV infection among TB patients will improve patient outcomes by allowing for closer clinical monitoring and management, which may reduce the risk of liver dysfunction and liver failure related to TB treatment.

Economic Evaluation of Multiple-Pharmacogenes Testing for the Prevention of Adverse Drug Reactions in People Living with HIV

Purpose

Pharmacogenetics (PGx) testing is one of the methods for determining whether individuals are at risk of adverse drug reactions (ADRs). It has been reported that multiple-PGx testing, a sequencing technology, has a higher predictive value than single-PGx testing. Therefore, this study aimed to determine the most cost-effective PGx testing strategies for preventing drug-induced serious ADRs in human immunodeficiency virus (HIV)-infected patients.

Patients and Methods

Potential strategies, including 1) single-PGx esting (ie, HLA-B*57:01 testing before prescribing abacavir, HLA-B*13:01 testing before prescribing co-trimoxazole and dapsone, and NAT2 testing before prescribing isoniazid) and 2) multiple-PGx testing as a combination of four single-gene PGx tests in one panel, were all compared to no PGx testing (current practice). To evaluate total cost in Thai baht (THB) and quality-adjusted life years (QALYs) for each strategy-based approach to a societal perspective, a hybrid decision tree and Markov model was constructed. Incremental cost-effectiveness ratios (ICERs) were estimated. Uncertainty, threshold, and scenario analyses were all performed.

Results

Before prescribing HIV therapy, providing single or multiple-PGx testing might save roughly 68 serious ADRs per year, and the number needed to screen (NNS) to avoid one serious ADR was 40. Consequently, approximately 35% and 40% of the cost of ADR treatment could be avoided by the implementation of single- and multiple-PGx testing, respectively. Compared with no PGx testing strategy, the ICERs were 146,319 THB/QALY gained for single-PGx testing and 152,014 THB/QALY gained for multiple-PGx testing. Moreover, the probability of multiple-PGx testing being cost-effective was 45% at the Thai willingness to pay threshold of 160,000 THB per QALY. Threshold analyses showed that multiple-PGx testing remained cost-effective under the range of cost, sensitivity at 0.95–1.00 and specificity at 0.98–1.00.

Conclusion

Single and multiple-PGx testing might be cost-effective options for reducing the incidence of drug-induced serious ADRs in people living with HIV.

Seroprevalence and Associated Factors of Hepatitis B and C Virus Among Pulmonary Tuberculosis Patients Attending Health Facilities in Gondar Town, Northwest Ethiopia

Background

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are hepatotropic viruses whose primary replication occurs in the liver. Despite the significant clinical importance of early screening of hepatitis B and C virus infection in decreasing the hepatotoxicity effect of anti-tuberculosis drugs, screening of hepatitis B and C virus among tuberculosis (TB) patients before treatment has not been practiced in Ethiopia. Thus, this study was conducted to determine the seroprevalence and associated factors of HBV and HCV infections among pulmonary TB (PTB) patients attending health facilities in Gondar, Northwest Ethiopia.

Methods

A cross-sectional study was conducted among 145 bacteriologically confirmed PTB patients from January 1 to May 30, 2019. After obtaining a signed informed consent from each participant, data on socio-demographic, clinical, and associated factors were collected using a structured pre-tested questionnaire. Besides, a blood sample was collected to determine HBsAg and HCV antibodies by enzyme linked immune sorbent assay (ELISA). The data were entered and analyzed using SPSS version 21. A Fisher's exact test was used to see the relationship between dependent and independent variables, and a p-value ≤0.05 was considered as statistically significant.

Results

Out of the 145 PTB patients screened, 5 (3.4%) patients tested positive for HBsAg, yet none of them were found to be positive for anti-HCV. Besides, the proportion of HIV-positive was 12 (8.3%). History of hospital admission (P= 0.005), tattooing (P= 0.009) and dental extraction (P=0.003) were significantly associated with HBsAg.

Conclusion

Although anti-HCV antibodies were not detected, the prevalence of HBV was relatively high in tuberculosis patients. This study highlights the need for the introduction of routine screening of viral hepatitis markers for all TB patients before anti-TB treatment for better management of patients. Likewise, further clinical and epidemiological studies are needed.

Concurrent central nervous system involvement in immunocompetent adults with pulmonary miliary TB: a prospective analysis

BACKGROUND

Wallgren's tuberculosis (TB) timetable demonstrated co-occurrence of miliary TB and tuberculous meningitis in children. To verify the same in immunocompetent adults, we prospectively evaluated the prevalence and spectrum of central nervous system (CNS) involvement in patients with pulmonary miliary TB.

MATERIALS AND METHODS

This was a tertiary care, University hospital-based, prospective evaluation performed from December 2018 to June 2020. Newly diagnosed patients with pulmonary miliary TB were subjected to a detailed clinical, laboratory and MRI-based evaluation. All patients received treatment as per WHO guidelines.

RESULTS

Out of 342 patients with pulmonary TB, 53 patients met the eligibility criteria. The median age at presentation was 32 y and approximately two-thirds of patients were female. Clinically, only two-fifths of patients had features of CNS involvement. Cerebrospinal fluid (CSF) and imaging abnormalities were noted in 46 patients each. Twelve (23.5%) patients were diagnosed with definite-category tuberculous meningitis. Presence of an infarct significantly correlated with neurological features. Mantoux positivity correlated significantly with the presence of choroid tubercles, CSF changes and brain tuberculomas.

CONCLUSION

This is the first study to endorse Wallgren's observations in immunocompetent adults. A high index of suspicion, even in asymptomatic patients, may uncover tuberculous lesions involving the CNS and guide optimal monitoring of patients.

HIV-MSS: A user-friendly management support system for better planning of HIV care services

The advent of antiretroviral therapy (ART) has transformed HIV infection from a deadly disease to a manageable chronic condition. The life expectancy of people living with HIV has been prolonged dramatically. Therefore, health systems are now confronted with new challenges, with ever-increasing number of newly diagnosed cases, fuelling the pool of existing patients, with many comorbidities and requiring hospital admissions. Are health systems prepared to handle large and increasing numbers of people with HIV? We developed a HIV-Management Support System (MSS) to support service evaluation and management using simulation by capturing individual patient's pathways within HIV services in the United Kingdom. Two scenarios were tested: (1) the impact of increasing the number of diagnosed cases in steps of 5% on human resources and (2) the impact of treating all patients with ART on hospital admissions. A 5% increase in newly diagnosed HIV cases increases human resource requirements between 4% and 8%, whereas the impact of treating all HIV patients with ART on hospital admissions is far greater. HIV services are under intense pressure and managing patient and service needs are far more important than ever, hence the development of our HIV MSS is timely, to support better planning of services. Note that the HIV simulation model presented in this study is the first of its kind.

Antiviral Therapy for Hepatitis B Prevents Liver Injury in Patients With Tuberculosis and Hepatitis B Coinfection

BACKGROUND

Chronic hepatitis B virus (HBV) infection increases the risk of liver injury in patients who undergo antituberculosis treatment. It is uncertain whether antiviral treatment for HBV at the time of tuberculosis diagnosis would reduce the risk of liver injury.

METHODS

We performed a population-level, retrospective, cohort study that involved all patients with tuberculosis-HBV coinfection treated in public hospitals in Hong Kong over a 16-year period. Patients who received antiviral treatment at the time of tuberculosis diagnosis were considered "patients on antiviral therapy." A multivariable Cox proportional hazards model was used to determine the adjusted hazard ratio of hospitalization due to drug-induced liver injury within 1 year in patients on antiviral therapy, adjusting for the propensity score.

RESULTS

Of 3698 patients with tuberculosis-HBV coinfection, 488 (13.2%) were patients on antiviral therapy. Of the remaining 3210 patients, 446 (13.9%) started antiviral therapy within 1 year of tuberculosis diagnosis. Adjusting for the propensity score, patients on antiviral therapy had a lower risk of hospitalization due to drug-induced liver injury compared with those not on treatment (adjusted hazard ratio, 0.44; 95% confidence interval .26-.72). Compared with patients who started antiviral therapy within 1 year of tuberculosis diagnosis, patients on antiviral therapy also had a lower risk of hospitalization due to drug-induced liver injury and a lower risk of liver-related mortality.

CONCLUSIONS

We show that antiviral treatment for HBV given at the time of tuberculosis diagnosis reduced the risk of liver injury in tuberculosis-HBV coinfected patients.

Increased Prevalence of Liver Fibrosis and HIV Viremia among Patients with HIV, HBV, and Tuberculosis in Botswana

People with concomitant human immunodeficiency virus (HIV) and tuberculosis (TB) have an increased risk of hepatotoxic reactions due to antiretroviral therapy (ART) and anti-TB therapy (ATT). Concomitant hepatitis B virus (HBV) in these patients may lead to poorer health outcomes. To assess liver enzyme levels and immune response in adults with HIV, HBV, and TB, data from 300 antiretroviral-naïve people living with HIV (PLWHIV) were analyzed. The prevalence of HIV/HBV (cHIV/HBV) and HIV/TB (cHIV/TB) was 28% (95% CI: 23.0-33.4) and 10% (95% CI: 6.8-14.0), respectively. HIV/HBV/TB (cHIV/HBV/TB) prevalence was 5.3% (95% CI: 3.1-8.5). There was a statistically significant difference between the groups of participants in HIV viral load (p = 0.004), hemoglobin levels (p = 0.025), and body mass index (p = 0.011). A larger proportion of cHIV/HBV/TB participants (37.5%) had an aspartate aminotransferase to platelet ratio index (APRI) score ≥0.5 (p = 0.013), a lower cutoff for significant liver fibrosis. Immunological non-responders (CD4+ T-cell count <20% gain and HIV viral load <400 copies/mL at 6 months) were observed in all groups except those with cHIV/TB. Our findings support the need to screen for infections that could cause excessive liver damage prior to ATT or ART initiation, such as HBV.

Impacts of hepatitis B and hepatitis C co-infection with tuberculosis, a prospective cohort study

BACKGROUND

This study was conducted to estimate the prevalence, determinants of hepatitis B, hepatitis C and the survival of tuberculosis patients until drug-induced hepatitis.

METHODS

Prospective cohort study design was implemented. The data were collected from September 2016 - May 2019. Systematic random sampling was used to select the study participants. Baseline data were collected before the patient starts DOTS, the sign of liver toxicity was assessed every week. Tuberculosis treatment outcomes and WHO clinical stage was recorded at the end of 6th months. Descriptive statistics were used to estimate the prevalence of hepatitis B, hepatitis C viral infections and their effect on tuberculosis treatment outcomes. Binary logistic regression was used to identify the determinants of hepatitis B and C infections. The Kaplan Meier survival curve was used to estimate the survival of tuberculosis patient and Cox regression was used to identify the predictors of drug-induced hepatitis.

RESULTS

A total of 3537 tuberculosis patients were followed. The prevalence of hepatitis B and C viral infection among tuberculosis patients were 15.1 and 17.3% respectively. Hepatitis B viral infection among tuberculosis patients was associated with alcohol, sex, HIV, chronic illness. Hepatitis C viral infection among tuberculosis patients was associated with alcohol, sex, HIV, chronic illness. The incidence density for liver toxicity among tuberculosis patients was 843/15707 person-months and liver toxicity was determined by HIV, Hepatitis B, Hepatitis C, the severity of tuberculosis and chronic illnesses.

CONCLUSION

Decision-makers should consider incorporating screening for hepatitis B and C viral infection during tuberculosis treatment.

Hepatitis C Virus Affects Tuberculosis-Specific T Cells in HIV-Negative Patients

The occurrence of tuberculosis (TB) and hepatitis C virus (HCV) infections in the same patient presents a unique clinical challenge. The impact of HCV infection on the immune response to TB remains poorly investigated in TB⁺/HCV⁺ patients. This study was conducted to evaluate the impact of HCV on the T-cell-mediated immune response to TB in coinfected patients. Sixty-four patients with active TB infections were screened for coinfection with HCV. The expression of immune activation markers IFN-γ, CD38, and HLA-DR on TB-specific CD4⁺ T cells was evaluated by flow cytometry in TB-monoinfected patients, TB/HCV-coinfected patients, and healthy controls. IL-2, IL-4, IFN-γ, TNF-α, and IL-10 levels were measured using ELISA. The end-of-treatment response to anti-TB therapy was recorded for both patient groups. Significantly lower levels of CD4⁺IFN-γ⁺CD38⁺ and CD4⁺IFN-γ⁺HLA-DR⁺ T cells were detected in TB/HCV-coinfected patients compared to TB monoinfected patients and controls. TB⁺/HCV⁺-coinfected patients showed higher serum levels of IL-10. The baseline frequencies of TB-specific activated T-cell subsets did not predict the response to antituberculous therapy in TB⁺/HCV⁺ patients. We concluded that different subsets of TB-specific CD4⁺ T cells in TB/HCV-infected individuals are partially impaired in early-stage HCV infection. This was combined with increased serum IL-10 level. Such immune modulations may represent a powerful risk factor for disease progression in patients with HCV/TB coinfection.

Safety implications of combined antiretroviral and anti-tuberculosis drugs

Introduction: Antiretroviral and anti-tuberculosis (TB) drugs are often co-administered in people living with HIV (PLWH). Early initiation of antiretroviral therapy (ART) during TB treatment improves survival in patients with advanced HIV disease. However, safety concerns related to clinically significant changes in drug exposure resulting from drug-drug interactions, development of overlapping toxicities and specific challenges related to co-administration during pregnancy represent barriers to successful combined treatment for HIV and TB.Areas covered: Pharmacokinetic interactions of different classes of ART when combined with anti-TB drugs used for sensitive-, drug-resistant (DR) and latent TB are discussed. Overlapping drug toxicities, implications of immune reconstitution inflammatory syndrome (IRIS), safety in pregnancy and research gaps are also explored.Expert opinion: New antiretroviral and anti-tuberculosis drugs have been recently introduced and international guidelines updated. A number of effective molecules and clinical data are now available to build treatment regimens for PLWH with latent or active TB. Adopting a systematic approach that also takes into account the need for individualized variations based on the available evidence is the key to successfully integrate ART and TB treatment and improve treatment outcomes.

Social Determinants Associated with Tuberculosis Mortality in a General Hospital in Mexico

Background:

Most TB deaths can be prevented with timely diagnosis and appropriate treatment. In fact, millions of people are diagnosed and treated successfully every year, avoiding millions of deaths. However, globally, there are still huge gaps in detection and treatment.

Objective:

To identify the social determinants associated with mortality due to TB in a general hospital in Mexico.

Methodology:

All patients admitted with a diagnosis of pulmonary tuberculosis to the Emergency Department of a hospital in Mexico were included during a 10-month period. At the end of the study, the condition of discharge of all cases was obtained from the electronic database of the State Tuberculosis Program.

Results:

One-hundred and twenty-four patients with tuberculosis were included in the sample. Thirty-eight patients (30.6%) died during their hospital stay and eleven (8.9%) died outside the hospital after their discharge, for a total of 49 (39.5%) deaths. Of the 29 patients with HIV/AIDS, 12 died (41.3%). Logistic regression analysis showed that older age, imprisonment, and previous tuberculosis were significant predictors of mortality.

Conclusion:

The mortality of tuberculosis patients diagnosed in HGT is very high, mainly because the diagnosis is established at the hospital level, which implies a late diagnosis.

ROLE OF HEPATITIS B AND HEPATITS C VIRUS COINFECTION IN TB DEVELOPMENT

Tuberculosis developed differently in each individual. The role of HIV in the disease development is widely known unlike the role of Hepatitis B and Hepatitis C infection. Therefore, this study is aimed at to describe the role of those co-infections in the TB development. The study employed observational – case control design with two groups, case and control group. Data collection include TB condition, whether latent or manifest, and history of Hepatitis B and Hepatitis C co-infection. The study successfully recruited the total of 32 respondents in each group. At the case group, the number of male and respondent is 19 and 13. Meanwhile, at the control group the number male respondent is 10 and the female respondent is 22. The study found that 20 and 12 respondents were positive Hepatitis B at the case and the control group. Chi-square test resulted significant different between two groups (P=0.0455 and a =0.05) with odd ratio p=0.479. Meanwhile, the study only tested one respondent with positive Hepatitis C at case group and one at control group. Comparison analysis found no significant different between groups (P=1 and a =0.05). This study reveals that TB patients are more likely to have history of Hepatitis B 2.7 times than those at the control group with the same infection but without TB development. Therefore, the possibility of Hepatitis B co-infection has role in the TB manifestation, but not for Hepatitis C co-infection.

Prevalence of hepatitis C virus and human immunodeficiency virus in a group of patients newly diagnosed with active tuberculosis in Porto Alegre, Southern Brazil

BACKGROUND

Porto Alegre is the Brazilian state capital with second highest incidence of tuberculosis (TB) and the highest proportion of people infected with human immunodeficiency virus (HIV) among patients with TB. Hepatitis C virus (HCV) infection increases the risk of anti-TB drug-induced hepatotoxicity, which may result in discontinuation of the therapy.

OBJECTIVES

The aim of this study was (i) to estimate prevalence of HCV and HIV in a group of patients newly diagnosed with active TB in a public reference hospital in Porto Alegre and (ii) to compare demographic, behavioural, and clinical characteristics of patients in relation to their HCV infection status.

METHODS

One hundred and thirty-eight patients with TB were tested for anti-HCV antibody, HCV RNA, and anti-HIV1/2 antibody markers. HCV RNA from real-time polymerase chain reaction (PCR)-positive samples was submitted to reverse transcription and PCR amplification. The 5′ non-coding region of the HCV genome was sequenced, and genotypes of HCV isolates were determined.

FINDINGS

Anti-HCV antibody, HCV RNA, and anti-HIV antibodies were detected in 27 [20%; 95% confidence interval (CI), 13-26%], 17 (12%; 95% CI, 7-18%), and 34 (25%; 95% CI, 17-32%) patients, respectively. HCV isolates belonged to genotypes 1 (n = 12) and 3 (n = 4). Some characteristics were significantly more frequent in patients infected with HCV. Among them, non-white individuals, alcoholics, users of illicit drugs, imprisoned individuals, and those with history of previous TB episode were more commonly infected with HCV (p < 0.05).

MAIN CONCLUSIONS

HCV screening, including detection of anti-HCV antibody and HCV RNA, will be important to improving the management of co-infected patients, given their increased risk of developing TB treatment-related hepatotoxicity.

Clinical Correlates and Drug Resistance in HIV-Infected and -Uninfected Pulmonary Tuberculosis Patients in South India

OBJECTIVES

To examine demographics, clinical correlates, sputum AFB (acid fast bacilli) smear grading DOTS (Directly Observed Therapy Short Course) uptake, and drug resistance in a cohort of newly-diagnosed, smear positive pulmonary tuberculosis (TB) patients with respect to HIV status at baseline, and compare smear conversion rates, side effects and mortality after two months.

DESIGN

A prospective study among 54 HIV positive and 41 HIV negative pulmonary TB patients. Data were collected via face-to-face interviews, review of medical records, and lab tests.

RESULTS

HIVTB co-infected patients, though more symptomatic at baseline, showed more improvement in their symptoms compared to HIV-uninfected TB patients at follow-up. The HIV co-infected group had more prevalent perceived side effects, and sputum smear positivity was marginally higher compared to the HIV negative group at follow-up. Mortality was higher among the HIV-infected group. Both groups had high rates of resistance to first-line anti-tubercular drugs, particularly isoniazid. There was no significant difference in the drug resistance patterns between the groups.

CONCLUSIONS

Prompt initiation and provision of daily regimens of ATT (Anti-Tubercular treatment) along with ART (Anti-Retroviral treatment) via ART centers is urgently needed in India. As resistance to ART and/or ATT is directly linked to medication non-adherence, the use of counseling, regular reinforcement, early detection and appropriate intervention strategies to tackle this complex issue could help prevent premature mortality and development of resistance in HIV-TB co-infected patients. The high rate of isoniazid resistance might preclude its use in India as prophylaxis for latent TB in HIV infected persons as per the World Health Organization (WHO) guideline.

Hepatotoxicity during Treatment for Tuberculosis in People Living with HIV/AIDS

Hepatotoxicity is frequently reported as an adverse reaction during the treatment of tuberculosis. The aim of this study was to determine the incidence of hepatotoxicity and to identify predictive factors for developing hepatotoxicity after people living with HIV/AIDS (PLWHA) start treatment for tuberculosis. This was a prospective cohort study with PLWHA who were monitored during the first 60 days of tuberculosis treatment in Pernambuco, Brazil. Hepatotoxicity was considered increased levels of aminotransferase, namely those that rose to three times higher than the level before initiating tuberculosis treatment, these levels being associated with symptoms of hepatitis. We conducted a multivariate logistic regression analysis and the magnitude of the associations was expressed by the odds ratio with a confidence interval of 95%. Hepatotoxicity was observed in 53 (30.6%) of the 173 patients who started tuberculosis treatment. The final multivariate logistic regression model demonstrated that the use of fluconazole, malnutrition and the subject being classified as a phenotypically slow acetylator increased the risk of hepatotoxicity significantly. The incidence of hepatotoxicity during treatment for tuberculosis in PLWHA was high. Those classified as phenotypically slow acetylators and as malnourished should be targeted for specific care to reduce the risk of hepatotoxicity during treatment for tuberculosis. The use of fluconazole should be avoided during tuberculosis treatment in PLWHA.

Prevalence, risk factors, management, and treatment outcomes of first-line antituberculous drug-induced liver injury: a prospective cohort study

PURPOSE

Antituberculosis drug-induced liver injury (ATDILI) is one of the most deleterious side effects associated with chemotherapy against tuberculosis (TB). In this study, our objective was to determine the incidence, risk factors, and management of ATDILI and analyze its impact on the treatment outcome in patients receiving standard anti-TB chemotherapy.

METHODS

A prospective cohort study of ATDILI prevalence was conducted in 938 enrolled patients of the 1426 TB cases in Shanghai from March 2011 to September 2012. Patients were followed up until February 2014. Univariate and multivariate logistic regression analyses were used to determine the risk factors of ATDILI. Successful therapeutic outcome, rates of drug resistance conversion, sputum smear/culture conversion, and lung cavity closure were analyzed.

RESULTS

Hepatitis B surface antigen/hepatitis B e antigen-positive hepatitis B carriers, complicated with systemic lupus erythematosus, albumin ≤ 25 g/L, and chronic alcoholism were independent risk factors for ATDILI. Of the 121 cases with ATDILI (incidence rate of 12.9%), 84 (69.4%) used modified anti-TB therapy after recovery of liver function. Compared with the non-ATDILI group, patients with ATDILI exhibited remarkably decreased lung cavity closure rate (84.6% vs. 93.0%, P < 0.001) along with significantly reduced sputum smear/culture conversion rate (85.4% vs. 94.0%, P < 0.001).

CONCLUSIONS

Our findings indicated that 12.9% patients developed ATDILI during standard anti-TB therapy, resulting in poor therapeutic outcome. Hepatitis B carriers with systemic lupus erythematosus, albumin ≤ 25 g/L, and chronic alcoholism manifested increased risks for ATDILI. Copyright © 2016 John Wiley & Sons, Ltd.

A 20-year retrospective cohort study of TB infection among the Hill-tribe HIV/AIDS populations, Thailand

Background

A retrospective cohort study was conducted to determine the situation, trend, and factors associated with TB infection, and factors related to the life status among the HIV/AIDS Hill-tribe in Northern Thailand. Hill-tribe people have been migrating to and formed settlements along the Thai border areas for many decades. There are now having 1.6 million people of 6 different groups–Akha, Lahu, Lisu, Hmong, Yao and Keren–each with a specific culture, language and lifestyle. The Hill-tribe becomes a new vulnerable of HIV and TB infections in Thailand.

Methods

A systematic data-reviewing approach was used to identify the information from the rosters of ARV clinics, OPD cards, and laboratory reports from 16 hospitals in Chiang Rai Province, Thailand. The data were collected from the first reported HIV/AIDS case of the Hill-tribe to the end of 2010. A chi-square test and logistic regression models were used to identify associations at the significance level of alpha = 0.05.

Results

A total of 3,130 cases were included in the study. The majority of patients were Akha (46.0 %) followed by Lahu (19.7 %), 54.6 % were males, 44.6 % were 26–35 years old. The major risk factor of HIV infection was sexual intercourse (93.1 %); 23.9 % were still alive at the date of data collection, 30.7 % were diagnosed with pulmonary TB. The Akha Hill-tribe HIV/AIDS individuals had a greater chance of TB infection than did Yao individuals with OR_adj = 1.50 (95 % CI = 1.01-1.92). Females had a greater chance of TB infection than males with OR_adj = 1.33 (95 % CI = 1.11-1.59); being classified as HIV and AIDS groups had a greater chance of TB infection than those asymptomatic group with OR_adj = 11.59 (95 % CI = 7.19-18.71), and OR_adj = 1.71 (95 % CI = 1.03-2.87); and not having received the ARV group had a greater chance of TB infection than those who having received the ARV group with OR_adj = 2.59 (95 % CI = 2.09-3.22). The patients who had been diagnosed with HIV infection during 1990–1995 and 1996–2000 had less chance of TB infection than those who were diagnosed from 2006–2010, with OR_adj = 0.04 (95 % CI = 0.01-0.14) and 0.11 (95 % CI = 0.07-0.17), respectively. Regarding life status; females had a better chance of being still alive at the date of data collection than being males with OR_adj = 1.41 (95 % CI = 1.19-1.66). Those who had a defined route of transmission in the category of “mother-to-child” and “IDU” had a better chance of being still alive compared to those who contracted HIV from “sexual intercourse,” with OR_adj = 2.05 (95 % CI = 1.56-2.18), and OR_adj = 8.45 (95 % CI = 1.55-46.13), respectively.

Conclusions

Thailand needs to create a TB and HIV/AIDS surveillance system for Hill-tribe populations to determine the situation and trend and to develop an appropriate model for providing care at the earlier stage of HIV/AIDS infection to prevent later TB infection.

Drug-induced hepatitis and the risk factors for liver injury in pulmonary tuberculosis patients

Introduction:

Short-course chemotherapy containing rifampicin and isoniazid in combination has proved to be highly effective in the treatment of tuberculosis, but one of its adverse effects is hepatotoxicity. Various risk factors have been found to be associated with drug-induced liver injury (DILI) in general population. The study aimed to determine the prevalence of drug-induced hepatitis and the risk factors associated with the DILI among the patients of pulmonary tuberculosis in Indian patients.

Setting and Design:

Prospective nested case control study.

Materials and Methods:

Out of the cohort of 3900 tuberculosis patients who were initiated on anti-tubercular therapy, 150 patients who developed drug-induced liver injury due to short-course chemotherapy under RNTCP were included in the analysis. Thirty cases were being followed up in our hospital and other 120 were referred to us for the management of drug-induced hepatitis from the primary health centers. The diagnostic criteria's for DILI were made according to the American Thoracic Society criteria. Analyses of various risk factors were done for the development of DILI.

Results:

The prevalence of DILI in the present study was 3.8%. It was observed that DILI patients were older and their serum albumin levels were lower, and they had multiple co-morbid conditions. Regular alcohol intake, more extensive disease associated with radiological and female gender were observed to be independent risk factors for the development of DILI.

Conclusions:

Of the various risk factors analyzed, advanced age, hypoalbuminemia, regular alcohol intake and advanced nature of the disease were independent risk factors for the development of DILI. The risk of development of hepatitis is increased in the presence of one or more of these risk factors.