BackgroundConcomitant treatment of Human Immunodeficiency Virus (HIV) infection and tuberculosis (TB) presents a series of challenges for treatment compliance for both providers and patients. We carried out this study to identify risk factors for default from TB treatment in people living with HIV.MethodsWe conducted a cohort study to monitor HIV/TB co-infected subjects in Pernambuco, Brazil, on a monthly basis, until completion or default of treatment for TB. Logistic regression was used to calculate crude and adjusted odds ratios, 95% confidence intervals and P-values.ResultsFrom a cohort of 2310 HIV subjects, 390 individuals (16.9%) who had started treatment after a diagnosis of TB were selected, and data on 273 individuals who completed or defaulted on treatment for TB were analyzed. The default rate was 21.7% and the following risk factors were identified: male gender, smoking and CD4 T-cell count less than 200 cells/mm3. Age over 29 years, complete or incomplete secondary or university education and the use of highly active antiretroviral therapy (HAART) were identified as protective factors for the outcome.ConclusionThe results point to the need for more specific actions, aiming to reduce the default from TB treatment in males, younger adults with low education, smokers and people with CD4 T-cell counts < 200 cells/mm3. Default was less likely to occur in patients under HAART, reinforcing the strategy of early initiation of HAART in individuals with TB.

OBJETIVO: Comparar a freqüência de desfecho desfavorável (óbito, abandono e falência de tratamento) entre pacientes com co-infecção tuberculose (TB)/HIV submetidos a tratamento para TB com confirmação etiológica do diagnóstico e pacientes co-infectados com TB/HIV e tratados sem confirmação diagnóstica. MÉTODOS: Coorte retrospectivo de pacientes co-infectados com TB/HIV que iniciaram tratamento para TB entre julho de 2002 e junho de 2004, em um serviço de referência para HIV/AIDS no Recife (PE) Brasil. A exposição principal, confirmação laboratorial da TB, foi ajustada pelas variáveis de três blocos: variáveis sócio-demográficas; variáveis relacionadas ao HIV/AIDS; e variáveis relacionadas à TB. Para avaliar a significância estatística dos resultados, utilizaram-se o intervalo de confiança de 95% das odds ratios e o valor de p (teste de qui-quadrado e razão de verossimilhança). RESULTADOS: Foram estudados 262 pacientes. Não se observou associação entre confirmação laboratorial do diagnóstico de TB e desfecho desfavorável, mesmo após o ajuste pelos fatores de confusão. Permaneceram no modelo final da regressão logística múltipla: coexistência de outras doenças oportunistas; contagem de linfócitos CD4 abaixo de 50 células/mm³; carga viral entre 10.000 e 100.000 cópias/mL; dispnéia; forma disseminada de TB; e mudança do tratamento da TB por reação adversa ou intolerância. CONCLUSÕES: Os resultados sugerem que o tratamento para TB sem confirmação etiológica, em pacientes co-infectados, baseado na decisão de profissionais experientes em serviços de referência, não aumentou o risco de desfecho desfavorável do tratamento para TB. Além disso, identificaram-se grupos com maior risco de desfecho desfavorável, os quais devem ser cuidadosamente monitorados.

ObjectiveTo identify the incidence of and risk factors for tuberculosis in people living with HIV (PLHIV).DesignObservational, prospective cohort study.MethodsA total of 2069 HIV-infected patients was observed between July 2007 and December 2010. The Kaplan-Meier method was used to estimate the probability of survival free of tuberculosis, and Cox regression analysis to identify risk factors associated with the development of tuberculosis.ResultsSurvival free of tuberculosis (TB) was 91%. The incidence rate of tuberculosis was 2.8 per 100 persons/years. Incidence of tuberculosis was higher when subjects had CD4 cell count <200 cells/mm3; were not on antiretroviral therapy; in those who had, a body mass index <18.5 kg/m2, anemia (or were not tested for it), were illiterate or referred previous tuberculosis treatment at entry into the cohort. Those not treated for latent TB infection had a much higher risk (HR = 7.9) of tuberculosis than those with a negative tuberculin skin test (TST). Having a TST≥5 mm but not being treated for latent TB infection increased the risk of incident tuberculosis even in those with a history of previous tuberculosis.ConclusionsPreventive actions to reduce the risk of TB in people living with HIV should include an appropriate HAART and treatment for latent TB infection in those with TST≥5 mm. The actions towards enabling rigorous implementation of treatment of latent TB infection and targeting of PLHIV drug users both at the individual and in public health level can reduce substantially the incidence of TB in PLHIV.

The use of HAART can prevent deaths among HIV-TB patients, corroborating the efficacy of starting HAART early in individuals with TB.

BackgroundTuberculosis is a serious public health problem worldwide. It is the leading cause of death amongst people living with HIV, and default from tuberculosis (TB) treatment in people living with HIV increases the probability of death. The aim of this study was to estimate the survival probability of people living with HIV who default treatment for TB compared to those who complete the treatment.MethodsThis was a longitudinal cohort study of people living with HIV, from June 2007 to December 2013 with two components: a retrospective (for those who started tuberculosis treatment before 2013 for whom failure (death) or censoring occurred before 2013), and prospective (those who started tuberculosis treatment at any time between 2007 and June 2013 and for whom death or censoring occurred after the beginning of 2013), at two referral hospitals for people living with HIV (Correia Picanço Hospital - HCP and at Hospital Universitário Oswaldo Cruz – HUOC), in Recife/PE. A total of 317 patients who initiated TB treatment were studied. Default from TB treatment was defined as any patient who failed to attend their pre-booked return appointment at the health center for more than 30 consecutive days, in accordance with Brazilian Ministry of Health recommendations.ResultsFrom a cohort of 2372 people living with HIV we analyzed 317 patients who had initiated TB treatment. The incidence of death was 5.6 deaths per 100 persons per year (CI 95% 4.5 to 7.08). Independent factors associated with death: default from TB treatment 3.65 HR (95% CI 2.28 to 5.83); CD4 < 200 cells/mm3 2.39 HR (95% CI 1.44 to 3.96); extrapulmonary tuberculosis 1.56 HR (95% CI 0.93 to 2.63); smoking 2.28 HR (95% CI 1.33 to 3.89); alcohol light 0.13 HR (95% CI 0.03 to 0.56).ConclusionThe probability of death in people living with HIV who default TB treatment is approximately four times greater when compared to those who do not default from treatment.

Despite the effectiveness of combination antiretroviral therapy in the treatment of people living with HIV/AIDS (PLWHA), nonadherence to medication has become a major threat to its effectiveness. This study aimed to estimate the prevalence of self-reported irregular use of antiretroviral therapy and the factors associated with such an irregularity in PLWHA. A cross-sectional study of PLWHA who attended two referral centers in the city of Recife, in Northeastern Brazil, between June 2007 and October 2009 was carried out. The study analyzed socioeconomic factors, social service support and personal habits associated with nonadherence to antiretroviral therapy, adjusted by multivariable logistic regression analysis. The prevalence of PLWHA who reported irregular use of combination antiretroviral therapy (cART) was 25.7%. In the final multivariate model, the irregular use of cART was associated with the following variables: being aged less than 40 years (OR = 1.66, 95%-CI: 1.29-2.13), current smokers (OR = 1.76, 95%-CI: 1.31-2.37) or former smokers (OR = 1.43, 95%-CI: 1.05-1.95), and crack cocaine users (OR = 2.79, 95%-CI: 1.24-6.32). Special measures should be directed towards each of the following groups: individuals aged less than 40 years, smokers, former smokers and crack cocaine users. Measures for giving up smoking and crack cocaine should be incorporated into HIV-control programs in order to promote greater adherence to antiretroviral drugs and thus improve the quality of life and prolong life expectancy.

Resumo Esse artigo analisa o conhecimento, atitudes e práticas sobre tuberculose de agentes comunitários de saúde (ACS) no Recife, município com altas taxas de incidência e de abandono do tratamento no Brasil. O estudo transversal foi conduzido em uma amostra representativa dos ACS utilizando questionário padronizado. Descreveram-se as frequências das variáveis referentes ao conhecimento, atitudes e práticas e analisou-se a associação do conhecimento satisfatório e práticas adequadas com características dos ACS. Dos 401 ACS elegíveis, 385 (96,0%) foram entrevistados. A maioria era composta por mulheres (87,5%), com idade ≥ 40 anos (66,0%) e desempenhando a função há mais de nove anos (74,5%). Um percentual de 61,7% tinha conhecimento satisfatório e esse conhecimento (75,8%) esteve associado às práticas adequadas (p = 0,008). Quanto às atitudes, 97,1% dos ACS acreditavam estar sob risco de contrair tuberculose e 53,2% atribuíram o risco à função. Parcela significativa dos ACS apresentou conhecimento satisfatório sobre tuberculose e esse conhecimento esteve associado às práticas adequadas. Esse resultado sugere a necessidade de investimentos em ações de capacitação que podem contribuir para a melhoria dos indicadores de tuberculose no município.

BackgroundThe delay in initiating treatment for tuberculosis (TB) in HIV-infected individuals may lead to the development of a more severe form of the disease, with higher rates of morbidity, mortality and transmissibility. The aim of the present study was to estimate the time interval between the onset of symptoms and initiating treatment for TB in HIV-infected individuals, and to identify the factors associated to this delay.MethodsA nested case-control study was undertaken within a cohort of HIV-infected individuals, attended at two HIV referral centers, in the state of Pernambuco, Brazil. Delay in initiating treatment for TB was defined as the period of time, in days, which was greater than the median value between the onset of cough and initiating treatment for TB. The study analyzed biological, clinical, socioeconomic, and lifestyle factors as well as those related to HIV and TB infection, potentially associated to delay. The odds ratios were estimated with the respective confidence intervals and p-values.ResultsFrom a cohort of 2365 HIV-infected adults, 274 presented pulmonary TB and of these, 242 participated in the study. Patients were already attending 2 health services at the time they developed a cough (period range: 1 – 552 days), with a median value of 41 days. Factors associated to delay were: systemic symptoms asthenia, chest pain, use of illicit drugs and sputum smear-negative.ConclusionThe present study indirectly showed the difficulty of diagnosing TB in HIV-infected individuals and indicated the need for a better assessment of asthenia and chest pain as factors that may be present in co-infected patients. It is also necessary to discuss the role played by negative sputum smear results in diagnosing TB/HIV co-infection as well as the need to assess the best approach for drug users with TB/HIV.