Associated factors for treatment delay in pulmonary tuberculosis in HIV-infected individuals: a nested case-control study

Abstract

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.

Factors associated with tuberculosis treatment delay in patients co-infected with HIV in a high prevalence area in Brazil

“…These clinical indicators likely increase the physician’s suspicion of severe TB and lead to empiric treatment. The factors found to be associated with both patient and health care delay in this study contrast with those from the study performed by Coimbra et al [ 15 ] where primarily clinical factors were found to be associated with greater total delay. Use of illicit drugs was the only social factor associated with later initiation of TB therapy in that study, but this finding was not replicated in our study.…”

“…Use of illicit drugs was the only social factor associated with later initiation of TB therapy in that study, but this finding was not replicated in our study. Furthermore, based on the study done by Coimbra et al and others from different countries [ 15 , 25 ], we had expected to find that AFB smear and Xpert-MTB-RIF results were associated with health care delay. Interestingly, the results of microbiological testing did not impact delays in our study, and likely reflects the fact that empiric TB treatment is common in Brazil, as shown previously,[ 27 ] and may be more so in our sample as patients were seen by highly experienced infectious disease specialists.…”

“…The majority of these studies focused on TB mono-infection with few focused exclusively on those co-infected with HIV. [ 15 – 18 ] In Brazil, there have been studies examining factors associated with TB treatment delay [ 15 – 19 ] but only Coimbra et al [ 15 ] focused on PLHIV. The study evaluated total treatment delay in patients with only pulmonary TB who were attending HIV care services at the time that they developed TB symptoms.…”

“…The presence of systemic symptoms, asthenia, chest pain, use of illicit drugs and a smear negative sputum were all associated with greater total delay in their study. [ 15 ] To the best of our knowledge, no study to date has included TB-HIV co-infected patients with recent diagnosis of HIV, nor separately examined patient and health care system delay in Brazil.…”

Determinants of delayed diagnosis and treatment of tuberculosis in high-burden countries: a mixed-methods systematic review and meta-analysis

“…This review also identified other sociodemographic and economic risk factors for patient delay, such as being older, lower education level, unmarried, being unemployed, absence of health insurance, and high cost of treatment and transportation to health facilities (Table 2). Urban residence [24,56,58] Widowed/di vorced/ separated/n ot married [67,75] Cost of health care incurred before diagnosis [46 ] Sub-urban residence [104 ] Widowed Unemployed [35,36,39] Cost of treatment/ transport to health facilities [86] Unemployed [101] Cost of treatment/ transport to health facilities [47] No health insurance [68,72,73,81] Cost of health care incurred before diagnosis [101 , 104] Behavioral Smoking [37] Recreational drug use [61] Smoking [77] Poor TB knowledge [98] Poor TB knowledge [46,104] Nonsmoking [99] Stigma[25, 40,57] Stigma [72,83] Stigma [ TB-HIV coinfection/HIV positive [30,88] No cough [66] No history of TB [97] Smear positive [78,99] No history of TB in the family [101] Chest pain [107] No history of TB [32,…”