HIV-related tuberculosis: mortality risk in persons without vs. with culture-confirmed disease

Abstract

SUMMARY BACKGROUND Tuberculosis (TB) diagnosis in human immunodeficiency virus (HIV) positive persons is difficult, particularly in resource-limited settings. The relationship between TB culture status and mortality in HIV-positive persons treated for TB is unclear. METHODS We evaluated HIV-positive adults treated for TB at or after their first HIV clinic visit in Argentina, Brazil, Chile, Honduras, Mexico or Peru from 2000 to 2015. Anti-tuberculosis treatment included 2 months of isoniazid, rifampicin (RMP)/rifabutin (RBT), pyrazinamide ± ethambutol, followed by continuation phase treatment with isoniazid + RMP/RBT. RESULTS Of 759 TB-HIV patients, 238 (31%) were culture-negative, 228 (30%) had unknown culture status or did not undergo culture and 293 (39%) were culturepositive. The median CD4 at TB diagnosis was 96 (interquartile range 40–228); 636 (84%) received concurrent antiretroviral therapy (ART) and antituberculosis treatment. There were 123 (16%) deaths: 90/466 (19%) with TB culture-negative, unknown or not performed vs. 33/293 (11%) who were TB culturepositive (P=0.005). In Kaplan-Meier analysis, mortality in TB patients without culture-confirmed disease was higher (P = 0.002). In a Cox model adjusted for age, sex, CD4, ART timing, disease site and stratified by study site, mortality in persons without culture-confirmed TB was not significantly increased compared to those with culture-positive TB (hazard ratio 1.39, 95%CI 0.89–2.16, P = 0.15). CONCLUSION Most HIV-positive patients treated for TB did not have culture-confirmed TB, and mortality tended to be higher in patients without culture-confirmed disease, although the association was not statistically different after adjusting for other variables. Accurate TB diagnosis in HIV-positive persons is crucial.

Mortality among adults living with HIV treated for tuberculosis based on positive, negative, or no bacteriologic test results for tuberculosis: the IeDEA consortium

“…This finding has been attributed to paucibacillary disease in the setting of advanced HIV, delay in diagnosis, and other opportunistic and non-communicable diseases [14, 21–23, 58–65]. Similar findings have been shown with respect to culture results among PLWH treated for TB, but no such studies have been performed for NAAT to our knowledge [66]. The lack of mortality difference in our study could also be related to the combination of smear, culture, and NAAT used to define the groups, overdiagnosis of TB in the negative test group (yielding lower than expected mortality), or higher bacterial burden due to more extensive TB disease or inadequate treatment of drug-resistant TB in the positive test group (yielding higher than expected mortality) [67].…”

Mortality from AIDS and tuberculosis-HIV coinfection in the Chilean AIDS Cohort of 2000-2017

“…This represents a failure of treatment in a marginalized population with less access to public health, as reported in other studies in the country 31,32 . Diagnosis of TB in HIV-positive persons can be limited, in part, to poor infrastructure and failure to address issues of culture, as demonstrated in studies conducted in Latin America countries, added to a delay in the start of ART and multidrug resistant TB 22,33 .…”

Burden of serious fungal infections in Honduras

“…Given relatively low pulmonary tuberculosis numbers and moderate numbers of people with asthma, lung cancer and COPD, our total CPA prevalence estimate is 1450 patients or 14.6 per 100,000 (Table 3). There are no reports of CPA from Honduras, but of note the mortality of unproven pulmonary tuberculosis was higher in unconfirmed tuberculosis at 19%, compared with confirmed tuberculosis (11%) in 759 patients from Latin America 65 . This higher mortality is most likely attributable to misdiagnosis, and CPA is probably the most common mimic of tuberculosis that is often fatal.…”