Incidence of tuberculosis among HIV infected individuals on long term antiretroviral therapy in private healthcare sector in Pune, Western India

Abstract

Background Despite rapid scale up of antiretroviral therapy (ART), Tuberculosis (TB) remains the commonest opportunistic infection and cause of death among HIV infected individuals in resource limited settings like India. Incidence of TB in individuals on ART in private healthcare sector in India is infrequently studied. Methods This retrospective cohort study conducted between 1st March 2009 and 1st March 2017 aimed to evaluate rate of incident TB in individuals initiated on ART at 3 private sector ART clinics in Pune, India. Individuals more than 12 years of age with ART duration of atleast 6 months were included. Patients were classified as having prevalent TB if they had a TB episode within the year prior to ART initiation or if they developed TB within 6 months of starting ART. Individuals who were diagnosed with TB after 6 months of starting ART were classified as incident TB cases. A recurrent episode of TB after treatment completion or cure of prevalent TB was also regarded as incident TB. Patients were classified as definitive TB if Mycobacterium tuberculosis was grown in culture from a biological sample or a positive rapid molecular test. Patients were classified as probable TB if there was radiologic evidence of TB in absence of confirmatory culture or PCR. Results 1904 patients with a median duration of follow up on ART of 57 (IQR = 32.0, 84.0) months were included. Of these, 182 developed incident TB (22% definitive TB, 38% recurrent cases). TB incidence at 6–12 months, 13–24 months, 25–60 months and > 60 months of ART was 24.32, 5.46, 2.54 and 0.75 cases per 100 person years respectively. Current time updated CD4 count < 500 cells/mm 3 ( p < 0.0001), virologic failure on ART (adjusted Hazard Ratio (aHR): 3.05 (95% CI: 2.094, 4.454), p < 0.0001) and receipt of ART without IPT (aHR: 8.24 (95% CI, 3.358, 20.204), p < 0.0001) were associated with higher risk of incident TB. Conclusion Starting ART early in treatment naïve individuals, prompt detection of virologic failure on ART and providing IPT along with ART will be useful in reducing incident TB. Efforts from private sector are crucial in achieving Sustainable Development Goals set by Government of India and attaining the vision of a TB free India.

Determinant factors for the occurrence of tuberculosis after initiation of antiretroviral treatment among adult patients living with HIV at Dessie Referral Hospital, South Wollo, Northeast Ethiopia, 2020. A case-control study

“…According to this study, CD4 count was identified as a determinant factor for TB in which patients with a CD4 count of 201–349 cells/mm3 were more likely to develop TB after ART initiation as compared with those with a CD4 count of ≥350 cells/mm3 (AOR: 3.383 95% CI: 1.520, 7.528). It is consistent with a retrospective cohort study conducted in India in which patients with a CD4 count of <200 cells/mm3 were at higher risk to develop TB after ART initiation as compared with those with a CD4 count of >500 cells/mm3 [ 29 ]. It is also consistent with a retrospective longitudinal study conducted in Ethiopia in which patients with a CD4 count of >350 cells/mm3 were at lower risk to develop TB [ 30 ].…”

Role of CD4/CD8 ratio on the incidence of tuberculosis in HIV-infected patients on antiretroviral therapy followed up for more than a decade

“…Another important consideration is the fact that the cohort was followed in a private health-care facility. Thus, better management of TB in the private sector might have contributed to the findings of lower incidence rate of TB, as has been reported from India [17]. We noted that CD4 count at initiation of ART was not associated with risk of developing TB.…”

“…A more recent meta-analysis from Ethiopia reported a pooled TB incidence rate of 3.79 (95% CI: 2.03-5.55) per 100 person years based on 7 studies in patients who received ART and IPT [35]. Several reports have shown the complementary effects of ART and IPT in preventing the development of TB [15,17,36,37]. All our cohort participants received IPT and this could also contribute to the lower incidence of TB.…”

“…Cumulative findings have demonstrated that antiretroviral therapy (ART) reduces the risk of developing tuberculosis (TB) significantly [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Despite the advent of ART, however, TB remains the major cause of death and morbidity among patients co-infected with HIV-1 in sub-Saharan Africa (SSA) [19][20][21][22].…”

Evaluation of routine Isoniazid Preventive Therapy among People Living with HIV for reducing Tuberculosis; a retrospective cohort study in Tanzania (2012-2016)

“…Sustainable Development Goals (SDG) and Joint United Nations Programme on HIV/AIDS (UNAIDS) have laid goals and targets to end AIDS epidemic by 2030 (1). One of the targets to achieve 2030 HIV targets is to achieve HIV viral suppression among People Living on HIV (PLHIV) who are on Antiretroviral Therapy (ART) (1).Tuberculosis (TB) among PLHIV is still a public health concern(2) which despite wide coverage of ART and other interventions to reduce TB among PLHIV, cause increased ill-health and death (3), thus posing threats towards achieving SDG goals.…”