Tuberculosis and HIV coinfection in Europe: looking at one reality from two angles

Modeling Transmission Dynamics of Tuberculosis-HIV Co-Infection in South Africa

South Africa has the highest number of people living with the human immunodeficiency virus (HIV) in the world, accounting for nearly one in five people living with HIV globally. As of 2021, 8 million people in South Africa were infected with HIV, which is 13% of the country's total population. Approximately 450,000 people in the country develop tuberculosis (TB) disease every year, and 270,000 of those are HIV positive. This suggests that being HIV positive significantly increases one's susceptibility to TB, accelerating the spread of the epidemic. To better understand the disease burden at the population level, a Susceptible-Infected-Recovered-Dead (SIRD) TB-HIV co-infection epidemic model is presented. Parameter values are estimated using the method of moments. The disease-free equilibrium and basic reproduction number of the model are also obtained. Finally, numeric simulations are carried out for a 30-year period to give insights into the transmission dynamics of the co-infection.

Management of Tuberculosis: Are the Practices Homogeneous in High-Income Countries?

Objectives: To evaluate and compare practices regarding the diagnosis, isolation measures, and treatment of tuberculosis (TB) in high-income countries and mainly in Europe.

Materials and Methods: A survey was conducted from November 2018 to April 2019 within the European Society of Clinical Microbiology and Infectious Diseases Study Group for Mycobacterial Infections (ESGMYC). The practices observed were compared to the main international guidelines.

Results: Among 136 ESGMYC members, 64 (17 countries) responded to the questionnaire. In their practice, two (20.7%) or three sputum samples (79.3%) were collected for the diagnosis of pulmonary TB, alternatively induced sputum (n = 37, 67.2%), bronchoscopy (34, 58.6%), and gastric aspirates (15, 25.9%). Nucleic acid amplification tests (NAATs) were performed by 41 (64%) respondents whatever the smear result and by 47 (73%) in case of smear-positive specimens. NAAT and adenosine deaminase measurement were used for extrapulmonary TB diagnosis in 83.6 and 40.4% of cases, respectively. For isolation duration, 21 respondents (42.9%) were keeping isolation until smear negativity. An initial treatment without ethambutol was offered by 14% (n = 9) of respondents. Corticosteroid therapy, cerebrospinal fluid opening pressure testing, and repeated lumbar puncture were carried out for central nervous system TB by 79.6, 51.9, and 46.3% of the respondents, respectively. For patients with human immunodeficiency virus–TB coinfection, the preferred antiretroviral therapy included dolutegravir 50 mg twice a day (56.8%). Comparing with the recommendations of the main guidelines, the practices are not totally consistent.

Conclusion: This study shows heterogeneous practices, particularly for diagnosis, and isolation, although rapid molecular testing is implemented in most centers. More standardization might be needed.

Predictors of Adverse TB Treatment Outcome among TB/HIV Patients Compared with Non-HIV Patients in the Greater Accra Regional Hospital from 2008 to 2016

Introduction

The convergence of TB and HIV dual epidemics is a major public health challenge in Ghana as well as many developing countries. Treatment outcome monitoring is a vital part of the surveillance needed to successfully eliminate TB. The impact of HIV status and demographic and treatment-related factors on adverse TB treatment outcome has not been studied in the Greater Accra Regional Hospital. This study determined factors associated with TB treatment outcome in patients with TB-HIV coinfection and TB-only infection in the hospital.

Method

A cross-sectional study was carried out in the Greater Accra Regional Hospital. We reviewed TB treatment cards of patients who received treatment for tuberculosis in the hospital from 2008 to 2016. Data on treatment outcome and sociodemographic and clinical characteristics were extracted on TB-only-infected and TB/HIV-coinfected patients. The chi-squared test and binary and multiple logistic regression models were used to assess factors associated with adverse treatment outcome.

Results

Out of the 758 patient records analyzed, 174 (22.9%) were TB-HIV-coinfected patients. Overall treatment success for all TB patients was 88.1% (668/758). About 11.9% (90/758) of the patients had an adverse treatment outcome, including treatment failure 0.9% (7/758), defaulting 0.9% (7/758), and death 10.0% (76/758). TB-HIV-coinfected patients' treatment success was 78.1% (136/174). TB-only patients' treatment success was 91.4% (532/582). Independent predictors of adverse treatment outcome were found to be as follows: being HIV positive (aOR: 3.85, 95% CI: 2.19-6.75; p < 0.01); aged 65 and above (aOR: 1.76, 95% CI: 1.44-1.54; p = 0.01); and previously failed TB treatment (aOR: 5.02, 95% CI: 2.09-28.87; p < 0.01).

Conclusion

Treatment outcome for TB-HIV-coinfected patients is below the WHO target. HIV status, age, and category of patient of the TB patients were associated with adverse treatment outcome. Strengthening the TB/HIV collaborative efforts by stakeholders is required for good treatment outcomes.

Trends of tuberculosis case detection, mortality and co-infection with HIV in Ghana: A retrospective cohort study

Background

In an era of renewed commitment to accelerate the declines in Tuberculosis (TB) incidence and mortality, there is the need for National Tuberculosis Programmes (NTPs) to monitor trends in key indicators across a geographical location and to provide reliable data for direct measurement of TB incidence and mortality. In this context, we explored the trends of TB case detection, mortality and HIV co-infection, and examined the predictors of TB deaths in Ten districts of the Volta region of Ghana.

Methods

We conducted a retrospective cohort study of all TB cases registered from 2013 to 2017 in 10 districts of the Volta Region of Ghana. Case detection rate (CDR) was computed as the ratio of the number of new and relapse TB case notified to NTP to the number of estimated incident TB cases in a given year. Case fatality rates were estimated using data from 2012–2016 cohort of TB patients. Simple and multiple logistic regression were used to identify predictors of TB deaths with odds ratios and 95% confidence intervals estimated.

Results

Overall, there were 3,735 new and relapse TB patients who commenced anti-TB treatment during the period, representing the case detection rate of 40.1% with district variations. The CDR remained stable during the 5 years. Of the total cases, HIV status was documented for 3,144 (84.2%), among whom, 712 (22.6%) were HIV positive. The TB/HIV co-infection was more prevalent among children under 15 years of age (30.1%), males (30.6%), treatment after lost to follow-up patients (33.3%), and smear-negative pulmonary TB patients (29.1%). The prevalence of TB/HIV co-infection did not significantly change over the years. The overall case fatality rate was 13% (n = 486), with considerable variation among HIV-positives and HIV-negative TB patients (21.8% and 11% respectively) (p<0.001) and among districts. TB/HIV co-infection, sputum smear-negative pulmonary TB and district of anti-TB treatment predicted TB mortality.

Conclusion

TB case detection rate was low and remained stable during the study period, whereas co-infection with HIV and mortality rates were quite high, indicating the need for feasible strategies such as active case finding to improve case detection, and improved case management to reduce mortality.

Reflecting on tuberculosis case notification and treatment outcomes in the Volta region of Ghana: a retrospective pool analysis of a multicentre cohort from 2013 to 2017

BACKGROUND

Tuberculosis (TB) remains a petrified condition with a huge economic and health impact on families and health systems in Ghana. Monitoring of TB programme performance indicators can provide reliable data for direct measurement of TB incidence and mortality. This study reflects on the trends of TB case notification and treatment outcomes and makes comparison among 10 districts of the Volta region of Ghana.

METHODS

This was a retrospective analysis of surveillance data of a cohort of TB cases from 2013 to 2017. Trends of case notification and treatment outcomes were examined and compared. Logistic regression was used to determine the independent relationship between patients and disease characteristics and unsuccessful treatment outcomes. Odds ratios, 95% confidence intervals and p-values were estimated.

RESULTS

A gradual declining trend of case notification of all forms of TB was noticed, with an overall case notification rate (CNR) of 65 cases per 100,000 population during the period. A wide variation of case notification of TB was observed among the districts, ranging from 32 to 124 cases per 100,000 population. Similarly, treatment success rate decreased slightly from 83.1% during the first year to 80.2% in 2017, with an overall treatment success rate of 82.5% (95% CI: 81.3-83.8%). Treatment failure, death, and lost to follow up rates were 0.8% (range 0.5-1.2%), 13.5% (range 12.4-14.7%), and 3.1% (range 2.6-3.8%) respectively. The treatment success rate among districts ranged from 70.5% in South Tongu to 90.8% in Krachi West district. Returned after treatment interruption (Adjusted odds ratio [AOR]: 3.62; 95% CI: 1.66-7.91; P < 0.001) and TB/HIV co-infection (AOR: 1.94; 95% CI: 1.57-2.40; P < 0.001) predicts poor treatment outcomes.

CONCLUSION

Over the past five years, TB case notification and successful treatment outcomes did not significantly improve. Wide district variations in CNR was observed. The overall treatment success rate observed in this study is below the target of > 90% set by the World Health Organization's (WHO) end TB strategy. Additionally, patients who returned to continue treatment after interruption and those who were co-infected with HIV strongly predict unsuccessful treatment outcomes. Sustained interventions to prevent treatment interruptions and improved management of co-morbidities can enhance treatment outcomes, as required to achieve the elimination goal.

Bayesian modeling of spatiotemporal patterns of TB-HIV co-infection risk in Kenya

Background

Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) diseases are globally acknowledged as a public health challenge that exhibits adverse bidirectional relations due to the co-epidemic overlap. To understand the co-infection burden we used the case notification data to generate spatiotemporal maps that described the distribution and exposure hypotheses for further epidemiologic investigations in areas with unusual case notification levels.

Methods

We analyzed the TB and TB-HIV case notification data from the Kenya national TB control program aggregated for forty-seven counties over a seven-year period (2012–2018). Using spatiotemporal poisson regression models within the Integrated Nested Laplace Approach (INLA) paradygm, we modeled the risk of TB-HIV co-infection. Six competing models with varying space-time formulations were compared to determine the best fit model. We then assessed the geographic patterns and temporal trends of coinfection risk by mapping the posterior marginal from the best fit model.

Results

Of the total 608,312 TB case notifications, 194,129 were HIV co-infected. The proportion of TB-HIV co-infection was higher in females (39.7%) than in males (27.0%). A significant share of the co-infection was among adults aged 35 to 44 years (46.7%) and 45 to 54 years (42.1%). Based on the Bayesian Defiance Information (DIC) and the effective number of parameters (pD) comparisons, the spatiotemporal model allowing space-time interaction was the best in explaining the geographical variations in TB-HIV coinfection. The model results suggested that the risk of TB-HIV coinfection was influenced by infrastructure index (Relative risk (RR) = 5.75, Credible Interval (Cr.I) = (1.65, 19.89)) and gender ratio (RR = 5.81e⁻⁰⁴, Cr. I = (1.06e⁻⁰⁴, 3.18e⁻⁰³). The lowest and highest temporal relative risks were in the years 2016 at 0.9 and 2012 at 1.07 respectively. The spatial pattern presented an increased co-infection risk in a number of counties. For the spatiotemporal interaction, only a few counties had a relative risk greater than 1 that varied in different years.

Conclusions

We identified elevated risk areas for TB/HIV co-infection and fluctuating temporal trends which could be because of improved TB case detection or surveillance bias caused by spatial heterogeneity in the co-infection dynamics. Focused interventions and continuous TB-HIV surveillance will ensure adequate resource allocation and significant reduction of HIV burden amongst TB patients.

Does oxidative stress contribute to adverse outcomes in HIV-associated TB?

In HIV infection, oxidative stress is a pronounced phenomenon, with likely links to HIV-related pathologies and the progression of HIV infection per se. TB is an AIDS-defining condition. HIV-associated oxidative stress, like that associated with diabetes mellitus, might adversely impact the outcomes of TB, probably through increased propensity for generation of metabolically dormant mycobacterial persisters, alongside other mechanisms. This hypothesis might help in guiding the exploration of relevant research directions to improve the care of patients.

Combining surveillance systems to investigate local trends in tuberculosis-HIV co-infection

Alameda County has some of the highest human immunodeficiency virus (HIV) and tuberculosis (TB) case rates of California counties. We identified TB-HIV co-infected patients in 2002-2015 by matching county TB and HIV registries, and assessed trends in TB-HIV case rates and estimated prevalence ratios for HIV co-infection. Of 2054 TB cases reported during 2002-2015, 91 (4%) were HIV co-infected. TB-HIV case rates were 0.29/100,000 and 0.40/100,000 in 2002 and 2015, respectively, with no significant change (P = 0.85). African-American TB case-patients were 9.77 times (95% confidence interval [CI] 5.90-16.17) more likely than Asians to be HIV co-infected, and men 2.74 times (95% CI 1.66-4.51) more likely co-infected than women. HIV co-infection was more likely among TB case-patients with homelessness (6.21, 95% CI 3.49-11.05) and injection drug use (11.75, 95% CI 7.61-18.14), but less common among foreign-born and older case-patients (both P < 0.05). Among foreign-born case-patients, 42% arrived in the U.S. within 5 years of TB diagnosis. TB-HIV case rates were low and stable in Alameda County, and co-infected patients were predominantly young, male, U.S.-born individuals with traditional TB risk factors. Efforts to reduce TB-HIV burden in Alameda County should target persons with traditional TB risk factors and recently arrived foreign-born individuals.

ERS/ECDC Statement: European Union standards for tuberculosis care, 2017 update

The International Standards for Tuberculosis Care define the essential level of care for managing patients who have or are presumed to have tuberculosis, or are at increased risk of developing the disease. The resources and capacity in the European Union (EU) and the European Economic Area permit higher standards of care to secure quality and timely TB diagnosis, prevention and treatment. On this basis, the European Union Standards for Tuberculosis Care (ESTC) were published in 2012 as standards specifically tailored to the EU setting. Since the publication of the ESTC, new scientific evidence has become available and, therefore, the standards were reviewed and updated.A panel of international experts, led by a writing group from the European Respiratory Society (ERS) and the European Centre for Disease Prevention and Control (ECDC), updated the ESTC on the basis of new published evidence. The underlying principles of these patient-centred standards remain unchanged. The second edition of the ESTC includes 21 standards in the areas of diagnosis, treatment, HIV and comorbidities, and public health and prevention.The ESTC target clinicians and public health workers, provide an easy-to-use resource and act as a guide through all the required activities to ensure optimal diagnosis, treatment and prevention of TB.

Tuberculosis, social determinants and co-morbidities (including HIV)

The risk of exposure, progression to active tuberculosis (TB) and then to cure is a process affected by several risk factors. Along with well known risk factors such as human immunodeficiency virus (HIV), use of immunosuppressive drugs and being of young age, emerging risk factors such socio-economic and behavioral aspects play a significant role in increasing the susceptibility to infection, and unsuccessful treatment outcomes. This paper summarizes the effects of these socio-economic determinants and co-morbidities (including HIV) on TB infection and disease.

The burden of HIV on Tuberculosis patients in the Volta region of Ghana from 2012 to 2015: implication for Tuberculosis control

Background

The impact of HIV on TB, and the implications for TB control, has been acknowledged as a public health challenge. It is imperative therefore to assess the burden of HIV on TB patients as an indicator for monitoring the control efforts of the two diseases in this part of the world. This study aimed at determining the burden of HIV infection in TB patients.

Methods

We conducted a retrospective review of TB registers in five districts of the Volta Region of Ghana. Prevalence of TB/HIV co-infection was determined. Bivariate and multivariate logistic regression were used to identify the predictors of HIV infection among TB patients and statistical significance was set at p-value <0.05.

Results

Of the 1772 TB patients, 1633 (92.2%) were tested for HIV. The overall prevalence of TB/HIV co-infection was (18.2%; 95% CI: 16.4–20.1). The prevalence was significantly higher among females (24.1%; 95%CI: 20.8–27.7), compared to males (15.1%; 95% CI: 13.1–17.4) (p < 0.001) and among children <15 years of age (27.0%; 95% CI: 18.2–38.1), compared to the elderly ≥70 years (3.5%; 95% CI: 1.6–7.4) (p < 0.001). Treatment success rate was higher among patients with only TB (90%; 95% CI: 88.1–91.5) than among TB/HIV co-infected patients (77.0%; 95% CI: 71.7–81.7) (p < 0.001). Independent predictors of HIV infection were found to be: being female (AOR: 1.79; 95% CI: 1.38–2.13; p < 0.001); smear negative pulmonary TB (AOR: 1.84; 95% CI: 1.37–2.47; p < 0.001); and patients registered in Hohoe, Kadjebi, and Kpando districts with adjusted odds ratios of 1.69 (95% CI: 1.13–2.54; p = 0.011), 2.29 (95% CI: 1.46–3.57; p < 0.001), and 2.15 (95% CI: 1.44–3.21; p < 0.001) respectively. Patients ≥70 years of age and those registered in Keta Municipal were less likely to be HIV positive with odds ratios of 0.09 (95% CI: 0.04–0.26; p < 0.001) and 0.62 (95% CI: 0.38–0.99; p = 0.047) respectively.

Conclusion

TB/HIV co-infection rate in five study districts of the Volta region is quite high, occurs more frequently in female patients than males; among smear negative pulmonary TB patients, and children <15 years of age. Findings also demonstrate that HIV co-infection affects TB treatment outcomes adversely. Strengthening the TB/HIV collaborative efforts is required in order to reduce the burden of co-infection in patients.