Treatment outcome, mortality and their predictors among HIV-associated tuberculosis patients

Is Tobacco Use Associated With Risk of Recurrence and Mortality Among People With TB?: A Systematic Review and Meta-Analysis

BACKGROUND

Associations between tobacco use and poor TB treatment outcomes are well documented. However, for important outcomes such as TB recurrence or relapse and mortality during treatment, as well as for associations with smokeless tobacco (ST), the evidence is not summarized systematically.

RESEARCH QUESTION

Is tobacco use associated with risk of poor treatment outcomes among people with TB?

STUDY DESIGN AND METHODS

The MEDLINE, Embase, and Cumulative Index of Nursing and Allied Health Literature databases were searched on November 22, 2021. Epidemiologic studies reporting associations between tobacco use and at least one TB treatment outcome were eligible. Independent double-screening, extractions, and quality assessments were undertaken. Random effects meta-analyses were conducted for the two primary review outcomes (TB recurrence or relapse and mortality during treatment), and heterogeneity was explored using subgroups. Other outcomes were synthesized narratively.

RESULTS

Our searches identified 1,249 records, of which 28 were included in the meta-analyses. Based on 15 studies, higher risk of TB recurrence or relapse was found with ever using tobacco vs never using tobacco (risk ratio [RR], 1.78; 95% CI, 1.31-2.43; I2 = 85%), current tobacco use vs no tobacco use (RR, 1.95; 95% CI, 1.59-2.40; I2 = 72%), and former tobacco use vs never using tobacco (RR, 1.84; 95% CI, 1.21-2.80; I2 = 4%); heterogeneity arose from differences in study quality, design, and participant characteristics. Thirty-eight studies were identified for mortality, of which 13 reported mortality during treatment. Ever tobacco use (RR, 1.55; 95% CI, 1.32-1.81; I2 = 0%) and current tobacco use (RR, 1.51; 95% CI, 1.09-2.10; I2 = 87%) significantly increased the likelihood of mortality during treatment among people with TB compared with never using tobacco and not currently using tobacco, respectively; heterogeneity was explained largely by differences in study design. Almost all studies in the meta-analyses scored high or moderate on quality assessments. Narrative synthesis showed that tobacco use was a risk factor for other unfavorable TB treatment outcomes, as previously documented. Evidence on ST was limited, but identified studies suggested an increased risk for poor outcomes with its use compared with not using it.

INTERPRETATION

Tobacco use significantly increases the risk of TB recurrence or relapse and mortality during treatment among people with TB, highlighting the need to address tobacco use to improve TB outcomes.

TRIAL REGISTRY

PROSPERO; No.: CRD42017060821; URL: https://www.crd.york.ac.uk/prospero/.

The estimation of long and short term survival time and associated factors of HIV patients using mixture cure rate models

BACKGROUND

HIV is one of the deadliest epidemics and one of the most critical global public health issues. Some are susceptible to die among people living with HIV and some survive longer. The aim of the present study is to use mixture cure models to estimate factors affecting short- and long-term survival of HIV patients.

METHODS

The total sample size was 2170 HIV-infected people referred to the disease counseling centers in Kermanshah Province, in the west of Iran, from 1998 to 2019. A Semiparametric PH mixture cure model and a mixture cure frailty model were fitted to the data. Also, a comparison between these two models was performed.

RESULTS

Based on the results of the mixture cure frailty model, antiretroviral therapy, tuberculosis infection, history of imprisonment, and mode of HIV transmission influenced short-term survival time (p-value < 0.05). On the other hand, prison history, antiretroviral therapy, mode of HIV transmission, age, marital status, gender, and education were significantly associated with long-term survival (p-value < 0.05). The concordance criteria (K-index) value for the mixture cure frailty model was 0.65 whereas for the semiparametric PH mixture cure model was 0.62.

CONCLUSION

This study showed that the frailty mixture cure models is more suitable in the situation where the studied population consisted of two groups, susceptible and non-susceptible to the event of death. The people with a prison history, who received ART treatment, and contracted HIV through injection drug users survive longer. Health professionals should pay more attention to these findings in HIV prevention and treatment.

Clinicodemographic profile and outcome of tuberculosis treatment in TB-HIV co-infected patients receiving daily ATT under a single window TB/HIV services delivery initiative

The risk of death in HIV-TB coinfected individuals is far greater than in HIV-only patients. It is critical to provide timely and appropriate therapy in HIV-TB coinfected patients in order to reduce morbidity and mortality. The purpose of this study was to evaluate the clinical presentation and outcome of TB treatment in HIV-TB co-infected patients receiving daily anti-tubercular therapy (ATT) and concurrent antiretroviral therapy (ART) at a tertiary respiratory care centre in New Delhi, India. The research was cross-sectional, observational, and hospital-based A. From September 2018 to August 2019, a total of 53 patients with HIV-TB coinfection were enrolled at the Institute's ART centre. Patients were evaluated with a structured proforma. Data were evaluated using SPSS version 23.0 and p-value of less than 0.05 was considered statistically significant. Among the patients enrolled, the mean age was 35.98 years. Among the patients enrolled, 56.6% patients had EPTB, 32% had PTB and 11.3% had both PTB and EPTB. The majority of the enrolled patients (n=46, 86.7%) had favourable TB treatment outcomes, while 13.3% (n=7) had unfavourable outcome [including death (n=5) and loss to follow up (n=2)]. During the study and follow-up period, no patients transferred out or relapsed. In univariate analysis, low SES, bedridden functional status, low BMI, anaemia, hypoalbuminemia, and a low CD-4 cell count (<100 cells/mm3 were significantly associated with an unfavourable outcome. Bedridden functional status (p=0.002), anaemia (p=0.040), and low BMI (p<0.001) were independently associated with a poor outcome. Adequate disease knowledge and health education can be very beneficial in reducing morbidity and mortality. Early ART in combination with ATT can reduce mortality in TB-HIV co-infected patients.

Effect of smoking on tuberculosis treatment outcomes: A systematic review and meta-analysis

INTRODUCTION

Numerous studies have explored an effect of cigarette smoking on tuberculosis treatment outcomes but with dissimilar conclusions.

OBJECTIVE

To determine the effect of cigarette smoking on tuberculosis treatment outcomes.

METHODS

PubMed, Cochrane library and Google scholar databases were searched last on February 27, 2019. We applied the random-effects model for the analysis. Publication bias was assessed using funnel plot and Egger's regression. Furthermore, we performed Orwin's Fail-Safe N and cumulative meta-analysis to check for small studies' effect.

RESULTS

Out of 22 studies we included in the qualitative synthesis, 12 studies reported p-values less than 0.05 where smoking significantly favored poor treatment outcomes. The remaining 10 studies reported p-values larger than 0.05 implying that smoking does not affect the treatment outcomes. Twenty studies met the criteria for inclusion in a meta-analysis. The meta-analysis found that smoking significantly increased the likelihood of poor tuberculosis treatment outcomes by 51% (OR = 1.51; 95% CI = 1.30 to 1.75 and I-square = 75.1%). In a sub-group analysis, the effect was higher for low- and middle-income countries (OR = 1.74; 95% CI = 1.31 to 2.30) and upper-middle-income economies (OR = 1.52; 95% CI = 1.16 to 1.98) than for high-income ones (OR = 1.34; 95% CI = 1.03 to 1.75) even though the differences in the effects among the strata were not statistically significant as demonstrated by overlapping of confidence intervals of the effects. Meta-regression analysis, adjusted for income economies, found the effect of smoking has not significantly improved over the years (p = 0.92) and thus implying neither of the covariates were source of the heterogeneity. Egger's regression test indicated that publication bias is unlikely (p = 0.403).

CONCLUSION

Cigarette smoking is significantly linked with poor tuberculosis treatment outcomes.

Mortality Among People With HIV Treated for Tuberculosis Based on Positive, Negative, or No Bacteriologic Test Results for Tuberculosis: The IeDEA Consortium

Background

In resource-constrained settings, many people with HIV (PWH) are treated for tuberculosis (TB) without bacteriologic testing. Their mortality compared with those with bacteriologic testing is uncertain.

Methods

We conducted an observational cohort study among PWH ≥15 years of age initiating TB treatment at sites affiliated with 4 International epidemiology Databases to Evaluate AIDS consortium regions from 2012 to 2014: Caribbean, Central and South America, and Central, East, and West Africa. The exposure of interest was the TB bacteriologic test status at TB treatment initiation: positive, negative, or no test result. The hazard of death in the 12 months after TB treatment initiation was estimated using a Cox proportional hazard model. Missing covariate values were multiply imputed.

Results

In 2091 PWH, median age 36 years, 53% had CD4 counts ≤200 cells/mm³, and 52% were on antiretroviral therapy (ART) at TB treatment initiation. The adjusted hazard of death was higher in patients with no test compared with those with positive test results (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.08–2.26). The hazard of death was also higher among those with negative compared with positive tests but was not statistically significant (HR, 1.28; 95% CI, 0.91–1.81). Being on ART, having a higher CD4 count, and tertiary facility level were associated with a lower hazard for death.

Conclusions

There was some evidence that PWH treated for TB with no bacteriologic test results were at higher risk of death than those with positive tests. Research is needed to understand the causes of death in PWH treated for TB without bacteriologic testing.

Risk Factors Associated with Survival of Pulmonary Tuberculosis

BACKGROUND

We conducted this study among adults with pulmonary tuberculosis (TB) who received treatment, in order to determine the risk factors associated with survival of during treatments.

METHODS

A retrospective cohort study was conducted from 2005-2015 with newly registered TB patients in the Hospital of Masih Daneshvari Doctor, Tehran, Iran. Overall, 5313 patients met our study's cohort definition, but the analysis was performed on 2299 patients (43.2%) who had a correct address and they could be traced-out by the Medical - registry. Time in days was used in survival model and patients who were still alive (until last follow-up date) considered as censored. To study the effect of risk factors on patients' survival, the generalized gamma regression model was used.

RESULTS

Based on the results of univariate analysis, gender (RR=2 (95% CI: 1.1-3.7), high school education (Relative Risk: RR=0.3 (95% CI: 0.2-0.7), higher education (RR=0.3 (95% CI: 0.1-0.9), smoker (RR=2.5 (95% CI: 1.4-4.2), drug user (RR=2.4 (95% CI: 1.4-4), TB contact (RR=0.5 (95% CI: 0.3-0.8) and HIV positive (RR=4 (95% CI: 1.7-9.2) affected patients' survival. Moreover, the results of multivariate analysis showed that, gender (RR=5.5 (95% CI: 2.2-13.5), age (RR=1.1 (95% CI: 1-1.1), adverse drug effect (RR=2.5 (95% CI: 1.2-5.4), smoker (RR=3.3 (95% CI: 1.2-9.4), TB contact (RR=0.2 (95% CI: 0.1-0.5), diabetic mellitus (RR=3 (95% CI: 1-8.3), HIV positive (RR=26 (95% CI: 4.6-145.9) and comorbidities (RR=4.9 (95% CI: 2-11.6) were identified as factors affecting patients' survival.

CONCLUSION

Our data indicated associated risk factors in TB mortality and could suggest way to progressing national tuberculosis program (NTP) for predicating and plan for effective interventional strategies.

[Treatment outcome, survival and their risk factors among new tuberculosis patients co-infected with HIV during the Ebola outbreak in Conakry]

BACKGROUND

Mortality among TB/HIV co-infected patients remains high in Africa. The study aimed to estimate survival and associated factors in a cohort of TB/HIV co-infected patients who started tuberculosis treatment during the Ebola outbreak in Conakry, Guinea.

METHODS

A prospective cohort study was conducted from April 2014 to December 2015. TB patients with HIV co-infection were enrolled at the University Hospital of Conakry. Survival and risk factors were analyzed according to Kaplan-Meier's method, log-rank test and Cox's regression.

RESULTS

Data from 573 patients were analyzed. From these, 86 (15.0%) died before the end of treatment, 52% occurring within eight weeks of treatment onset. Survival at 4, 12 and 24 weeks after the beginning of the TB treatment was 92%, 86% and 83%, respectively. Independent risk factors associated with death were in the cell CD4 <200 cells/mm³ [adjusted hazard ratio (AHR): 2.25; 95% CI (confidence intervals): 1.16-4.37], opportunistic infections other than TB [AHR: 2.89; 95% CI: 1.39-6.02], and comorbidities [AHR: 4.12; 95% CI: 2.10-8.10]. An increase of one unit in hemoglobin [AHR: 0.81; 95% CI: 0.75-0.91] was protective of death.

CONCLUSION

TB/HIV co-infected patients had a higher fatality rate during treatment of tuberculosis. Prevention of opportunistic infections, anemia and proper management of tuberculosis treatment in early comorbidities may improve survival for TB/HIV co-infected patients in restoring immune function.

Adjuvant Efficacy of Nutrition Support During Pulmonary Tuberculosis Treating Course: Systematic Review and Meta-analysis

Background:

Malnutrition and tuberculosis (TB) tend to interact with each other. TB may lead to nutrition deficiencies that will conversely delay recovery by depressing immune functions. Nutrition support can promote recovery in the subject being treated for TB. The aim of this study was to evaluate the effectiveness of nutrition support on promoting the recovery of adult pulmonary TB patients with anti-TB drug therapy.

Methods:

English database of the Cochrane Controlled Trials Register, PubMed, EMBASE, and Chinese database of CBM, CNKI, VIP, and WANFANG were searched. Randomized controlled trials comparing nutrition support (given for more than 2 weeks) with no nutrition intervention, nutrition advice only, or placebo-control for TB patients being anti-TB treated were included. Two reviewers conducted data extraction, assessed the quality of the studies independently, and any discrepancies were solved by the third reviewer. Data were entered and analyzed by RevMan 5.2 software, and meta-analysis was done using risk ratios (RRs) for dichotomous variables and mean differences (MDs) for continuous variables with 95% confidence intervals (CIs).

Results:

A total of 19 studies (3681 participants) were included. In nutritional support for TB patients, pooled RR and its 95% CI of sputum smears- or culture-negative conversion rate and chest X-ray (CXR) absorption rate were 1.10 (1.04, 1.17) and 1.22 (1.08, 1.39), respectively, the pooled MD and its 95% CI of body mass index (BMI) and time of sputum smears or culture negativity were 0.59 (0.16, 1.2) and − 5.42 (−7.93, −2.92), respectively, compared with the control group. The differences in outcomes of CXR zone affected, TB score, serum albumin, and hemoglobin were not statistically significant (P = 0.76, 0.24, 0.28, and 0.20, respectively) between the intervention group and the control group. No systemic adverse events were recorded.

Conclusions:

During anti-TB course, nutrition support may be helpful in treatment of TB patients by improving both sputum smears- or culture-negative conversion rate and BMI, shortening the time of sputum conversion negative. Whether it can improve the final clinical effect, there still needs high-level quality studies to confirm in the future.

Determination the Research Priorities in the Field of HIV/AIDS in Iran: A Systematic Review Article

BACKGROUND

HIV and AIDS have many different epidemiological, social and political aspects. The aim of this study was to determine the research priorities according to the necessary aspects of HIV and AIDS in Iran.

METHODS

The national and international databases were searched to obtain the published articles regarding HIV and AIDS in Iran. All Epidemiologic studies were included in this review for assess research priorities.

RESULTS

Of 3059 retrieved references, 362 studies were included. The most studies were conducted in Tehran, Kermanshah, Fars and Kerman provinces. The cross-sectional studies with 71.55% have higher proportion. Studies related to adherence to treatment (0.55%), drug resistance (0.83%) and experience, perception and behavior of HIV/AIDS patients (0.83%) had the lowest proportion of conducted studies. Proportion of studies regarding prevention of HIV was 2.76%. The authors of studies on female sex workers (FSWs) (63.64%) and prisoners (58.82%) suggested further studies on these groups.

CONCLUSION

According to our results, the high-risk groups such as female sex workers, injecting drug users and prisoners are in priority for research. Moreover, topics related to the prevention of HIV and AIDS, adherence to treatment and antiretroviral drug resistance are other research priorities in Iran.

Diagnosing active and latent tuberculosis among Iranian HIV-infected patients

OBJECTIVE

To screen for Tuberculosis (TB) in human immunodeficiency virus (HIV) people in an effort to improve early TB diagnosis and reduce TB transmission.

METHODS

A prospective study was conducted on adult HIV people from 2008 to 2011. Three samples of sputum, cell blood count, tuberculin skin test (TST) and chest X-ray were obtained from all patients. The characteristics of HIV patients with TB and HIV patients without TB were compared to each other.

RESULTS

Of the 154 HIV patients included, 58 (38%) had tuberculosis with a mean CD4 cell count of 68 cells/mm³ . Active TB was found in 56 (47%) patients with a history of intravenous drug use. Cough (OR = 3.1, 95% CI 1.2-7.79), positive TST (OR = 8.15, 95% CI 3.28-20.25) and an abnormal chest X-ray (OR = 5.1, 95% CI 1.84-14.2) were the predicting factors for detecting active TB among HIV patients. The sensitivity and specificity of a combination of any symptoms with chest X-ray, smear, TST or all of these were 96.5% and 86.5%, respectively. CD4 cell count <100 (OR = 2.67; 95% CI 1.23-5.78) and smoking (OR = 13.4; 95% CI 3.04-59.4) remained independently associated with TB in a multivariate analysis.

CONCLUSION

There was a high prevalence of TB within the HIV population. Screening for TB among these patients can be carried out at every clinic or health facility using a combination of symptoms, TST, chest X-ray and smear sample.

Estimation of Ten-Year Survival of Patients with Pulmonary Tuberculosis Based on the Competing Risks Model in Iran

BACKGROUND

Tuberculosis (TB) is a chronic bacterial disease, which despite the presence of effective drug strategies, still remains a serious health problem worldwide. Estimation of survival rate is an appropriate indicator for prognosis in patients with pulmonary TB. Therefore, this research was designed with the aim of accurate estimation of the survival of patients by taking both the death event and relapse into consideration.

MATERIALS AND METHODS

Based on a retrospective cohort study, information of 2,299 patients with pulmonary TB that had been referred to and treated in Masih Daneshvari Hospital from 2005 to 2015 was reviewed. To estimate the survival of patients with pulmonary TB, the competing risks model, which considered death and relapse as competing events, was used. In addition, the effect of factors affecting the cumulative incidence function (CIF) of death event and relapse was also examined.

RESULTS

The effect of risk factors on the CIF of death events and relapse showed that patients' age, marital status, contact with TB patients, adverse effect of drugs, imprisonment and HIV positivity were factors that affected the CIF of death. Meanwhile, sex, marital status, imprisonment and HIV positivity were factors affecting the CIF of relapse (P <0.05). Considering death and relapse as competing events, survival estimation in pulmonary TB patients showed that survival in this group of patients in the first, third, fifth and tenth year after treatment was 39%, 14%, 7% and 0%, respectively.

CONCLUSION

The use of competing risks model in survival analysis of patients with pulmonary TB with consideration of competing events, enables more accurate estimation of survival.

Predictors of progression to AIDS and mortality post-HIV infection: a long-term retrospective cohort study

This study was conducted to better understand the prognostic factors influencing the disease progression and mortality in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in a high-middle-income country. This registry-based retrospective cohort study was conducted in Tehran from April 2004 to March 2014. We enrolled 2473 HIV-infected patients who had a medical record in Behavioral Diseases Counseling Centers. The outcomes of interest were the estimation of time: (1) from HIV diagnosis to AIDS progression and (2) from AIDS to AIDS-related death. The 1-year, 5-year, and 10-year probability of disease progression from HIV diagnosis to AIDS was 45.0%, 69.9%, and 90.4%, and that of AIDS-related death was 17.2%, 30.3%, and 39.2%, respectively. Multivariate Cox regression analysis indicated that AIDS progression was significantly associated with male sex (P = 0.022), an increase in age (P = 0.001), low educational levels (P = 0.001), and a decreased level of CD4 cell count (P = 0.001). Furthermore, the AIDS-related mortality was significantly associated with male sex (P = 0.010), tuberculosis coinfection (P = 0.001), and antiretroviral therapy (P = 0.001). The results of this study indicated that progression to AIDS and AIDS-related death is affected by several modifiable and non-modifiable predictors. We indicated that a substantial proportion of the HIV-positive people were unaware of their status and were diagnosed very late. This hidden source of HIV infection had the opportunity to transmit the infection to other people.

The Bandim TBscore--reliability, further development, and evaluation of potential uses

Background

The tuberculosis (TB) case detection rate has stagnated at 60% due to disorganized case finding and insensitivity of sputum smear microscopy. Of the identified TB cases, 4% die while being treated, monitored with tools that insufficiently predict failure/mortality.

Objective

To explore the TBscore, a recently proposed clinical severity measure for pulmonary TB (PTB) patients, and to refine, validate, and investigate its place in case finding.

Design

The TBscore’s inter-observer agreement was assessed and compared to the Karnofsky Performance Score (KPS) (paper I). The TBscore’s variables underlying constructs were assessed, sorting out unrelated items, proposing a more easily assessable TBscoreII, which was validated internally and externally (paper II). Finally, TBscore and TBscoreII’s place in PTB-screening was examined in paper III.

Results

The inter-observer variability when grading PTB patients into severity classes was moderate for both TBscore (κ_W=0.52, 95% CI 0.46–0.56) and KPS (κ_W=0.49, 95% CI 0.33–0.65). KPS was influenced by HIV status, whereas TBscore was unaffected by it. In paper II, proposed TBscoreII was validated internally, in Guinea-Bissau, and externally, in Ethiopia. In both settings, a failure to bring down the score by ≥25% from baseline to 2 months of treatment predicted subsequent failure (p=0.007). Finally, in paper III, TBscore and TBscoreII were assessed in health-care-seeking adults and found to be higher in PTB-diagnosed patients, 4.9 (95% CI 4.6–5.2) and 3.9 (95% CI 3.8–4.0), respectively, versus patients not diagnosed with PTB, 3.0 (95% CI 2.7–3.2) and 2.4 (95% CI 2.3–2.5), respectively. Had we referred only patients with cough >2 weeks to sputum smear, we would have missed 32.1% of the smear confirmed cases in our cohort. A TBscoreII>=2 missed 8.6%.

Conclusions

TBscore and TBscoreII are useful monitoring tools for PTB patients on treatment, as they could fill the void which currently exists in risk grading of patients. They may also have a role in PTB screening; however, this requires our findings to be repeated elsewhere.

Pharmacokinetics of rifampin and isoniazid in tuberculosis-HIV-coinfected patients receiving nevirapine- or efavirenz-based antiretroviral treatment

This is a substudy of the Agence Nationale de Recherches sur le Sida et les Hépatites Virales (ANRS) Comparison of Nevirapine and Efavirenz for the Treatment of HIV-TB Co-infected Patients (ANRS 12146-CARINEMO) trial, which assessed the pharmacokinetics of rifampin or isoniazid with or without the coadministration of nonnucleoside reverse transcriptase inhibitor-based HIV antiretroviral therapy in HIV-tuberculosis-coinfected patients in Mozambique. Thirty-eight patients on antituberculosis therapy based on rifampin and isoniazid participated in the substudy (57.9% males; median age, 33 years; median weight, 51.9 kg; median CD4(+) T cell count, 104 cells/μl; median HIV-1 RNA load, 5.5 log copies/ml). The daily doses of rifampin and isoniazid were 10 and 5 mg/kg of body weight, respectively. Twenty-one patients received 200 mg of nevirapine twice a day (b.i.d.), and 17 patients received 600 mg of efavirenz once a day (q.d.) in combination with lamivudine and stavudine from day 1 until the end of the study. Blood samples were collected at regular time-dosing intervals after morning administration of a fixed-dose combination of rifampin and isoniazid. When rifampin was administered alone, the median maximum concentration of drug in serum (Cmax) and the area under the concentration-time curve (AUC) at steady state were 6.59 mg/liter (range, 2.70 to 14.07 mg/liter) and 27.69 mg · h/liter (range, 11.41 to 109.75 mg · h/liter), respectively. Concentrations remained unchanged when rifampin was coadministered with nevirapine or efavirenz. When isoniazid was administered alone, the median isoniazid Cmax and AUC at steady state were 5.08 mg/liter (range, 1.26 to 11.51 mg/liter) and 20.92 mg · h/liter (range, 7.73 to 56.95 mg · h/liter), respectively. Concentrations remained unchanged when isoniazid was coadministered with nevirapine; however, a 29% decrease in the isoniazid AUC was observed when isoniazid was combined with efavirenz. The pharmacokinetic parameters of rifampin and isoniazid when coadministered with nevirapine or efavirenz were not altered to a clinically significant extent in these severely immunosuppressed HIV-infected patients. Patients experienced favorable clinical outcomes. (This study has been registered at ClinicalTrials.gov under registration no. NCT00495326.).

Diagnostic and Prognostic Value of Serum Albumin for Tuberculosis in HIV Infected Patients Eligible for Antiretroviral Therapy: Datafrom an HIV Cohort Study in India

INTRODUCTION

Tuberculosis is difficult to diagnose and it is the leading cause of death in HIV infected individuals in developing countries. There is an urgent need of low-cost diagnostic markers for resource-limited settings.

METHODS

The study involved 1571 patients from an HIV cohort study in India with known serum albumin concentrations at the time of becoming eligible for antiretroviral therapy (ART). We investigated the diagnostic accuracy of serum albumin to predict tuberculosis within six months of ART eligibility and the prognostic value in patients who experienced tuberculosis.

RESULTS

The diagnostic accuracy of serum albumin, measured by the area under the receiver operating characteristic curve, to predict tuberculosis was 0.81 (95% confidence interval 0.78-0.83). Serum albumin concentrations <3.2 g/dL were associated with 85% specificity and <4.1 g/dL were associated with negative predictive values >90%, even in settings with high tuberculosis prevalence. Hypoalbuminemia was associated with an increased risk of mortality in patients with tuberculosis.

CONCLUSION

Serum albumin can be a useful low-cost diagnostic marker for tuberculosis in HIV infected patients eligible for ART. However, we failed to find thresholds to rule out or rule in tuberculosis. If these results are confirmed by other studies, serum albumin could be used to improve the diagnostic accuracy of intensive case finding algorithms for HIV-related tuberculosis. In patients who experience tuberculosis, hypoalbuminemia is associated with poor prognosis.

Initial Antituberculous Regimen with Better Drug Penetration into Cerebrospinal Fluid Reduces Mortality in HIV Infected Patients with Tuberculous Meningitis: Data from an HIV Observational Cohort Study

Tuberculous meningitis (TM) is the deadliest form of tuberculosis. Nearly two-thirds of HIV infected patients with TM die, and most deaths occur within one month. Current treatment of TM involves the use of drugs with poor penetration into the cerebro-spinal fluid (CSF). In this study, we present the mortality before and after implementing a new antituberculous regimen (ATR) with a higher drug penetration in CSF than the standard ATR during the initial treatment of TM in an HIV cohort study. The new ATR included levofloxacin, ethionamide, pyrazinamide, and a double dose of rifampicin and isoniazid and was given for a median of 7 days (interquartile range 6-9). The new ATR was associated with an absolute 21.5% (95% confidence interval (CI), 7.3-35.7) reduction in mortality at 12 months. In multivariable analysis, independent factors associated with mortality were the use of the standard ATR versus the new ATR (hazard ratio 2.05; 95% CI, 1.2-3.5), not being on antiretroviral therapy, low CD4 lymphocyte counts, and low serum albumin levels. Our findings suggest that an intensified initial ATR, which likely results in higher concentrations of active drugs in CSF, has a beneficial effect on the survival of HIV-related TM.

Survival rate of AIDS disease and mortality in HIV-infected patients in Hamadan, Iran: a registry-based retrospective cohort study (1997-2011)

There remains a need to better understand the prognostic factors affecting the long-term survival in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), particularly in developing countries. We extracted data from 585 patients' medical records available at the triangular clinics for behavioural diseases. The outcomes of interest were the survival rates of progression to AIDS and death in HIV-positive subjects. The effect of several prognostic factors on survival time was investigated. One-year, five-year and 10-year survival rates from time of HIV diagnosis to AIDS were 89%, 69% and 30%, respectively. One-year and five-year survival rates from AIDS to death were 76% and 46%, respectively. One-year, five-year and 10-year survival rate from HIV diagnosis to death were 87%, 67% and 40%, respectively. Hazard ratio of progression to AIDS in HIV-positive subjects who were co-infected with tuberculosis was 4.50 (p < 0.001). Hazard ratio of death from AIDS-related causes was 4.77 in patients who did not receive highly active antiretroviral therapy compared to those who did (p < 0.001). Co-infection with tuberculosis was one of the most important prognostic factors of progression to AIDS and antiretroviral treatment was found to be an effective measure in suppressing HIV viral replication and improving the survival of patients living with HIV.