Factors associated with death during tuberculosis treatment of patients co-infected with HIV at the Yaoundé Central Hospital, Cameroon: an 8-year hospital-based retrospective cohort study (2006-2013)

Survival Rate and Predictors of Mortality Among TB-HIV Co-Infected Patients During Tuberculosis Treatment at Public Health Facilities in Bahir Dar City, Northwest Ethiopia

Background

Tuberculosis and human immunodeficiency virus co-infection pose a major public health concern, particularly in developing countries. The survival and predictors of mortality were not sufficiently studied among TB-HIV co-infected patients in Ethiopia.

Objective

This study aimed to investigate the survival rate and predictors of mortality among TB-HIV co-infected patients during TB treatment at public health facilities in Bahir Dar, Northwest Ethiopia.

Methods

A retrospective follow-up study was conducted among 401 TB-HIV co-infected patients who were treated for tuberculosis between July 2018 and June 2022 at public health facilities in Bahir Dar city, Ethiopia. Data were collected using a structured checklist from patient charts. Data entry and analysis were done using EpiData 3.1 and Stata version 15, respectively. A Cox proportional Hazard regression model was used to identify predictors of mortality. Predictors with P < 0.05 in the multivariable regression were considered statistically significant.

Results

Among the 401 TB-HIV co-infected patients, 59 (14.7%) died during the follow-up period. Predictors like lower BMI (AHR = 3.00, 95% CI = 1.44, 6.28), extrapulmonary TB infection (AHR = 3.30, 95% CI = 1.50, 7.29), presence of opportunistic infection (AHR = 5.07, 95% CI = 2.55, 10.08), functional status (bedridden: AHR = 4.49, 95% CI = 1.63, 12.33), and adherence to TB treatment (fair = AHR = 2.74, 95% CI = 1.41, 7.20, and poor = AHR = 3.75, 95% CI = 1.52, 9.23) were associated with mortality.

Conclusion

Mortality among TB and HIV coinfected people was high at public health facilities in Bahir Dar city. This result suggested that in order to increase patient survival, it would be necessary to enhance nutritional status, increase adherence to TB treatment, and prevent opportunistic infections.

Treatment Outcomes of Tuberculosis and Associated Factors Among Tuberculosis and Human Immunodeficiency Virus Co-infected Patients in Public Health Facilities in Jigjiga, Somali Region, Ethiopia

BACKGROUND

Worldwide, tuberculosis (TB) is a serious public health issue, especially in low-income countries, including Ethiopia. For those who are HIV-positive, TB poses a major risk to their health. The development of chemotherapy and the effectiveness of treatment have resulted in notable increases in patient survival. The evaluation of TB treatment outcomes is an essential metric for determining the success of TB and HIV co-morbidity control strategies.

PURPOSE

This study aims to identify TB treatment outcomes and associated factors among TB/HIV co-infected patients in public health facilities in Jigjiga, Somali Region, Ethiopia, in 2021.

PATIENTS AND METHODS

A hospital-based cross-sectional study design was done on three facilities (Karamara, Hasan Yabare Referral Hospital, and Jigjiga Health Center) with a total of 194 study participants. Data were extracted using a checklist, entered into EpiData version 3 (The EpiData Association, Odense, Denmark), and analyzed using SPSS Statistics version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) for descriptive and inferential analysis of the study objectives. Variables in the bivariate logistic regression analysis with p-values less than 0.25 were entered into a multivariate logistic regression to identify the independent factors of TB treatment outcome. Associations were computed using an adjusted odds ratio with a 95% CI. P-values less than 0.05 were finally considered statistically significant.

RESULTS

The following TB treatment outcomes were observed among all TB/HIV co-infected patients enrolled in this study: 126 (67.4%) completed treatment, three (1.8%) died, 42 (22.5%) were cured, and 16 (8.6%) were transferred out; 168 (89.8%) had a successful treatment outcome. Category of the patient (AOR = 0.194, 95% CI: 0.041, 0.923), sex of the patient (AOR = 1.490, 95% CI: 1.449, 4.951), and cotrimoxazole preventive therapy (CPT) initiation (AOR = 0.073, 95% CI: 0.021, 0.254) were found to be significant predictors for successful TB treatment outcome at a p-value less than 0.05 with a 95% CI.

CONCLUSION

Overall, 89.8% of TB treatments were successful among TB/HIV co-infected patients. This study has found sex, socioeconomic status, and CPT initiation were significant factors for a successful TB treatment outcome. Based on these findings, governmental and non-governmental organizations should facilitate the implementation and enforce the availability of all TB/HIV co-infected patients.

Epidemiology and treatment outcomes of recurrent tuberculosis in Tanzania from 2018 to 2021 using the National TB dataset

BACKGROUND

Patients with recurrent TB have an increased risk of higher mortality, lower success rate, and a relatively feeble likelihood of treatment completion than those with new-onset TB. This study aimed to assess the epidemiology of recurrent TB in Tanzania; specifically, we aim to determine the prevalence of TB recurrence and factors associated with unfavourable treatment outcomes among patients with recurrent TB in Tanzania from 2018 to 2021.

METHODS

In this cross-sectional study, we utilized Tanzania's routinely collected national TB program data. The study involved a cohort of TB patients over a fixed treatment period registered in the TB and Leprosy case-based District Health Information System (DHIS2-ETL) database from 2018 to 2021 in Tanzania. We included patients' sociodemographic and clinical factors, facility characteristics, and TB treatment outcomes. We conducted bivariate analysis and multivariable multi-level mixed effects logistic regression of factors associated with TB recurrence and TB treatment outcomes to account for the correlations at the facility level. A purposeful selection method was used; the multivariable model included apriori selected variables (Age, Sex, and HIV status) and variables with a p-value <0.2 on bivariate analysis. The adjusted odds ratio and 95% confidence interval were recorded, and a p-value of less than 0.05 was considered statistically significant.

FINDINGS

A total of 319,717 participants were included in the study; the majority were adults aged 25-49 (44.2%, n = 141,193) and above 50 years (31.6%, n = 101,039). About two-thirds were male (60.4%, n = 192,986), and more than one-fifth of participants (22.8%, n = 72,396) were HIV positive. Nearly two in every hundred TB patients had a recurrent TB episode (2.0%, n = 6,723). About 10% of patients with recurrent TB had unfavourable treatment outcomes (9.6%, n = 519). The odds of poor treatment outcomes were two-fold higher for participants receiving treatment at the central (aOR = 2.24; 95% CI 1.33-3.78) and coastal zones (aOR = 2.20; 95% CI 1.40-3.47) than the northern zone. HIV-positive participants had 62% extra odds of unfavourable treatment outcomes compared to their HIV-negative counterparts (aOR = 1.62; 95% CI 1.25-2.11). Bacteriological TB diagnosis (aOR = 1.39; 95% CI 1.02-1.90) was associated with a 39% additional risk of unfavourable treatment outcomes as compared to clinical TB diagnosis. Compared to community-based DOT, patients who received DOT at the facility had 1.39 times the odds of poor treatment outcomes (aOR = 1.39; 95%CI 1.04-1.85).

CONCLUSION

TB recurrence in Tanzania accounts for 2% of all TB cases, and it is associated with poor treatment outcomes. Unfavourable treatment outcomes were recorded in 10% of patients with recurrent TB. Poor TB treatment outcome was associated with HIV-positive status, facility-based DOT, bacteriologically confirmed TB and receiving treatment at the hospital level, differing among regions. We recommend post-treatment follow-up for patients with recurrent TB, especially those coinfected with HIV. We also propose close follow-up for patients treated at the hospital facility level and strengthening primary health facilities in TB detection and management to facilitate early treatment initiation.

Tuberculosis Treatment Outcomes in Brazil: Different Predictors for Each Type of Unsuccessful Outcome

BACKGROUND

Successful tuberculosis (TB) treatment is necessary for disease control. The World Health Organization (WHO) has a target TB treatment success rate of ≥90%. We assessed whether the different types of unfavorable TB treatment outcome had different predictors.

METHODS

Using data from Regional Prospective Observational Research for Tuberculosis-Brazil, we evaluated biological and behavioral factors associated with each component of unsuccessful TB outcomes, recently updated by WHO (death, loss to follow-up [LTFU], and treatment failure). We included culture-confirmed, drug-susceptible, pulmonary TB participants receiving standard treatment in 2015-2019. Multinomial logistic regression models with inverse probability weighting were used to evaluate the distinct determinants of each unsuccessful outcome.

RESULTS

Of 915 participants included, 727 (79%) were successfully treated, 118 (13%) were LTFU, 44 (5%) had treatment failure, and 26 (3%) died. LTFU was associated with current drug-use (adjusted odds ratio [aOR] = 5.3; 95% confidence interval [CI], 3.0-9.4), current tobacco use (aOR = 2.9; 95% CI, 1.7-4.9), and being a person with HIV (PWH) (aOR = 2.0; 95% CI, 1.1-3.5). Treatment failure was associated with PWH (aOR = 2.7; 95% CI, 1.2-6.2) and having diabetes (aOR = 2.2; 95% CI, 1.1-4.4). Death was associated with anemia (aOR = 5.3; 95% CI, 1.4-19.7), diabetes (aOR = 3.1; 95% CI, 1.4-6.7), and PWH (aOR = 3.9; 95% CI, 1.3-11.4). Direct observed therapy was protective for treatment failure (aOR = 0.5; 95% CI, .3-.9) and death (aOR = 0.5; 95% CI, .2-1.0).

CONCLUSIONS

The treatment success rate was below the WHO target. Behavioral factors were most associated with LTFU, whereas clinical comorbidities were correlated with treatment failure and death. Because determinants of unsuccessful outcomes are distinct, different intervention strategies may be needed to improve TB outcomes.

Perceptions, preferences, and experiences of tuberculosis education and counselling among patients and providers in Kampala, Uganda: A qualitative study

Tuberculosis (TB) education seeks to increase patient knowledge about TB, while TB counselling seeks to offer tailored advice and support for medication adherence. While universally recommended, little is known about how to provide effective, efficient, patient-centred TB education and counselling (TEC) in low-income, high HIV-TB burden settings. We sought to characterise stakeholder perceptions of TEC in a public, primary care facility in Kampala, Uganda, by conducting focus group discussions with health workers and TB patients in the TB and HIV clinics. Participants valued TEC but reported that high-quality TEC is rarely provided, because of a lack of time, space, staff, planning, and prioritisation given to TEC. To improve TEC, they recommended adopting practices that have proven effective in the HIV clinic, including better specifying educational content, and employing peer educators focused on TEC. Patients and health workers suggested that TEC should not only improve TB patient knowledge and adherence, but should also empower and assist all those undergoing evaluation for TB, whether confirmed or not, to educate their households and communities about TB. Community-engaged research with patients and front-line providers identified opportunities to streamline and standardise the delivery of TEC using a patient-centred, peer-educator model.

Modeling Survival Time to Death Among TB and HIV Co-infected Adult Patients: an Institution-Based Retrospective Cohort Study

BACKGROUND

Tuberculosis is a serious health threat, particularly for people living with human immunodeficiency virus (HIV), and HIV-positive people are more likely than others to contract the disease. Globally, tuberculosis (TB) is one of the leading causes of death among people living with HIV. The purpose of the current study was to identify factors associated with survival rates of TB/HIV co-infected patients using survival models.

METHODS

A retrospective study was conducted on TB/HIV co-infected adult patients registered and under follow-up at Tepi General Hospital (TGH) and Mizan-Tepi University Teaching Hospital (MTUTH), southwest Ethiopia. All TB/HIV co-infection patients who were registered and under follow-up from 1st January 2015 through 1st January 2020 were considered. The global Schoenfeld test was used to test the proportional hazard (PH) assumption. Various accelerated failure time (AFT) models were compared to determine the best model for the time to death of TB/HIV co-infected patients' data set. Among the most commonly used accelerated failure time models (AFT models), the study used exponential, Weibull, log-logistic, and log-lognormal AFT models. AIC and BIC were used to compare the performance of fitted models. The data were analyzed with the statistical software R.

RESULTS

Of 363 TB/HIV co-infected patients followed for 60 months, 79 (21.8%) died, while the remaining 284 (78.2%) were censored. The overall median survival time was 15.6 months. The proportional hazard assumption was checked and it was violated. In comparison to other models, the lognormal AFT model performed better. The results of the multivariable lognormal AFT model showed that age, residence, substance use, educational status, clinical stages of the disease, cluster of differentiation 4 (CD4 count/mm³), functional status, cotrimoxazole prophylactic therapy use (CPT use), and INH were all found to be significant factors, while gender, illness other than TB, and disclosure of status were insignificant variables at 5% level of significance.

CONCLUSION

Current study results revealed that older age, substance use, advanced WHO clinical stages of the disease (stage IV), bedridden functional status, and CD4 less than 200 count/mm³ were significantly associated with shorter survival time to death of HIV/TB co-infected patients while having advanced educational status, being from urban residence, CPT use, and INH significantly increase the survival time to death of TB/HIV co-infected patients. Patients with TB/HIV co-infection should be given special attention based on these important factors to improve their health and prolong their lives. HIV-positive patients are more likely than others to contract the TB disease. The risk of death among TB/HIV co-infected patients was found to be high. Out of all patients, 79 (21.8%) died. Accelerated failure time models are good alternatives for scenario Cox proportional hazard assumptions not met.

Mortality and associated factors among adult patients on tuberculosis treatment in Tanzania: A retrospective cohort study

INTRODUCTION

Tuberculosis (TB) is the global leading cause of death from an infectious agent. Tanzania is among the 30 high TB burden countries with a mortality rate of 47 per 100,000 population and a case fatality of 4%. This study assessed mortality rate, survival probabilities, and factors associated with death among adult TB patients on TB treatment in Tanzania.

METHODS

A retrospective cohort study was conducted utilizing case-based national TB program data of adult (≥15 years) TB cases enrolled on TB treatment from January 2017 to December 2017. We determined survival probabilities using the Kaplan-Meier estimator and a Cox proportional hazard model was used to identify independent risk factors of TB mortality. Hazard ratios and their respective 95% confidence intervals were reported.

RESULTS

Of 53,753 adult TB patients, 1927 (3.6%) died during TB treatment and the crude mortality rate was 6.31 per 1000 person-months. Male accounted for 33,297 (61.9%) of the study population and the median (interquartile range [IQR]) age was 40 (30-53) years. More than half 1027 (56.7%) of deaths occurred in first two months of treatment. Overall survival probabilities were 96%, and 92% at 6th and 12th month respectively. The independent risk factors for TB mortality among TB patients included: advanced age ≥ 45 years (adjusted hazard ratio (aHR) = 1.74, 95% confidence interval (CI) = 1.45-2.08); receiving service at the hospital level (aHR = 1.22, 95% CI = 1.09-1.36); TB/HIV co-infection (aHR = 2.51, 95% CI = 2.26-2.79); facility-based direct observed therapy (DOT) option (aHR = 2.23, 95% CI = 1.95-2.72); having bacteriological unconfirmed TB results (aHR = 1.58, 95% CI = 1.42-1.76); and other referral type (aHR = 1.44, 95% CI = 1.16-1.78).

CONCLUSION

Advanced age, TB/HIV co-infection, bacteriological unconfirmed TB results, other referral types, receiving service at facility-based DOT option and obtaining service at the hospital level were significant contributors to TB death in Tanzania. Appropriate targeted intervention to improve TB referral systems, improve diagnostic capacity in the primary health facilities, minimize delay and misdiagnosis of TB patients might reduce TB mortality.

Baseline Xpert MTB/RIF ct values predict sputum conversion during the intensive phase of anti-TB treatment in HIV infected patients in Kampala, Uganda: a retrospective study

Background

In resource-limited settings, sputum smear conversion is used to document treatment response. Many People living with HIV (PLHIV) are smear-negative at baseline. The Xpert MTB/RIF test can indirectly measure bacterial load through cycle threshold (ct) values. This study aimed to determine if baseline Xpert MTB/RIF could predict time to culture negativity in PLHIV with newly diagnosed TB.

Methods

A subset of 138 PLHIV from the ‘SOUTH’ study on outcomes related to TB and antiretroviral drug concentrations were included. Bacterial load was estimated by Mycobacterium Growth Indicator Tubes (MGIT) culture time-to-positivity (TTP) and Lowenstein Jensen (LJ) colony counts. Changes in TTP and colony counts were analyzed with Poisson Generalised Estimating Equations (GEE) and multilevel ordered logistic regression models, respectively, while time to culture negativity analysed with Cox proportional hazard models. ROC curves were used to explore the accuracy of the ct value in predicting culture negativity.

Results

A total of 81 patients (58.7%) were males, median age 34 (IQR 29  – 40) years, median CD4 cell count of 180 (IQR 68  – 345) cells/μL and 77.5% were ART naive. The median baseline ct value was 25.1 (IQR 21.0  – 30.1). A unit Increase in the ct value was associated with a 5% (IRR = 1.05 95% CI 1.04  – 1.06) and 3% (IRR = 1.03 95% CI 1.03  – 1.04) increase in TTP at week 2 and 4 respectively. With LJ culture, a patient’s colony grade was reduced by 0.86 times (0R = 0.86 95% CI 0.74  – 0.97) at week 2 and 0.84 times (OR = 0.84 95% CI 0.79  – 0.95 P = 0.002) at week 4 for every unit increase in the baseline ct value. There was a 3% higher likelihood of earlier conversion to negativity for every unit increase in the ct value. A ct cut point ≥28 best predicted culture negativity at week 4 with a sensitivity of 91. 7% & specificity 53.7% while a cut point ≥23 best predicted culture negativity at week 8.

Conclusion

Baseline Xpert MTB/RIF ct values predict sputum conversion in PLHIV on anti-TB treatment. Surrogate biomarkers for sputum conversion in PLHIV are still a research priority.

Tuberculosis Chemotherapy Outcome in the Littoral Region of Cameroon: A Meta-analysis of Treatment Success Rate between 2014 and 2016

Background

Tuberculosis (TB) is a public health concern, especially in resource-constrained countries like Cameroon. TB drug resistance is a major obstacle to control and prevent.

Design

Data from 2014 to 2016 on the outcome of anti-TB treatment in the Littoral Region were reviewed manually and analysed using the meta-analysis concept. The treatment success rates (TSR) were the primary outcome used for this study. The heterogeneity statistics (I ²) was computed to orientate the choice of the best statistical model (binary fixed effect or random) to compute pooled value of TSR.

Results

Using an intention-to-treat analysis, the pooled proportions of HIV-uninfected TB patients successfully cured from TB were low and slightly decreased by 1% between 2014 and 2016. Regarding HIV-infected TB patients, pooled values of TSR were lower than those of their HIV-negative counterparts with values ranging from 71% (95% CI: 63%-83%; I ² = 71.16%) in 2014 to 68% (95% CI: 58%-79%; I ² = 70.97%) in 2016. In addition, no heterogeneity was found in three years (I ² = 0.0%; P value = 1). These cure rates were strongly and negatively correlated with the rates of patients lost to follow-up regardless of the year. In HIV-infected patients, the pooled values of ITT analysis-based treatment success rates were 73% (χ ² = 13.92, P value = 0.0002), 71% (χ ² = 7.26, P value = 0.007), and 68% (χ ² = 8.02, P value = 0.004), respectively. The coverage rates with cotrimoxazole (CTX) gradually increased over year ranging from 78.90% in 2014 to 94.17% in 2016, similar to the coverage rate for ARV therapy that was 60.06% in 2014 against 90% in 2016. A positive and statistically significant correlation was found between the success of the anti-TB therapy in HIV-infected patients and coverage rates with CTX and ARV.

Conclusion

An improvement in the reduction of percentage of lost to follow-up and coverage with CTX and ARV therapy could greatly increase chances to efficiently control TB in Cameroon.

Brief Report: Yield and Efficiency of Intensified Tuberculosis Case-Finding Algorithms in 2 High-Risk HIV Subgroups in Uganda

BACKGROUND

Tuberculosis (TB) risk varies among different HIV subgroups, potentially impacting intensified case finding (ICF) performance. We evaluated the performance of the current ICF algorithm [symptom screening, followed by Xpert MTB/RIF (Xpert) testing] in 2 HIV subgroups and evaluated whether ICF performance could be improved if TB screening was based on C-reactive protein (CRP) concentrations.

METHODS

We enrolled consecutive adults with CD4 counts ≤350 cells/µL initiating antiretroviral therapy and performed symptom screening, CRP testing using a low-cost point-of-care (POC) assay, and collected sputum for Xpert testing. We compared the yield and efficiency of the current ICF algorithm to POC CRP-based ICF among patients new to HIV care and patients engaged in care.

RESULTS

Of 1794 patients, 126/1315 (10%) new patients and 21/479 (4%) engaged patients had Xpert-positive TB. The current ICF algorithm detected ≥98% of all TB cases in both subgroups but required ≥85% of all patients to undergo Xpert testing. POC CRP-based ICF halved the proportion of patients in both subgroups requiring Xpert testing relative to the current ICF algorithm and had lower yield among patients engaged in care [81% vs. 100%, difference -19% (95% confidence interval: -41 to 3)]. Among patients new to care, POC CRP-based ICF had similar yield as the current ICF algorithm [93% vs. 98%, difference -6% (95% confidence interval: -11 to 0)].

CONCLUSIONS

Among patients new to care, POC CRP-based screening can improve ICF efficiency without compromising ICF yield, whereas symptom-based screening may be necessary to maximize ICF yield among patients engaged in care.

Does time to loss to follow-up differ among adult tuberculosis patients initiated on tuberculosis treatment and care between general hospital and health centers? A retrospective cohort study

BACKGROUND

Patients' loss to follow-up (LTFU) from tuberculosis treatment and care is a growing worry in Ethiopia. But, available information is inadequate in assessing the time to tuberculosis patient loss to follow-up difference between health centers and a general hospital in Ethiopia. We aimed to assess time to LTFU difference between health centers and a general hospital in rural Ethiopia.

METHODS

We conducted a retrospective cohort study from September 2008 to August 2015 and collected data from September 1 to October 02, 2016. A total of 1341 TB patients with known treatment outcomes were included into the study. Log rank test was used to compare the difference in time to TB patient loss to follow-up between health centers and a general hospital, whereas Cox proportional hazard model was used to assess factors associated with time to loss to follow-up in both settings.

RESULTS

We reviewed a total of 1341 patient records, and the overall follow-up time was 3074.7 and 3974 person months of observation (PMOs) for TB patients followed at health centers and a general hospital, respectively. The incidence of loss to follow-up rate was 27.3 per 1000 PMOs and 9.6 per 1000 PMOs, at health centers and a general hospital, respectively. From the overall loss to follow-ups that occurred, 55 (65.5%) and 33 (86.8%) of LTFUs occurred during the intensive phase and grew to 78 (92.9%) and 38 (100%) at health center and a general hospital, respectively, at the end of 6-month observation period. Older age (AOR = 1.7, 95%CI, 1.2-2.5, P < 0.001), being a rural resident (AHR = 2.7, 95%CI, 1.6-4.6), HIV reactive (AHR = 2.2, 95%CI, 1.5-3.2), following treatment and care in health center (AHR = 3.38, 95%CI, 2.06-5.53), and living at more than 10 km away from the health facility (AHR = 3.4, 95%CI, 2.1-5.7) were predictors for time to loss to follow-up among TB patients on treatment and care.

CONCLUSION

Time to TB patient loss to follow-up between health centers and a general hospital was significant. Loss to follow-up was high in patients with older age, rural residence, sero positive for HIV, living further from the health facilities, and following treatment and care at health centers. Strengthening the DOTs program with special emphasis on health centers is highly recommended.

Factors predictive of the success of tuberculosis treatment: A systematic review with meta-analysis

OBJECTIVE

To produce pooled estimates of the global results of tuberculosis (TB) treatment and analyze the predictive factors of successful TB treatment.

METHODS

Studies published between 2014 and 2019 that reported the results of the treatment of pulmonary TB and the factors that influenced these results. The quality of the studies was evaluated according to the Newcastle-Ottawa quality assessment scale. A random effects model was used to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) in February 2019 under number CRD42019121512.

RESULTS

A total of 151 studies met the criteria for inclusion in this review. The success rate for the treatment of drug-sensitive TB in adults was 80.1% (95% CI: 78.4-81.7). America had the lowest treatment success rate, 75.9% (95% CI: 73.8-77.9), and Oceania had the highest, 83.9% (95% CI: 75.2-91.0). In children, the success rate was 84.8% (95% CI: 77.7-90.7); in patients coinfected with HIV, it was 71.0% (95% CI: 63.7-77.8), in patients with multidrug-resistant TB, it was 58.4% (95% CI: 51.4-64.6), in patients with and extensively drug-resistant TB it was 27.1% (12.7-44.5). Patients with negative sputum smears two months after treatment were almost three times more likely to be successfully treated (OR 2.7; 1.5-4.8), whereas patients younger than 65 years (OR 2.0; 1.7-2.4), nondrinkers (OR 2.0; 1.6-2.4) and HIV-negative patients (OR 1.9; 1.6-2.5 3) were two times more likely to be successfully treated.

CONCLUSION

The success of TB treatment at the global level was good, but was still below the defined threshold of 85%. Factors such as age, sex, alcohol consumption, smoking, lack of sputum conversion at two months of treatment and HIV affected the success of TB treatment.

Treatment Outcome of Tuberculosis and Associated Factors among TB-HIV Co-Infected Patients at Public Hospitals of Harar Town, Eastern Ethiopia. A five-year retrospective study

BACKGROUND

The bidirectional relationship between the twin epidemics of Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) causes major global health challenges in the twenty-first century. TB-HIV co-infected people are facing multifaceted problems like high lost to follow up rates, poor treatment adherence, high TB recurrence rate, and high mortality risk. Our objective was to assess the outcomes of TB treatment and associated factors among TB-HIV co-infected patients in Harar town, Eastern part of Ethiopia, 2018.

METHODS

A retrospective study was conducted among systematically selected 349 TB/HIV co-infected patients who registered from 2012 to 2017 in two public hospitals in Harar town. The data were collected through document review by using a pre-tested structured data extraction checklist. The data were analyzed using SPSS Version 21. Bivariate and multivariate logistic regression were determined at 95% confidence intervals.

RESULTS

Among the 349 TB/HIV co-infected patients included in the study, 30.1% were cured, 56.7% had completed their treatment, 7.7% died, 1.7% were lost to follow up, and 3.7% were treatment failure. Overall, 86.8% of the TB-HIV co-infected patients had successful TB treatment outcomes. The patients who were on re-treatment category (AOR = 2.91, 95% CI: 1.17-7.28), who had a history of opportunistic infection (AOR = 3.68, 95% CI: 1.62-8.33), and who did not take co-trimoxazole prophylaxis (AOR = 3.54, 95% CI: 1.59-7.89) had 2.91, 3.68, and 3.54 times higher odds of having unsuccessful TB treatment outcome than their counterparties, respectively. The chance of unsuccessful TB treatment outcome was 4.46 (95% CI: 1.24-16.02), 5.94 (95% CI: 1.87-18.85), and 3.01 (95% CI: 1.15-7.91) times higher among TB/HIV patients in stage 2, 3 and 4 than those in stage 1, respectively.

CONCLUSIONS

The overall rate of the success of the TB treatment among TB-HIV co-infected patients in this study was higher compared with many previous studies. TB/HIV patients with a history of previous TB treatment, smear-positive pulmonary TB, late HIV stage, history of opportunistic infection and not being on co-trimoxazole prophylaxis therapy were at a high risk of getting poor treatment outcomes.

Effect of TB/HIV Integration on TB and HIV Indicators in Rural Ugandan Health Facilities

BACKGROUND

The World Health Organization recommends integrating services for patients coinfected with tuberculosis (TB) and HIV. We assessed the effect of TB/HIV integration on antiretroviral therapy (ART) initiation and TB treatment outcomes among TB/HIV-coinfected patients using data collected from 14 rural health facilities during 2 previous TB and HIV quality of care studies.

METHODS

A facility was considered to have integrated TB/HIV services if patients with TB/HIV had combined treatment for both illnesses by 1 provider or care team at 1 treatment location. We analyzed the effect of integration by conducting a cross-sectional analysis of integrated and nonintegrated facility periods comparing performance on ART initiation and TB treatment outcomes. We conducted logistic regression, with the patient as the unit of analysis, controlling for other intervention effects, adjusting for age and sex, and clustering by health facility.

RESULTS

From January 2012 to June 2014, 996 patients with TB were registered, 97% were tested for HIV, and 404 (42%) were HIV-positive. Excluding transfers, 296 patients were eligible for analysis with 117 and 179 from nonintegrated and integrated periods, respectively. Being treated in a facility with TB/HIV integration was associated with lower mortality [adjusted odds ratio (aOR) = 0.38, 95% confidence interval (CI): 0.18 to 0.77], but there was no difference in the proportion initiating ART (aOR = 1.34, 95% CI: 0.40 to 4.47), with TB treatment success (aOR = 1.43, 95% CI: 0.73 to 2.82), lost to follow-up (aOR = 1.64, 95% CI: 0.53 to 5.04), or failure (aOR = 1.21, 95% CI: 0.34 to 4.32).

CONCLUSIONS

TB/HIV service integration was associated with lower mortality during TB treatment even in settings with suboptimal proportions of patients completing TB treatment and starting on ART.

Factors associated with directly observed treatment in tuberculosis/HIV coinfection cases in Porto Alegre, 2009-2013: A retrospective cohort

Background

TB/HIV coinfection is a serious public health issue in Brazil, and patients with coinfection have difficulty adhering to treatments. Directly observed treatment (DOT) has been recommended by the World Health Organization, considering the vulnerability of those affected. The purpose is to investigate the occurrence of DOT and associated factors compared to conventional treatment in Porto Alegre, Brazil.

Methods

A retrospective cohort study was carried out with all patients with coinfection from 2009 to 2013 in the city of Porto Alegre, Brazil, the state capital with the highest rate of coinfection in Brazil. The data came from national health information systems. The dependent variable was the performance of DOT. Bivariate and multivariable models were used to determine factors associated with DOT. The percentage of cure and death was verified in a period of two years, comparing patients who received and did not receive DOT.

Results

2,400 cases of coinfection were reported, with 1,574 males and 826 females and a mean age of 38 years ± 9.91 years. The occurrence of DOT was 16.9%. In the multivariable analysis, factors independently associated to DOT were the year (with greater chances of being received in 2012 and 2013), place of origin, non-white race (OR = 1.29, 95% CI = 1.08–1.54), cases of relapse (OR = 1.33; 95% CI = 1.03–1.73), readmission after abandonment (OR = 1.48, 95% CI = 1.20–1.83), transfer (OR = 2.04; 95% CI = 1.40–2.98), acid-fast bacilli (AFB) test with positive result in first sample (OR = 1.73, 95% CI = 1.24–2.42), alcohol abuse (OR = 1.39; 95% CI = 1.16–1.67), and mental disorders (OR = 1.83; 95% CI = 1.38–2.44.) Of the 532 cases of death, occurring in two years, 10.2% were in patients who underwent DOT and 89.8% in patients who did not undergo DOT (p<0.001). O percentual de óbitos em pessoas que receberam DOT foi de 13% e o percentual de óbitos para pessoas que receberam tratamento convencional foi de 24%.

Conclusions

There was an increase in the percentage of DOT over the years in the scenario studied, and the predictors for DOT were related to social vulnerability. In relation to death within two years, a lower proportion was found in patients who underwent DOT, suggesting a protective effect of the strategy.

Epidemiological profile of tuberculosis cases with HIV coinfection in Porto Alegre city, Brazil

OBJECTIVE

To describe and compare the epidemiological profile of cases of tuberculosis and HIV coinfection of the District Administration Health Units of Porto Alegre, Brazil, from 2009 to 2013.

METHOD

Retrospective cohort with data from national health information systems. Sociodemographic, clinical and follow-up variables were investigated through association tests.

RESULTS

2,419 cases of tuberculosis and HIV coinfection were reported, with a mean age of 38 ± 9.91 years, predominantly white and with up to 7 years of study. The comparison between the District Administration Health Units was significant in terms of race/color (p<0.001), gender (p<0.001), schooling (p<0.004), age (p<0.003), place of origin (p<0.001), (p<0.001), alcoholism (p<0.001), indication and performance of Directly Observed Therapy (p<0.001), closure (p<0.001).

CONCLUSION

Socioeconomic and treatment variables influence the occurrence of coinfection in different areas of Porto Alegre, reinforcing that the sum of different factors explains the indicators of the disease.

Tuberculosis treatment outcome and its associated factors among people living with HIV and AIDS in Fako Division of Cameroon

Background

Tuberculosis (TB) and HIV co-infection challenges treatment and worsens the outcome of TB treatment. This study aimed to assess the outcome of TB treatment and factors facilitating treatment success among people living with HIV/AIDS in Fako Division of the South West Region of Cameroon.

Methods

A hospital-based retrospective cohort study was conducted by manually reviewing medical records of HIV/TB co-infected patients from January 2010 to September 2017. A structured data collection form was used to review the medical records of HIV patients co-infected with TB aged 10 years and older. Patients with incomplete files were dropped from the study. Treatment success was defined as the sum of patients who were declared cured and those who had completed treatment, as per the World Health Organization’s recommendations. Data were analyzed using Statistical Package for Social Sciences version 21. Bivariate and multivariate logistic regression model was carried out to identify factors facilitating successful TB treatment outcome. Significance was obtained through adjusted odds ratio with its 95% confidence interval and a p<0.05.

Results

A total of 2,986 files were reviewed but 2,928 (98.1%) were retained. Out of the 2,928 medical files of adult TB patients reviewed, 1,041 (35.6%, [95% CI 33.8%-37.3%]) were HIV/TB co-infected. The 1,041 co-infected patients had a mean age of 37.07 (SD of10.02) years and 56.3% were females. The treatment outcome of TB patients were 795(76.4%) cured, 23(2.2%) treatment completed, 99(9.5%) were lost to follow-up, 16 (1.5%) failed, 72(6.9%) died and 36(3.5%) transferred out. A successful treatment outcome was achieved in 818(78.6%,[95% CI: 76.0%–81.0%]) patients. Being a female [COR 1.61, 95% CI: 1.19–2.17, p = 0.002], receiving TB treatment in 2014 [COR 2.00, 95% CI: 1.11–3.60, p = 0.021] and 2015 [COR 2.50, 95% CI: 1.39–4.50, p = 0.002], having relapsed TB infection [COR 0.46, 95% CI: 0.23–0.93, p = 0.031], receiving ART [COR 1.95, 95% CI: 1.28–2.97, p = 0.002] and Cotrimoxazole [COR 2.03, 95% CI: 1.12–3.66, p = 0.019] were factors significantly associated with successful treatment. After adjusting for confounders, successful treatment outcome were associated with being a female [AOR 1.6; 95% CI: 1.21–2.22, p = 0.001], diagnosis of TB in 2014 [AOR 1.90; 95% CI: 1.04–3.45, p = 0.036] and 2015 [AOR 2.43; 95% CI: 1.33–4.43, p = 0.004].

Conclusion

There is a high TB treatment success rate among HIV/TB co-infected patients in our setting, although below the target set by the WHO. Specific interventions aimed at enhancing patient outcomes are recommended.

Mortality during treatment for tuberculosis; a review of surveillance data in a rural county in Kenya

Background

Globally in 2016, 1.7 million people died of Tuberculosis (TB). This study aimed to estimate all-cause mortality rate, identify features associated with mortality and describe trend in mortality rate from treatment initiation.

Method

A 5-year (2012–2016) retrospective analysis of electronic TB surveillance data from Kilifi County, Kenya. The outcome was all-cause mortality within 180 days after starting TB treatment. The risk factors examined were demographic and clinical features at the time of starting anti-TB treatment. We performed survival analysis with time at risk defined from day of starting TB treatment to time of death, lost-to-follow-up or completing treatment. To account for ‘lost-to-follow-up’ we used competing risk analysis method to examine risk factors for all-cause mortality.

Results

10,717 patients receiving TB treatment, median (IQR) age 33 (24–45) years were analyzed; 3,163 (30%) were HIV infected. Overall, 585 (5.5%) patients died; mortality rate of 12.2 (95% CI 11.3–13.3) deaths per 100 person-years (PY). Mortality rate increased from 7.8 (95% CI 6.4–9.5) in 2012 to 17.7 (95% CI 14.9–21.1) in 2016 per 100PY (P_trend<0.0001). 449/585 (77%) of the deaths occurred within the first three months after starting TB treatment. The median time to death (IQR) declined from 87 (40–100) days in 2012 to 46 (18–83) days in 2016 (P_trend = 0·04). Mortality rate per 100PY was 7.3 (95% CI 6.5–7.8) and 23.1 (95% CI 20.8–25.7) among HIV-uninfected and HIV-infected patients respectively. Age, being a female, extrapulmonary TB, being undernourished, HIV infected and year of diagnosis were significantly associated with mortality.

Conclusions

We found most deaths occurred within three months and an increasing mortality rate during the time under review among patients on TB treatment. Our results therefore warrant further investigation to explore host, disease or health system factors that may explain this trend.

Infection of multiple Mycobacterium tuberculosis strains among tuberculosis/human immunodeficiency virus co-infected patients: A molecular study in Myanmar

Background:

Appearance of Mycobacterium tuberculosis (MTB) in the sputum of a tuberculosis (TB)/human immunodeficiency virus (HIV) co-infected patient under treatment may indicate either failure or new infection. This study aims to evaluate whether TB treatment failure among TB/HIV co-infected patients is a real failure.

Methods:

A prospective cohort study was conducted among 566 TB/HIV co-infected patients who started TB treatment in 12 townships in the upper Myanmar. Among the 566 participants, 16 (2.8%) resulted in treatment failure. We performed a molecular study using mycobacterial interspersed repetitive-unit-variable number of tandem repeat (MIRU-VNTR) genotyping for them. The MIRU-VNTR profiles were analyzed using the web server, MIRU-VNTRplus. All data were entered into EpiData version 3.1 and analyzed using R version 3.4.3.

Results:

Among 16 failure patients, seven had incomplete laboratory results. Of the nine remaining patients, nobody had exactly the same MIRU-VNTR pattern between the initial and final isolates. Four patients had persistent East-African Indian (EAI) lineages and one each had persistent Beijing lineage, changing from EAI to Beijing, from Beijing to EAI, NEW-1 to Beijing, and NEW-1 to X strains. Female patients have significantly larger genetic difference between MTB of the paired isolates than male patients (t-test, P = 0.04).

Conclusion:

Thus, in our study patients, infection of multiple MTB strains is a possible cause of TB treatment failure. Explanation for the association between gender and distance of genotypes from the initial to subsequent MTB infection needs further studies.

Effect of HIV infection on TB treatment outcomes and time to mortality in two urban hospitals in Ghana-a retrospective cohort study

Introduction

Tuberculosis (TB) is currently causing more deaths than Human Immunodeficiency Virus (HIV) globally. Ghana as one of the 30 high burden TB/HIV countries has a high annual TB case-fatality rate of 10%. The study sought to assess the effect of HIV infection on TB treatment outcomes and assess the time to mortality after treatment onset.

Methods

We conducted a review of treatment files of TB patients who were treated from January 2013 to December 2015 in two urban hospitals in the Accra Metropolis. Modified Poisson regression analysis was used to measure the association between HIV infection and TB treatment outcomes. Kaplan-Meier survival estimates were used to plot survival curves.

Results

Seventy-seven percent (83/107) of HIV infected individuals had successful treatment, compared to 91.2% (382/419) treatment success among HIV non-infected individuals. The proportion of HIV-positive individuals who died was 21.5% (23/107) whilst that of HIV-negative individuals was 5.5% (23/419). Being HIV-positive increased the risk of adverse outcome relative to successful outcome by a factor of 2.89(95% CI 1.76-4.74). The total number of deaths recorded within the treatment period was 46; of which 29(63%) occurred within the first two months of TB treatment. The highest mortality rate observed was among HIV infected persons (38.6/1000 person months). Of the 107 TB/HIV co-infected patients, 4(3.7%) initiated ART during TB treatment.

Conclusion

The uptake of ART in co-infected individuals in this study was very low. Measures should be put in place to improve ART coverage among persons with TB/HIV co-infection to help reduce mortality.

Cotrimoxazole prophylaxis decreases tuberculosis risk among Asian patients with HIV

INTRODUCTION

Cotrimoxazole (CTX) is recommended as prophylaxis against Pneumocystis jiroveci pneumonia, malaria and other serious bacterial infections in HIV-infected patients. Despite its in vitro activity against Mycobacterium tuberculosis, the effects of CTX preventive therapy on tuberculosis (TB) remain unclear.

METHODS

Adults living with HIV enrolled in a regional observational cohort in Asia who had initiated combination antiretroviral therapy (cART) were included in the analysis. Factors associated with new TB diagnoses after cohort entry and survival after cART initiation were analysed using Cox regression, stratified by site.

RESULTS

A total of 7355 patients from 12 countries enrolled into the cohort between 2003 and 2016 were included in the study. There were 368 reported cases of TB after cohort entry with an incidence rate of 0.99 per 100 person-years (/100 pys). Multivariate analyses adjusted for viral load (VL), CD4 count, body mass index (BMI) and cART duration showed that CTX reduced the hazard for new TB infection by 28% (HR 0.72, 95% CI l 0.56, 0.93). Mortality after cART initiation was 0.85/100 pys, with a median follow-up time of 4.63 years. Predictors of survival included age, female sex, hepatitis C co-infection, TB diagnosis, HIV VL, CD4 count and BMI.

CONCLUSIONS

CTX was associated with a reduction in the hazard for new TB infection but did not impact survival in our Asian cohort. The potential preventive effect of CTX against TB during periods of severe immunosuppression should be further explored.

Incidence and predictors of LTFU among adults with TB/HIV co-infection in two governmental hospitals, Mekelle, Ethiopia, 2009-2016: survival model approach

Background

Lost to follow-up (LTFU) negatively affects the treatment success of Anti-Retroviral Therapy (ART) and thus, increases Tuberculosis-Human Immunodeficiency Virus (TB/HIV) related morbidity, mortality and hospitalization. However, the incidence and predictors of loss to follow up (LTFU) among adults with TB/HIV co-infection have not yet well-investigated in Ethiopia. Therefore, this study was aimed at investigating the incidence and predictors of LTFU in the study setting in particular.

Methods

A facility based retrospective cohort study was employed among 305 (114 anemic and 191 normal) TB/HIV co-infected adults in two governmental hospitals (Mekelle Hospital and Ayder Comprehensive Specialized Hospital), Mekelle, Ethiopia from 2009 to 2016 and data were collected using checklist. Besides to descriptive statistics, a cox regression analysis was applied to identify statistically significant predictors of LTFU at 5% level of significance. Eventually, the Adjusted Hazard Ratio (AHR) and 95% Confidence Interval (CI) were estimated and interpreted for predictors of LTFU in the final cox model.

Results

Generally, 45 of 305 (14.8%) of TB/HIV co-infected adults were LTFU with an incidence rate of 4.5 new LTFUs per 100 Person Years (PYs) and a median follow up time of 3.1 years (Interquartile Range (IQR): 0.8–5.3 Years). Hemoglobin level ≤ 11.0 g/dl (AHR = 2.660; 95%CI: 1.459–4.848), and any history of OI/s (AHR = 3.795; 95%CI: 1.165–12.364) were risk factors of LTFU. While, adverse drug events (AHR = 0.451; 95%CI: 0.216–0.941), TB treatment completion (AHR = 0.121; 95% CI: 0.057–0.254), and being on Isoniazid Preventive Therapy (IPT) (AHR = 0.085; 95%CI: 0.012–0.628) had protective effect against LTFU.

Conclusions

One in approximately seven TB/HIV co-infected adults had experienced of LTFU with an incidence rate 4.5 LTFUs per 100 PYs. The LTFU rate was higher among adults with low baseline hemoglobin level, no adverse drug events, presence of OI/s, failure to complete TB treatment, and being not on IPT. Therefore, it is advisable to treat anemia and active TB, and preventing the occurrence of OIs including TB using IPT to reduce the incidence of LTFU among TB/HIV co-infected adults.

Factors associated with hospitalization and death among TB/HIV co-infected persons in Porto Alegre, Brazil

In locations with a high rate of tuberculosis (TB) and HIV infection, there are a number of strategies to prevent negative outcomes such as opportunistic infections, hospitalizations and death, and this article investigates risk factors for the occurrence of hospitalization and death in cases of TB/HIV co-infection in the south of Brazil. The data are taken from a population-based retrospective cohort study on cases of TB/HIV co-infection from 2009 to 2013 in Porto Alegre, Brazil. Sociodemographic, epidemiological and clinical variables were analyzed. Relative risk (RR) estimates for hospitalization and death were determined by regression models. There were 2,419 co-infection cases, of which 1,527 (63.1%) corresponded to hospitalizations, and 662 (27.4%) to death. The occurrence of hospitalization was associated with ≤ 7 years of schooling (RR = 3.47, 95%CI: 1.97–6.29), 8–11 years of schooling (RR = 2.56, 95%CI: 1.44–4.69), place of origin—district health authorities Northwest/Humaitá/Navegantes/Ilhas (RR = 2.01, 95%CI: 1.44–2.82), type of entry into the surveillance system as in cases of reentry after withdrawal (RR = 1,35, 95%CI: 1.07–1.70), closure in surveillance as in withdrawal of treatment (RR = 1.47, 95%CI: 1.18–1.83) and multidrug-resistant tuberculosis (RR = 3.94, 95%CI: 1.97–8.81). The occurrence of death was associated with age (RR = 1.07, 95%CI: 1,01–1,14), ≤ 7 years of schooling (RR = 3.94, 95%CI: 2.26–7.09), 8–11 years of schooling (RR = 2.84, 95%CI: 1.61–5.16), place of origin—district health authorities Baltazar (RR = 2.05, 95%CI: 1.48–2.86), type of entry in the surveillance system as cases of re-entry after withdrawal (RR = 1.53, 95%CI: 1.22–1.91), relapse (RR = 1.33, 95%CI: 1.03–1.73). The occurrence of hospitalizations and deaths is high among co-infected patients. Our estimation approach is important in order to identify, from the surveillance data, the risk factors for hospitalization and death in co-infected patients, so that they may receive more attention from the Brazilian national healthcare system.

Tuberculosis-Human Immunodeficiency Virus (HIV) co-infection in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) are the double burden diseases of the world. The African continent takes a great share of TB-HIV cases worldwide. This study was aimed to determine the prevalence of TB-HIV co-infection in Ethiopia, using a meta-analysis based on a systematic review of published articles.

METHODS

An electronic search was conducted in databases including PubMed, HINARI, EMBASE, Cochrane library and Google Scholar to extract the articles. Articles published between 1995 and November 2017 had been searched for using different keywords. The analysis was performed using MetaXL software and R statistical software (version 3.2.3).

RESULT

Our searches returned a total of (n = 26,746) records from 30 articles of which 21 were cross-sectional, 7 were retrospectives and 2 were prospective studies. The range of prevalence of TB-HIV co-infection was found to be from 6 to 52.1% with random effects pooled prevalence of 22% (95% CI 19-24%) and with substantial heterogeneity chi-square (X2) = 746.0, p < 0.001, (I2 = 95.84%).

CONCLUSION

Our analysis indicated that the prevalence of TB-HIV co-infection is high in Ethiopia with substantial regional variation. An integrated, facility-based and community-based effort towards the prevention, early detection and management of cases should be further strengthened throughout the country to mitigate the double burden disease.

Prevalence of extrapulmonary tuberculosis among people living with HIV/AIDS in sub-Saharan Africa: a systemic review and meta-analysis

BACKGROUND

The double burden of infectious diseases such as tuberculosis (TB) and HIV disproportionately affects Africa. Our objective was to summarize the prevalence of extrapulmonary TB (EPTB) among people living with HIV/AIDS (PLWHA) in sub-Saharan Africa (SSA).

METHODS

We searched PubMed and Google Scholar for studies done on the prevalence of EPTB among PLWHA which published in English from 1990 to 2017. We also searched bibliographic indices and browsed through reference lists of articles and journals. We critically appraised the quality of articles and abstracted the data with Joanna Briggs Institute (JBI) checklists. We used Review Manager Software (version 5.3) and Compressive Meta-analysis Software (version 2.2) for analysis. Finally, we summarized the effect estimate by using random-effects model and explored potential sources of heterogeneity by subgroup and sensitivity analyses. We assessed publication bias by funnel plot and statistical test. Finally, we used PRISMA format for reporting.

RESULTS

We included, in this review, 31 studies that fulfilled our inclusion criteria, with a total population of 28,659. The prevalence estimate of EPTB among PLWHA ranged from 6.4% (95% CI: 3.8, 9.0) to 36.8% (95% CI: 28.6, 45); random-effects pooled prevalence of EPTB among PLWHA was found to be 20% (95% CI: 17, 22; heterogeneity: τ2=0; χ2=509.09, degrees of freedom [df]=30, P<0.00001; I 2=94%). No evidence of publication bias was observed (P=0.44 for Egger's regression analysis and P=0.11 for Begg's rank correlation analysis).

CONCLUSION

We can conclude from our analyses that the prevalence of EPTB among PLWHA was high. It is necessary to give emphasis for EPTB, especially when screening TB among PLWHA, widening the spectrum of screening to include all EPTB sites in the countries with high EPTB and/or HIV prevalence in the general population.

Hospitalization of HIV positive patients in a referral tertiary care hospital in Antananarivo Madagascar, 2010-2016: Trends, causes and outcome

BACKGROUND

During the last few years, significant efforts have been made to improve access to antiretroviral therapy which led to dramatic reduction in AIDS-related events and mortality in HIV positive patients at the global level. However, current data in Africa suggested modest impact of widespread antiretroviral therapy scale-up especially regarding HIV-related hospitalization. In this study, we aimed to describe causes of hospitalization and factors associated with AIDS-defining events and inpatient mortality.

MATERIALS AND METHODS

A retrospective study was performed on medical records of HIV positive patients admitted for at least 24 hours in the Infectious Diseases Unit of the University Hospital Joseph Raseta Befelatanana Antananarivo. Cause of hospitalization was considered as the main diagnosis related to the symptoms at admission. Diagnostic criteria were based on criteria described in WHO guidelines. AIDS-defining events were defined as diseases corresponding to WHO stage 4 or category C of CDC classification.

RESULTS

From 2010 to 2016, 236 hospital admissions were included. AIDS-defining events were the most frequent cause of hospitalization (61.9%) with an increasing trend during the study period. Tuberculosis (28.4%), pneumocystis pneumonia (11.4%), cerebral toxoplasmosis (7.2%) and cryptococcosis (5.5%) were the most frequent AIDS-defining events. Tuberculosis was also the most frequent cause of overall hospitalization. In multivariate analysis, recent HIV diagnosis (aOR = 2.0, 95% CI: 1.0-3.9), CD4<200 cells/μl (aOR = 4.0, 95%CI: 1.9-8.1), persistent fever (aOR = 4.4, 95%CI: 2.1-9.0), duration of symptoms≥ 6 weeks (aOR = 2.6, 95%CI: 1.2-5.4) were associated with AIDS-defining events. Overall inpatient mortality was 19.5%. Age≥55 years (aOR = 4.9, 95%CI: 1.5-16.6), neurological signs (aOR = 3.2, 95%CI: 1.5-6.9) and AIDS-defining events (aOR = 2.9, 95%CI: 1.2--7.2) were associated with inpatient mortality.

CONCLUSIONS

AIDS-defining events were the most frequent cause of hospitalization during the study period. Factors associated with AIDS-defining events mostly reflected delay in HIV diagnosis. Factors associated with mortality were advanced age, neurological signs and AIDS-defining events.

Factors Associated with Mortality of TB/HIV Co-infected Patients in Ethiopia

BACKGROUND

Despite the large number of TB patients on ART in Ethiopia, their mortality remains high. This study reports the effect of TB on HIV related mortality and determinants of TB/HIV co-infection related mortality.

METHODS

A longitudinal study design was employed as part of the Advanced Clinical Monitoring of ART (ACM) in Ethiopia. All patients started on ART at or after January 1, 2005 were included. Survival analysis was done to compare survival patterns of HIV patients with TB against HIV patients without TB. In addition, determinants of survival among TB/HIV co-infected patients were analyzed. Adjusted effects of the different factors on time to death were generated using Cox-proportional hazards regression.

RESULTS

A total of 3,889 patients were enrolled in the ACM study, of which 355 TB cases were identified, making the crude prevalence 9% (95% CI 8.3 - 10.2). Overall, incidence of TB was 2.2 (95% CI 1.9-2.4) per 100 person-years. TB was highest in the first 2 months and declined with time on ART to reach 1 per 100 person years after 24 months on ART. TB was significantly associated with mortality among HIV patients on HAART (AHR 2.0, 95% CI 1.47-2.75). Male gender was associated with mortality among TB/HIV co-infected patients.

CONCLUSION

Tuberculosis plays a key role in HIV associated mortality. Targeted interventions which can keep patients free of TB in the early stages of their treatment are required to reduce TB related mortality.

[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.

Old antibiotics for emerging multidrug-resistant/extensively drug-resistant tuberculosis (MDR/XDR-TB)

Recently, multidrug-resistant tuberculosis (MDR-TB) has become a therapeutic challenge. In addition to drug resistance, drug adverse events, intravenous delivery, cost and availability of some antibiotics in low-income countries have led to a look back to old drugs, especially those efficient against closely related organisms such as Mycobacterium leprae. Here we review the available drugs that respect the conditions above and could be upgraded to first-line therapy for treating MDR-TB and extensively drug-resistant tuberculosis (XDR-TB).

Factors Associated with Mortality among Patients on TB Treatment in the Southern Region of Zimbabwe, 2013

Background. In 2013, the tuberculosis (TB) mortality rate was highest in southern Zimbabwe at 16%. We therefore sought to determine factors associated with mortality among registered TB patients in this region. Methodology. This was a retrospective record review of registered patients receiving anti-TB treatment in 2013. Results. Of 1,971 registered TB patients, 1,653 (84%) were new cases compared with 314 (16%) retreatment cases. There were 1,538 (78%) TB/human immunodeficiency virus (HIV) coinfected patients, of whom 1,399 (91%) were on antiretroviral therapy (ART) with median pre-ART CD4 count of 133 cells/uL (IQR, 46-282). Overall, 428 (22%) TB patients died. Factors associated with increased mortality included being ≥65 years old [adjusted relative risk (ARR) = 2.48 (95% CI 1.35-4.55)], a retreatment TB case [ARR = 1.34 (95% CI, 1.10-1.63)], and being HIV-positive [ARR = 1.87 (95% CI, 1.44-2.42)] whilst ART initiation was protective [ARR = 0.25 (95% CI, 0.22-0.29)]. Cumulative mortality rates were 10%, 14%, and 21% at one, two, and six months, respectively, after starting TB treatment. Conclusion. There was high mortality especially in the first two months of anti-TB treatment, with risk factors being recurrent TB and being HIV-infected, despite a high uptake of ART.

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.

Impact of food on the pharmacokinetics of first-line anti-TB drugs in treatment-naive TB patients: a randomized cross-over trial

OBJECTIVES

Concomitant food intake influences pharmacokinetics of first-line anti-TB drugs in healthy volunteers. However, in treatment-naive TB patients who are starting with drug treatment, data on the influence of food intake on the pharmacokinetics are absent. This study aimed to quantify the influence of food on the pharmacokinetics of isoniazid, rifampicin, ethambutol and pyrazinamide in TB patients starting anti-TB treatment.

METHODS

A prospective randomized cross-over pharmacokinetic study was conducted in treatment-naive adults with drug-susceptible TB. They received isoniazid, rifampicin and ethambutol intravenously and oral pyrazinamide on day 1, followed by oral administration of these drugs under fasted and fed conditions on two consecutive days. Primary outcome was the bioavailability while fasting and with concomitant food intake. This study was registered with clinicaltrials.gov identifier NCT02121314.

RESULTS

Twenty subjects completed the study protocol. Absolute bioavailability in the fasted state and the fed state was 93% and 78% for isoniazid, 87% and 71% for rifampicin and 87% and 82% for ethambutol. Food decreased absolute bioavailability of isoniazid and rifampicin by 15% and 16%, respectively. Pyrazinamide AUC0-24 was comparable for the fasted state (481 mg·h/L) and the fed state (468 mg·h/L). Food lowered the maximum concentrations of isoniazid, rifampicin and pyrazinamide by 42%, 22% and 10%, respectively. Time to maximum concentration was delayed for isoniazid, rifampicin and pyrazinamide. The pharmacokinetics of ethambutol were unaffected by food.

CONCLUSIONS

Food decreased absolute bioavailability and maximum concentration of isoniazid and rifampicin, but not of ethambutol or pyrazinamide, in treatment-naive TB patients. In patients prone to low drug exposure, this may further compromise treatment efficacy and increase the risk of acquired drug resistance.

Early Mortality during Initial Treatment of Tuberculosis in Patients Co-Infected with HIV at the Yaoundé Central Hospital, Cameroon: An 8-Year Retrospective Cohort Study (2006-2013)

Background

Understanding contributors to mortality during the initial phase of tuberculosis (TB) treatment in patients co-infected with HIV would guide targeted interventions to improve survival. The aim of this study was to ascertain the incidence of death during the initial 2 months (new cases) and 3 months (retreatment cases) of TB treatment and to assess correlates of mortality in HIV co-infected patients.

Methods

We conducted a hospital-based retrospective cohort study from January 2006 to December 2013 at Yaoundé Central Hospital, Cameroon. We reviewed medical records to identify co-infected TB/HIV inpatients aged 15 years and older who died during TB treatment. Death was defined as any death occurring during TB treatment, as per World Health Organization recommendations. We collected socio-demographic, clinical and laboratory data. We conducted multivariable logistic binary regression analysis to identify factors associated with death during the intensive phase of TB treatment. Magnitudes of associations were expressed by adjusted odds ratio (aOR) with 95% confidence interval. A p value < 0.05 was considered statistically significant.

Results

The 99 patients enrolled had a mean age of 39.5 (standard deviation 10.9) years and 53% were male. Patients were followed for 276.3 person-months of observation (PMO). Forty nine patients were died during intensive phase of TB treatment. Death incidence during the intensive phase of TB treatment was 32.2 per 100 PMO. Having a non-AIDS comorbidity (aOR 2.47, 95%CI 1.22-5.02, p = 0.012), having extra-pulmonary TB (aOR 1.89, 95%CI 1.05-3.43, p = 0.035), and one year increase in duration of known HIV infection (aOR 1.23, 95%CI 1.004-1.49) were independently associated with death during the intensive phase of TB treatment.

Conclusions

Mortality incidence during intensive phase of TB treatment was high among TB/HIV co-infected patients during TB treatment; and strongly associated with extra pulmonary TB suggesting advanced stage of immunosuppression and non-AIDS comorbidities. Early HIV diagnosis and care and good management of non-comorbidities can reduce this incidence.