Incidence and predictors of Tuberculosis among patients enrolled in Anti-Retroviral Therapy after universal test and treat program, Addis Ababa, Ethiopia. A retrospective follow -up study

HIV-tuberculosis co-infection in conflict zones of Nigeria

BACKGROUND

Nigeria bears a high burden of infectious diseases, with the second-highest human immunodeficiency virus (HIV) prevalence globally and the largest tuberculosis (TB) burden in Africa. The country faces significant challenges from armed conflicts, insurgency, kidnapping and banditry, which severely strain its healthcare system, particularly for people living with HIV (PLHIV). This study hypothesizes that PLHIV in conflict-affected regions of Nigeria experience a higher burden of TB than those in non-conflict areas.

METHODS

This cross-sectional household survey utilised a two-stage cluster sampling design to examine HIV/TB co-infection and associated behaviours in Nigeria, based on data from the 2018 Nigeria HIV/ acquired immune deficiency syndrome (AIDS) Indicator and Impact Survey. The sample included adults aged 15 to 64 in the selected households. We mapped the distribution of HIV/TB co-infection across the country and calculated its prevalence, stratified by conflict and non-conflict zones. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) from survey-weighted logistic regression models were used to assess the likelihood of being diagnosed with TB disease among PLHIV.

RESULTS

We analysed weighted data from 1,319,719 PLHIV across Nigeria, with 200,201(15.2%) residing in conflict zones and 1,119,518 (84.8%) in non-conflict zones. Overall, the prevalence of HIV/TB co-infection was 40.4% (52,118), with PLHIV residents of conflict zones exhibiting a significantly higher prevalence (59%, 14,976) compared to those from non-conflict zones (36%, 37,413). After adjusting for confounders, PLHIV in conflict zones were more than four times more likely to acquire TB than those from non-conflict zones (AOR: 4.21, 95% CI: 1.72-10.5, p = 0.002).

CONCLUSIONS

Conflicts amplify the risk of TB among PLHIV in Nigeria, highlighting an urgent need for targeted interventions to strengthen healthcare access in these regions. The efforts are essential in achieving the goals of reducing TB prevalence by 50% and TB mortality by 75% by 2025, as well as meeting the 95-95-95 targets to control HIV by 2030.

A Meta-Analysis of Prevalence and Moderating Factors of Malnutrition Among People Living With HIV Across Countries

ABSTRACT

Malnutrition is a critical issue for people living with HIV (PLWH), affecting their immune function, health outcomes, and response to antiretroviral therapy. This meta-analysis assessed the prevalence of malnutrition among PLWH and explored key moderating factors across countries. A systematic search of six databases-Cumulative Index to Nursing and Allied Health Literature, Embase, ProQuest, PubMed, Scopus, and Web of Science, included 103 studies involving 240,879 PLWH. The pooled prevalence of malnutrition was 16.6% (95% confidence interval = 14.1-19.5). Subgroup analysis revealed higher prevalence in Southeast Asia (31.1%), PLWH with primary education (37.7%), those on antiretroviral therapy for over a year (51.7%), and World Health Organization Stage 3 (36.4%). Meta-regression identified alcohol consumption, smoking, hepatitis, and tuberculosis as significant moderators. The prevalence of malnutrition among PLWH is substantial, with several moderating factors identified. Addressing malnutrition among PLWH requires routine nutritional assessments and targeted interventions to improve health outcomes and quality of life for PLWH globally.

Undernutrition as a risk factor for tuberculosis disease

BACKGROUND

Tuberculosis (TB) is a leading cause of mortality due to an infectious disease, with an estimated 1.6 million deaths due to TB in 2022. Approximately 25% of the global population has TB infection, giving rise to 10.6 million episodes of TB disease in 2022. Undernutrition is a key risk factor for TB and was linked to an estimated 2.2 million TB episodes in 2022, as outlined in the World Health Organization (WHO) Global Tuberculosis Report.

OBJECTIVES

To determine the prognostic value of undernutrition in the general population of adults, adolescents, and children for predicting tuberculosis disease over any time period.

SEARCH METHODS

We searched the literature databases MEDLINE (via PubMed) and WHO Global Index Medicus, as well as the WHO International Clinical Trials Registry Platform (ICTRP) on 3 May 2023 (date of last search for all databases). We placed no restrictions on the language of publication.

SELECTION CRITERIA

We included retrospective and prospective cohort studies, irrespective of publication status or language. The target population comprised adults, adolescents, and children from diverse settings, encompassing outpatient and inpatient cohorts, with varying comorbidities and risk of exposure to tuberculosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the Quality In Prognosis Studies (QUIPS) tool to assess the risk of bias of the studies. Prognostic factors included undernutrition, defined as wasting, stunting, and underweight, with specific measures such as body mass index (BMI) less than two standard deviations below the median for children and adolescents and low BMI scores (< 18.5) for adults and adolescents. Prognostication occurred at enrolment/baseline. The primary outcome was the incidence of TB disease. The secondary outcome was recurrent TB disease. We performed a random-effects meta-analysis for the adjusted hazard ratios (HR), risk ratios (RR), or odds ratios (OR), employing the restricted maximum likelihood estimation. We rated the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 51 cohort studies with over 27 million participants from the six WHO regions. Sixteen large population-based studies were conducted in China, Singapore, South Korea, and the USA, and 25 studies focused on people living with HIV, which were mainly conducted in the African region. Most studies were in adults, four in children, and three in children and adults. Undernutrition as an exposure was usually defined according to standard criteria; however, the diagnosis of TB did not include a confirmatory culture or molecular diagnosis using a WHO-approved rapid diagnostic test in eight studies. The median follow-up time was 3.5 years, and the studies primarily reported an adjusted hazard ratio from a multivariable Cox-proportional hazard model. Hazard ratios (HR) The HR estimates represent the highest certainty of the evidence, explored through sensitivity analyses and excluding studies at high risk of bias. We present 95% confidence intervals (CI) and prediction intervals, which present between-study heterogeneity represented in a measurement of the variability of effect sizes (i.e. the interval within which the effect size of a new study would fall considering the same population of studies included in the meta-analysis). Undernutrition may increase the risk of TB disease (HR 2.23, 95% CI 1.83 to 2.72; prediction interval 0.98 to 5.05; 23 studies; 2,883,266 participants). The certainty of the evidence is low due to a moderate risk of bias across studies and inconsistency. When stratified by follow-up time, the results are more consistent across < 10 years follow-up (HR 2.02, 95% CI 1.74 to 2.34; prediction interval 1.20 to 3.39; 22 studies; 2,869,077 participants). This results in a moderate certainty of evidence due to a moderate risk of bias across studies. However, at 10 or more years of follow-up, we found only one study with a wider CI and higher HR (HR 12.43, 95% CI 5.74 to 26.91; 14,189 participants). The certainty of the evidence is low due to the moderate risk of bias and indirectness. Odds ratio (OR) Undernutrition may increase the odds of TB disease, but the results are uncertain (OR 1.56, 95% CI 1.13 to 2.17; prediction interval 0.61 to 3.99; 8 studies; 173,497 participants). Stratification by follow-up was not possible as all studies had a follow-up of < 10 years. The certainty of the evidence is very low due to the high risk of bias and inconsistency. Contour-enhanced funnel plots were not reported due to the few studies included. Risk ratio (RR) Undernutrition may increase the risk of TB disease (RR 1.96, 95% CI 1.73 to 2.21; prediction interval 1.50 to 2.56; 4 studies; 1,475,867 participants). Stratification by follow-up was not possible as all studies had a follow-up of < 10 years. The certainty of the evidence is low due to the high risk of bias. Contour-enhanced funnel plots were not reported due to the few studies included.

AUTHORS' CONCLUSIONS

Undernutrition probably increases the risk of TB two-fold in the short term (< 10 years) and may also increase the risk in the long term (> 10 years). Policies targeted towards the reduction of the burden of undernutrition are not only needed to alleviate human suffering due to undernutrition and its many adverse consequences, but are also an important part of the critical measures for ending the TB epidemic by 2030. Large population-based cohorts, including those derived from high-quality national registries of exposures (undernutrition) and outcomes (TB disease), are needed to provide high-certainty estimates of this risk across different settings and populations, including low and middle-income countries from different WHO regions. Moreover, studies including children and adolescents and state-of-the-art methods for diagnosing TB would provide more up-to-date information relevant to practice and policy.

FUNDING

World Health Organization (203256442).

REGISTRATION

PROSPERO registration: CRD42023408807 Protocol: https://doi.org/10.1002/14651858.CD015890.

Active tuberculosis incidence among treatment failure experienced patients in North Wollow Zone: A multicenter historical cohort

Background

In Ethiopia, tuberculosis (TB) is a significant cause of death among individuals living with HIV, especially in resource-limited areas and those who have experienced treatment failure. However, there is the paucity of data regarding TB among treatment failures experienced people living with HIV. This study aimed to estimate the rate and identify predictors of tuberculosis among patients who received second-line treatment in North Wollo, Northeast Ethiopia.

Methods

A retrospective follow-up study was conducted on 474 HIV-infected patients who experienced treatment failure. The study period ranged from January 2015 to September 30, 2021. The incidence of TB was assessed using a Cox proportional hazard regression model, after ensuring that all assumptions were met. Factors associated with active TB were determined by analyzing adjusted hazard ratios and 95% confidence intervals.

Results

In a study of 474 HIV-positive patients on second-line antiretroviral treatment, we found an incidence rate of 3.6% with 17 new cases of TB observed over 4412.4 persons per year (PPY). The overall incidence density rate was estimated to be 0.39 cases per 100 PPY (95% CI: 0.239-0.618). Regarding the occurrence of active TB in second-line patients, WHO clinical treatment stage (T3 and T4), missed isoniazid preventive therapy had a significantly higher risk (AHR: 13.225, 95% CI: 2.894-60.434, p = 0.001), while being married was associated with a lower risk (AHR: 0.203, 95% CI: 0.045-0.907, p = 0.001).

Conclusion

A high incidence of active TB was observed shortly after initiating second-line antiretroviral treatment. Factors such as being in the WHO clinical treatment stage (T3 and T4) and marital status were determinants for active TB. To improve overall survival rates, it is vital to enhance early TB screening and implement effective isoniazid preventive therapy.

Isoniazid Preventive Therapy Uptake and Its Effect on Tuberculosis Incidence Among People Living with HIV in Illubabor and Buno Bedelle Zones, South-West Ethiopia, 2022: A Retrospective Cohort Study

Introduction

Tuberculosis (TB) remains the leading cause of death among human immune deficiency virus (HIV) patients. Based on the 2020 global TB report, Ethiopia was among the 30 high TB and TB/HIV burden countries. This study filled gaps regarding IPT uptake in the study area and representative sample determination for assessing TB incidence and its predictors at public health facilities in Illubabor and Buno Bedelle zones, south-west Ethiopia.

Methods

This retrospective cohort study was conducted among people living with HIV (PLHIV) who were on antiretroviral therapy (ART) at public health facilities in Illubabor and Buno Bedelle zones, south-west Ethiopia. Both isoniazid preventive therapy (IPT) exposed and unexposed PLHIV were followed from the date of ART initiation until the date of TB diagnosis of the most recent visit prior to the end of follow-up. The Cox proportional hazard model was employed to identify variables that predicted the incidence of TB at a P value of <0.05.

Results

Data were collected on 421 PLHIV, with a response rate of 97.4%. The median (interquartile range (IQR)) age of the study participants was 32 (28-40) year. The incidence rate of pulmonary TB was 3.1 per 1000 person-months (95% CI: 2.4-3.9). The incidence rate of TB among IPT-exposed PLHIV was 1.45 per 1000 person-months, but it was 6.2 per 1000 person-months in the unexposed group. Patient's residence, IPT exposure, baseline ART adherence, baseline hemoglobin level, baseline CD4+ cell, recent hemoglobin level, recent CD4+ cell, recent BMI, and recent WHO HIV clinical stage were independently associated with the incidence of TB.

Conclusion

Healthcare professionals working in ART clinics should routinely assess HIV-positive individuals for changes in clinical indicators and environmental exposures like living conditions, which will help HIV-positive individuals in reducing their risk for TB. Likewise, patients attending ART clinics should receive counseling on a regular basis.

The incidence rate of tuberculosis and its associated factors among HIV-positive persons in Sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Tuberculosis, along with HIV, is the leading cause of mortality and morbidity globally. Despite the fact that several primary studies have been conducted on the incidence rate of tuberculosis in HIV-infected people in Sub-Saharan Africa, the regional-level tuberculosis incidence rate remains unknown. The objective of this study is to determine the tuberculosis incidence rate and its associated factors in HIV-infected people in Sub-Saharan Africa.

METHODS

A systematic review and meta-analysis were conducted by searching four databases for studies published in English between January 1, 2000, and November 25, 2022. The study was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. To assess the quality of the studies, the Joanna Briggs Institute critical appraisal checklist was used. A random-effects model meta-analysis was used to determine the pooled incidence of tuberculosis using STATA version 15. The I2 heterogeneity test was used to assess heterogeneity. Subgroup and sensitivity analyses were performed. Funnel plots and Egger's regression tests were used to investigate publication bias. The pooled estimate predictors of tuberculosis incidence rate with a 95% confidence interval were also determined using the hazard ratio of each factor (HR).

RESULTS

Out of a total of 3339 studies, 43 were included in the analysis. The overall pooled incidence rate of tuberculosis in HIV-infected people was 3.49 per 100 person-years (95% CI: 2.88-4.17). In the subgroup analysis, the pooled incidence rate of tuberculosis in HIV-infected children was 3.42 per 100 person-years (95% CI: 1.78, 5.57), and it was 3.79 per 100 person-years (95% CI: 2.63, 5.15) in adults. A meta-analysis revealed that underweight (AHR = 1.79, 95% CI: 1.61-1.96), low CD4 count (AHR = 1.23, 95% CI: 1.13-1.35), male gender (AHR = 1.43, 95% CI: 1.22-1.64), advanced WHO clinical stages (AHR = 2.29, 95% CI: 1.34-3.23), anemia (AHR = 1.73, 95% CI: 1.34-2.13), bedridden or ambulatory (AHR = 1.87, 95%), lack of isoniazid preventive therapy (AHR = 3.32, 95% CI: 1.08-2.28), and lack of cotrimoxazole (AHR = 1.68, 95% CI: 1.08-2.28) were risk factors for tuberculosis incidence. HIV patients who received antiretroviral therapy had a 0.53 times higher risk of acquiring tuberculosis than HIV patients who did not receive antiretroviral therapy (AHR = 0.53; 95% CI: 0.3-0.77).

CONCLUSION

In this systematic review and meta-analysis study, the incidence rate of tuberculosis among HIV-positive people was higher than the WHO 2022 Africa regional estimated report. To reduce the incidence of tuberculosis among HIV patients, HIV patients should take isoniazid prevention therapy (IPT), cotrimoxazole prophylaxis, and antiretroviral therapy (ART) without interruption, as well as increase the frequency and diversity of their nutritional intake. Active tuberculosis screening should be increased among HIV-infected people.