High Rates of Tuberculosis in Patients Accessing HAART in Rural South Africa

Abstract

Background The challenge of early Tuberculosis (TB) infection among rural patients accessing HAART in a resource-limited setting with high HIV and TB burden has not been fully quantified. Methods This is a retrospective study nested within a prospective study of 969 patients consecutively initiated onto HAART at the CAPRISA AIDS Treatment programme in rural KwaZulu-Natal between January 2007 and December 2010. Patients were screened for clinical symptoms consistent with TB using a standardized checklist, and routine clinical investigations that included sputum microscopy and chest X-Ray diagnosis. Results Of 969 HIV-infected patients initiated on HAART, 173 (17.9%; 95% CI: 15.5 to 20.4) had active TB at HAART initiation. TB incidence rates were three fold higher in the first 3 months (early incident TB) following HAART initiation (11.5/100 person years (py); 95%CI: 7.1 to 17.5); compared to 4 – 24 months (late incident TB) post HAART initiation (3.2/100 py; 95%CI: 2.2 to 4.5; incidence rate ratio (IRR): 3.6; 95%CI: 2.0 to 6.4; p value <0.001). Immune status of patients at HAART initiation did not impact TB incidence rates in patients with CD4+ counts <50 (5.3/100) and >200 (4.9/100 py; p=0.81); cells/mm3. CD4+ count gains achieved 12 months post HAART initiation were significantly different in patients with early incident TB versus late incident TB; p=0.03. Conclusion Rural HIV treatment programmes in TB endemic settings experience high rates of TB irrespective of immunologic status of patients at HAART initiation, or duration on HAART.

High mortality rates in men initiated on anti-retroviral treatment in KwaZulu-Natal, South Africa

“…Our findings demonstrate that the absence of a diagnosis of prevalent TB increased risk of mortality. Published literature has cited that undiagnosed TB is higher among patients accessing ART than in the general population; with the majority of incident TB diagnosed in the early weeks of ART initiation being TB prevalent but missed at baseline screening [ 19 , 31 , 32 ]. It is possible that undiagnosed TB at ART initiation also contributed to higher risk of mortality in our study.…”

Incidence and mortality of tuberculosis before and after initiation of antiretroviral therapy: an HIV cohort study in India

“…Our results are in accordance with other studies from low- and middle-income countries. In rural South Africa, incidence rates of TB were three-fold higher in the first three months of ART, especially in those with CD4 lymphocytes count of 50–200 cells/mm 3 , whereas prevalent TB was more frequent in those with CD4 lymphocytes count of <50 cells/mm 3 [ 3 ]. In our study, the risk of TB was highest after two to three months of ART.…”

“…In areas of endemic TB, the use of ART is associated with a significant reduction in the incidence of TB [ 2 ]. On the other hand, patients who initiate ART are at higher risk of experiencing TB during the first months of treatment [ 3 , 4 ]. However, differences between TB before ART and TB after ART initiation are not well known [ 5 ].…”

Yield of household contact tracing for tuberculosis in rural South Africa

“…More aggressive approaches to finding cases are essential if we are to accelerate the decline in TB incidence [ 1 ]. While most TB control interventions have focused largely on urban, high-burden settings, high TB incidence rates have been observed in rural populations [ 2 , 3 ], where long distances [ 4 ], inadequate infrastructure, poor-quality health facilities, and limited human resources present major obstacles to active case finding efforts [ 5 , 6 ]. To date, the majority of research on active TB case finding has been done in urban, peri-urban, or congregate settings [ 7 ]; limited research has been done on the efficacy and feasibility of these interventions in rural areas [ 8 ].…”