The contribution of late HIV diagnosis on the occurrence of HIV-associated tuberculosis

Abstract

Objectives: To describe the timing of tuberculosis (TB) presentation in relation to diagnosis of HIV infection and antiretroviral therapy (ART) initiation and to evaluate whether the established impact from late presentation to care and late initiation of ART on the risk of TB is retained beyond the observation period of clinical trials. Design:We used marginal structural models to emulate a clinical trial with up to 5 years of follow-up to evaluate the impact of late initiation on TB risk.Methods: People with HIV (PWH) were enrolled from 2007 to 2016 in observational cohorts from Uganda, Peru, Mexico and Italy. The risk of TB was compared in LP (accessing care with CD4 þ cell count 350 cells/ml) vs. nonlate presentation using survival curves and a weighted Cox regression. We emulated two strategies: initiating ART with CD4 þ cell count less than 350 cells/ml vs. CD4 þ cell count at least 350 cells/ml (late initiation). We estimated TB attributable risk and population attributable fraction up to 5 years from the emulated date of randomization.Results: Twenty thousand one hundred and twelve patients and 1936 TB cases were recorded. Over 50% of TB cases were diagnosed at presentation for HIV care. More than 50% of the incident cases of TB after ART initiation were attributable to late presentation; nearly 70% of TB cases during the first year of follow-up could be attributed to late presentation and more than 50%, 5 years after first attending HIV care. Conclusion:Late presentation accounted for a large share of TB cases. Delaying ART initiation was detrimental for incident TB rates, and the impact of late presentation persisted up to 5 years from HIV care entry.

Reporting of Observational Studies Explicitly Aiming to Emulate Randomized Trials

“…We retrieved 3133 unique records, of which 200 were included in the review (Figure 1). All reasons for excluding records after full-text review are given in eAppendix 6 in Supplement 1.…”

“…Seventy studies (35%) reported in the title that the study aimed to emulate a target trial; 180 (90%) did so in the Methods section. Twenty studies (10%) reported the study was prospectively registered, 16 of these 20 (80%)…”

“…Most studies (187 [94%]) reported the set of variables that authors had decided to adjust for (eg, because they were potential confounders) in analyses, and 77 (39%) reported how these variables were selected. One hundred and thirty-one studies (66%)…”

“…One hundred and thirty-one studies (66%) reported conducting a sensitivity analysis for statistical or causal assumptions; the most frequent (42 of 131 [32%]) was the use of a different approach to confounding adjustment (eg, using weighting rather than outcome regression). One hundred and fifty-eight studies (79%)…”

“…This systematic review summarized items reported in observational studies that explicitly aimed to emulate a target trial. We included 200 studies published from 2013 to 2022, the majority of which (168 [84%]) were published between January 2020 and October 2022. The studies spanned 26 fields of medicine and mostly used sources of data that were routinely collected, such as electronic health records, health insurance claims data, or these data linked with other data sources.…”