Incidence and risk factors of tuberculosis in patients with human immunodeficiency virus infection

Challenges and knowledge gaps in the management of non-tuberculous mycobacterial pulmonary disease in sub-Saharan African countries with a high tuberculosis burden: a scoping review

INTRODUCTION

In sub-Saharan African (SSA) countries endemic for tuberculosis (TB), previous TB is a significant risk factor for non-tuberculous mycobacterial pulmonary disease (NTM-PD). The deployment of GeneXpert MTB/RIF in pulmonary TB diagnostic work-up regularly identifies symptomatic patients with a positive smear microscopy but negative GeneXpert, indicative of NTM presence. This scoping review outlines recent evidence for NTM-PD diagnosis and management in SSA.

OBJECTIVE

The review's objective was to outline the risk factors, available diagnostics, management options and outcomes of NTM-PD in high-burden TB settings in SSA using the population-concept-context framework.

DESIGN AND DATA SOURCES

We searched existing literature from PubMed, Web of Science, African Journals Online, Google Scholar and grey literature. Studies published between January 2005 and December 2022 were retained. Data were extracted into Rayyan software and Mendeley and summarised using Excel.

RESULTS

We identified 785 potential articles, of which 105 were included in the full-text review, with 7 papers retained. Included articles used international criteria for diagnosing NTM-PD. Multiple papers were excluded due to non-application of the criteria, suggesting challenging application in the SSA setting. Identified risk factors include previous TB, smoking and mining. Most commonly, chest radiography and not CT was used for the radiological diagnosis of PD, which may miss early changes related to NTM-PD. Molecular methods for NTM species identification were employed in research settings, usually at referral centres, but were unavailable for routine care. Most studies did not report a standardised approach to treatment and they were not offered treatment for the specific disease, marking a lack of guidance in treatment decision-making. When treatment was provided, the outcome was often not reported due to the lack of implementation of standardised outcome definitions.

CONCLUSIONS

These outlined challenges present a unique opportunity for researchers to undertake further studies in NTM-PD and proffer solutions more applicable to SSA.

Prevalence of Multidrug-Resistant Tuberculosis in HIV/Tuberculosis Co-Infected Patients

Tuberculosis (TB) is a common opportunistic infection in human immunodeficiency virus (HIV)-infected patients. Patients with multidrug-resistant (MDR)-TB have poor outcomes. This study aimed to determine the prevalence of MDR-TB in HIV/TB co-infected patients in the Korea. We reviewed the medical records of HIV/TB co-infected patients at two university hospitals between January 1998 and December 2020. During the study period, a total of 87 HIV/TB co-infected patients were identified, and drug susceptibility test results were available for 44 of them. The prevalence of MDR-TB in the study population was 15.9% (7/44, 95% confidence interval, 5.1 - 26.7).

History of Acquired Immune Deficiency Syndrome in Korea

The first human immunodeficiency virus (HIV) infection was reported in Korea in 1985. The number of HIV-infected persons domestically increased in the 1990s showing epidemic indigenousization. Since then, the number of new infections gradually increased every year, and recently more than 1,000 newly infected cases were reported per year. A total of 12,522 infected individuals have been reported up to 2015, of which 2,020 died. The male to female ratio was 15.4:1, and 34.2% of them were under 30 years old. The infection route was homosexual and bisexual contact in 60.1% of cases and heterosexual contact in 34.6% of cases. Candidiasis, Pneumocystis pneumonia, tuberculosis were common as a AIDS (acquired immune deficiency syndrome)-defining illness. But with the introduction of antiretroviral therapy in the late 1990s, non-AIDS defining illnesses such as metabolic complications, cardiovascular diseases, bone diseases, and neuropsychiatric disorders such as neurocognitive dysfunction, depression, and anxiety are emerging as new health problems. The management policy switched its focus from regulating and monitoring of HIV-infected persons to ensuring access to treatment and promotion of voluntary HIV testing in high-risk groups. Also as the age of the infected persons increases, a need for various supports such as social rehabilitation, life counseling, and welfare has emerged.

End-stage Renal Disease and Risk of Active Tuberculosis: a Nationwide Population-Based Cohort Study

BACKGROUND

The converging epidemics of tuberculosis (TB) and end-stage renal disease (ESRD) have generated a significant public health burden, however, previous studies have been limited to a small number of patients. This nationwide cohort study aimed to assess the rate of developing active TB among patients receiving dialysis for ESRD.

METHODS

The Korean national health insurance database was used to identify patients receiving dialysis for new-onset ESRD during 2004-2013, who were propensity score matched to an equivalent number of non-dialysis subjects from the general population. The incidences of active TB in the ESRD and control cohorts were calculated for 2004-2013, and multivariable Cox proportional hazards model was used to evaluate the ESRD-related risk of active TB.

RESULTS

During 2004-2013, 59,584 patients received dialysis for newly diagnosed ESRD. In the dialysis and control cohorts, 457 (0.8%) and 125 (0.2%) cases of active TB were detected, respectively. Patients with ESRD were associated with a significantly higher risk of active TB compared to the controls (incidence rate ratio, 4.80). The ESRD cohort had an independently elevated risk of active TB (adjusted hazard ratio, 4.39; 95% confidence interval, 3.60-5.37).

CONCLUSION

We found that patients receiving dialysis for ESRD had an elevated risk of active TB. These results highlight the need for detailed and well-organised guidelines for active TB screening among patients with ESRD.

Multistate recursively imputed survival trees for time-to-event data analysis: an application to AIDS and mortality post-HIV infection data

BACKGROUND

This study aimed to introduce recursively imputed survival trees into multistate survival models (MSRIST) to analyze these types of data and to identify the prognostic factors influencing the disease progression in patients with intermediate events. The proposed method is fully nonparametric and can be used for estimating transition probabilities.

METHODS

A general algorithm was provided for analyzing multi-state data with a focus on the illness-death and progressive multi-state models. The model considered both beyond Markov and Non-Markov settings. We also proposed a multi-state random survival method (MSRSF) and compared their performance with the classical multi-state Cox model. We applied the proposed method to a dataset related to HIV/AIDS patients based on a retrospective cohort study extracted in Tehran from April 2004 to March 2014 consist of 2473 HIV-infected patients.

RESULTS

The results showed that MSRIST outperformed the classical multistate method using Cox Model and MSRSF in terms of integrated Brier score and concordance index over 500 repetitions. We also identified a set of important risk factors as well as their interactions on different states of HIV and AIDS progression.

CONCLUSIONS

There are different strategies for modelling the intermediate event. We adapted two newly developed data mining technique (RSF and RIST) for multistate models (MSRSF and MSRIST) to identify important risk factors in different stages of the diseases. The methods can capture any complex relationship between variables and can be used as a useful tool for identifying important risk factors in different states of this disease.

Incidence and determinants of tuberculosis infection among adult patients with HIV attending HIV care in north-east Ethiopia: a retrospective cohort study

OBJECTIVE

This study assessed the incidence of tuberculosis (TB) and its predictors among adults living with HIV/AIDS in government health facilities in north-east Ethiopia.

SETTING

A 5-year retrospective cohort study was conducted from May to June 2015 on 451 adult HIV/AIDS-infected individuals who enrolled in the HIV care clinics of government health facilities in north-east Ethiopia.

PARTICIPANTS

A total of 451 HIV-infected adults who newly enrolled in the adult HIV care clinic from 1 July 2010 with complete information were followed until May 2015.

PRIMARY OUTCOME MEASURE

The primary outcome was the proportion of patients diagnosed with TB or the TB incidence rate.

SECONDARY OUTCOME MEASURE

The incidence of TB was investigated in relation to years of follow-up.

RESULTS

A total of 451 charts with complete information were followed for 1377.41 person-years (PY) of observation. The overall incidence density of TB was 8.6 per 100 PYof observation. Previous TB disease (adjusted HR (AHR) 3.65, 95% CI 1.97 to 6.73), being bedridden (AHR 5.45, 95% CI 1.16 to 25.49), being underweight (body mass index (BMI) <18.5 kg/m²) (AHR 2.53, 95 % CI 1.27 to 5.05), taking isoniazid preventive therapy (IPT) (AHR 0.14, 95% CI 0.05 to 0.39), haemoglobin below 11 g/dL (AHR 2.31, 95% CI 1.35 to 3.93), and being in WHO clinical stages III and IV (AHR 2.84, 95% CI 1.11 to 7.27; AHR 3.07, 95% CI 1.08 to 8.75, respectively) were significant for the incidence of TB.

CONCLUSION

The incidence of TB among adults living with HIV/AIDS in the first 3 years of follow-up was higher compared with that of subsequent years. Previous TB disease, no IPT, low BMI and haemoglobin level, advanced WHO clinical stage, and bedridden condition were the determinants of the incidence of TB. Therefore, addressing the significant predictors and improving TB/HIV collaborative activities should be strengthened in the study setting.

The 2015 Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-Infected Koreans: Guidelines for Opportunistic Infections

The Committee for Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections of the Korean Society for AIDS was founded in 2011. The first edition of the Korean guidelines was published in 2012. The guideline recommendations contain important information for physicians working with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in the clinical field. It has become necessary to revise the guidelines due to new data in this field. These guidelines aim to provide up-to-date, comprehensive information regarding the treatment and prevention of opportunistic infections in HIV-infected Koreans. These guidelines deal with several common opportunistic infections, including pneumocystis pneumonia, tuberculosis, cryptococcal meningitis, etc. A brief summary of the revised guidelines is provided below. Recommendations are rated using the same system used in the previous guidelines.

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.

Predictors of tuberculosis and human immunodeficiency virus co-infection: a case-control study

OBJECTIVES:

The human immunodeficiency virus (HIV) and Mycobacterium tuberculosis co-infection is a major global challenge. It is not clear why some HIV-positive people are co-infected with tuberculosis (TB) while others are not. This study addressed that question.

METHODS:

This case-control study was conducted in Tehran, Iran in June 2004, enrolling 2,388 HIV-positive people. Cases were selected from those who were co-infected with TB and controls from those without TB. Multiple logistic regression analysis was performed to assess the association between M. tuberculosis/HIV co-infection and several predictors. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated.

RESULTS:

In this study, 241 cases were compared with 2,147 controls. Sex, age, marital status, educational level, imprisonment, smoking, narcotic use, route of HIV transmission, previous TB infection, isoniazid preventive therapy (IPT), antiretroviral therapy (ART), and low CD4 count (<350 cells/mm³) were independently associated with M. tuberculosis/HIV co-infection (p<0.001). However, after adjusting for all other variables in the model, only the association between M. tuberculosis/HIV co-infection and the following predictors remained statistically significant: imprisonment (odds ratio [OR], 3.82; 95% confidence interval [CI], 2.11-6.90), previous TB infection (OR, 5.54; 95% CI, 1.99-15.39), IPT (OR, 0.13; 95% CI, 0.06-0.31), ART (OR, 1.81; 95% CI, 1.26-2.61), and CD4 count <350 cells/mm³ (OR, 2.34; 95% CI, 1.36-4.02).

CONCLUSIONS:

Several predictors are associated with M. tuberculosis/HIV co-infection, but only a few indicators were significantly associated with M. tuberculosis/HIV co-infection. It is estimated that a number of predictors of M. tuberculosis/HIV co-infection remain unknown and require further investigation.

Risk factors for death during pulmonary tuberculosis treatment in Korea: a multicenter retrospective cohort study

The data regarding risk factors for death during tuberculosis (TB) treatment are inconsistent, and few studies examined this issue in Korea. The purpose of this study was to evaluate baseline prognostic factors for death during treatment of adult patients with pulmonary TB in Korea. A multicenter retrospective cohort study of 2,481 patients who received TB treatment at eight hospitals from January 2009 to December 2010 was performed. Successful treatment included cure (1,129, 45.5%) and treatment completion (1,204, 48.5%) in 2,333 patients (94.0%). Unsuccessful treatment included death (85, 3.4%) and treatment failure (63, 2.5%) occurred in 148 patients (6.0%). In multivariate analysis, male sex, anemia, dyspnea, chronic heart disease, malignancy, and intensive care unit (ICU) admission were significant risk factors for death during TB treatment. Therefore, male sex, anemia, dyspnea, chronic heart disease, malignancy, and ICU admission could be baseline prognostic factors for death during treatment of adult patients with pulmonary TB in Korea.