Tuberculosis among adults starting antiretroviral therapy in South Africa: the need for routine case finding

Hanifa, Yasmeen; Fielding, Katherine; Charalambous, Salome; Variava, Ebrahim; Luke, Binnu; Churchyard, Gavin J.; Grant, Alfred D.

doi:10.5588/ijtld.11.0733

Cited by 41 publications

(40 citation statements)

References 24 publications

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“…The review included four studies conducted during the ART era and, though overall ART coverage was not included, TB prevalence in these four studies was equal to or greater than in studies conducted prior to ART rollout, suggesting that individuals are initiating ART too late or are not linked to treatment at all. Studies conducted in clinics in South Africa have previously highlighted the large burden of undiagnosed TB among the ambulatory HIV-positive population [30,31], but investigation for TB is largely based on reporting respiratory symptoms, using sputum-based diagnostic tests [32,33]. A recent study conducted in Cape Town found that, of 139 HIV-positive individuals diagnosed with TB during admission to hospital (median CD4 count 80 cells/μL; 35% on ART for a median 1.3 years), 115 (83%) had at least one non-respiratory sample that was positive on testing with Xpert® MTB/RIF, or culture positive for M .…”

Section: Discussionmentioning

confidence: 99%

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

et al. 2016

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BackgroundEarly mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”).Methods and FindingsAdults with CD4 ≤150 cells/μL, not on ART or TB treatment, were enrolled to TB Fast Track and followed up for at least six months. Minimally invasive autopsy (MIA) was conducted as soon as possible after death. Lungs, liver, and spleen were biopsied; blood, CSF, and urine aspirated; and bronchoalveolar lavage fluid obtained. Samples underwent mycobacterial, bacterial, and fungal culture; molecular testing (including Xpert® MTB/RIF); and histological examination. 34 MIAs were conducted: 18 (53%) decedents were female; median age was 39 (interquartile range 33–44) years; 25 (74%) deaths occurred in hospitals; median time from death to MIA was five (IQR 3–6) days. 16/34 (47%) had evidence of TB (14/16 [88%] with extrapulmonary disease; 6/16 [38%] not started on treatment antemortem); 23 (68%) had clinically important bacterial infections; four (12%) cryptococcal disease; three (9%) non-tuberculous mycobacterial disease; and two (6%) Pneumocystis pneumonia. Twenty decedents (59%) had evidence of two or more concurrent infections; 9/16 (56%) individuals with TB had evidence of bacterial disease and two (13%) cryptococcal disease.ConclusionsTB, followed by bacterial infections, were the leading findings at autopsy among adults with advanced HIV enrolled from primary care clinics. To reduce mortality, strategies are needed to identify and direct those at highest risk into a structured pathway that includes expedited investigation and/or treatment of TB and other infections.

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Section: Discussionmentioning

confidence: 99%

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

et al. 2016

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“…In developing countries, the diagnosis of pulmonary TB is heavily dependent on AFB sputum smear microscopy, which has low sensitivity among PLHIV [14], who often present extra pulmonary or sputum smear-negative pulmonary TB, resulting in late diagnosis [15] and therefore either delayed or no treatment [16]. This has led to the suggestion that empirical treatment of tuberculosis (i.e.…”

Section: Introductionmentioning

confidence: 99%

Empirical treatment for TB in HIV: lessons from a cohort study of people living with HIV treated in Recife, Brazil

et al. 2014

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BackgroundTuberculosis (TB) is the leading cause of death related to HIV worldwide. This study analyzes the survival of People Living with HIV (PLHIV) reporting cough without bacteriological confirmation of TB and identify factors associated with death.MethodsProspective cohort with a consecutive sample of PLHIV, aged ≥ 18 years. Patient inclusion criteria were complaint of current cough of any duration at the time of the first study interview or during their subsequent routine visits to health services and for whom AFB sputum smear was either negative or not performed during the whole follow-up period. Kaplan-Meier method was used to calculate the probability of survival. We estimated the Hazard Ratio (HR) in bivariate and multivariate Cox regression analyses.ResultsMortality was 4.6 per 100 py; 73% were receiving HAART at recruitment. Average time from the first recorded date of cough until empirical treatment for tuberculosis was six months. Mortality was higher when the CD4 count was low (HR = 5.3; CI 95%: 3.2-9.0; p = 0.000), in those with anemia (HR = 3.0; CI 95%: 1.6-5.6; p = 0.001) and with abnormal chest X-rays (HR = 2.4; CI 95%: 1.4-4.0; p = 0.001). Mortality was higher in those receiving empirical TB treatment (HR = 2.4; CI 95%: 1.4-4.0; p = 0.002), but only in those with normal X-rays, no history of tuberculosis and no bacteriology requests. Empirical treatment for TB was more frequent in PLHIV with low CD4 counts, anemia, history of opportunistic infections, weight loss, previous tuberculosis, negative bacteriology test (as opposed to not having a test) and abnormal chest X-ray.ConclusionsHigher mortality in PLHIV reporting a current cough without bacteriological confirmation of tuberculosis was identified for those with a CD4 cell count <200, abnormal chest X-ray, anemia and empirical treatment for tuberculosis. Mortality was not significantly higher in those empirically treated for TB, who had three characteristics suggestive of the disease (abnormal chest X-ray, history of TB treatment, AFB sputum smear or M.tb culture testing). Routine cohorts are not an adequate setting to evaluate the impact of empirical treatment for TB on the mortality of PLHIV.

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“…The World Health Organisation (WHO) estimates that approximately 20e40% of the world's population are affected, with 8e9 million new cases of active disease being reported every year [9e16]. TB is ultimately responsible for most deaths among patients infected with the human immunodeficiency virus (HIV) [8,17,18,19,20].…”

Section: Introduction Q1mentioning

confidence: 99%

Cutaneous tuberculosis overview and current treatment regimens

2015

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Tuberculosis among adults starting antiretroviral therapy in South Africa: the need for routine case finding

Abstract: Background:We investigated the prevalence of, and evaluated screening modalities

Cited by 41 publications

References 24 publications

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

Empirical treatment for TB in HIV: lessons from a cohort study of people living with HIV treated in Recife, Brazil

Cutaneous tuberculosis overview and current treatment regimens

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