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1. The impact of HIV and ART on recurrent tuberculosis in a sub-Saharan setting

Author

J. Mpunga, Mwenibabu M, Rein M G J Houben, Amelia C. Crampin, Glynn, Neil French, N. J. Mwaungulu, Sebastian Mboma, Lorren Mwaungulu, and Mzemba T

Subjects
Adult, Male, Pediatrics, medicine.medical_specialty, Malawi, Tuberculosis, Adolescent, Anti-HIV Agents, Immunology, Human immunodeficiency virus (HIV), Antitubercular Agents, Disease, Rate ratio, medicine.disease_cause, Drug Administration Schedule, Cohort Studies, Young Adult, Recurrence, Risk Factors, HIV Seropositivity, Isoniazid, Immunology and Allergy, Medicine, Humans, Survival analysis, AIDS-Related Opportunistic Infections, business.industry, Incidence (epidemiology), Incidence, Middle Aged, medicine.disease, Survival Analysis, Confidence interval, Surgery, CD4 Lymphocyte Count, Infectious Diseases, Treatment Outcome, Population Surveillance, Streptomycin, Female, Rifampin, business, Cohort study, Follow-Up Studies
Abstract

OBJECTIVE: To estimate the impact of antiretroviral therapy (ART) on the incidence of recurrent tuberculosis (TB) in an African population. DESIGN: A long-term population cohort in Karonga District, northern Malawi. METHODS: Patients who had completed treatment for laboratory-confirmed TB diagnosed since 1996 were visited annually to record vital status, ART use and screen for TB. Survival analysis estimated the effect of HIV/ART status at completion of treatment on mortality and recurrence. Analyses were stratified by time since treatment completion to estimate the effects on relapse (predominates during first year) and reinfection disease (predominates later). RESULTS: Among 1133 index TB cases contributing 4353 person-years of follow-up, there were 307 deaths and 103 laboratory-confirmed recurrences (recurrence rate 4.6 per 100 person-years). Half the recurrences occurred in the first year since completing treatment. HIV infection increased the recurrence rate [rate ratio adjusted for age, sex, period and TB type 2.69, 95% confidence interval (CI) 1.69-4.26], but with less effect in the first year (adjusted rate ratio 1.71, 95% CI 0.87-3.35) than subsequently (adjusted rate ratio 4.2, 95% CI 2.16-8.15). Recurrence rates on ART were intermediate between those of HIV-negative individuals and HIV-positive individuals without ART. Compared with HIV-positive individuals without ART, the adjusted rate ratio was 0.74 (95% CI 0.27-2.06) in the first year, and 0.43 (95% CI 0.11-1.73) later. CONCLUSION: The increased incidence of TB recurrence observed in HIV-positive patients appeared to be reduced by ART. The effects are mostly on later (likely reinfection) disease so the impact of ART on reducing recurrence will be highest in high TB incidence settings.

Published
2012

2. The impact of HIV and ART on recurrent tuberculosis in a sub-Saharan setting.

Author

Houben RM, Glynn JR, Mboma S, Mzemba T, Mwaungulu NJ, Mwaungulu L, Mwenibabu M, Mpunga J, French N, and Crampin AC

Subjects
AIDS-Related Opportunistic Infections epidemiology, AIDS-Related Opportunistic Infections immunology, Adolescent, Adult, CD4 Lymphocyte Count, Cohort Studies, Drug Administration Schedule, Female, Follow-Up Studies, HIV Seropositivity epidemiology, HIV Seropositivity immunology, Humans, Incidence, Isoniazid administration & dosage, Malawi epidemiology, Male, Middle Aged, Population Surveillance, Recurrence, Rifampin administration & dosage, Risk Factors, Streptomycin administration & dosage, Survival Analysis, Treatment Outcome, Tuberculosis epidemiology, Tuberculosis immunology, Young Adult, AIDS-Related Opportunistic Infections drug therapy, Anti-HIV Agents administration & dosage, Antitubercular Agents administration & dosage, HIV Seropositivity drug therapy, Tuberculosis drug therapy
Abstract

Objective: To estimate the impact of antiretroviral therapy (ART) on the incidence of recurrent tuberculosis (TB) in an African population., Design: A long-term population cohort in Karonga District, northern Malawi., Methods: Patients who had completed treatment for laboratory-confirmed TB diagnosed since 1996 were visited annually to record vital status, ART use and screen for TB. Survival analysis estimated the effect of HIV/ART status at completion of treatment on mortality and recurrence. Analyses were stratified by time since treatment completion to estimate the effects on relapse (predominates during first year) and reinfection disease (predominates later)., Results: Among 1133 index TB cases contributing 4353 person-years of follow-up, there were 307 deaths and 103 laboratory-confirmed recurrences (recurrence rate 4.6 per 100 person-years). Half the recurrences occurred in the first year since completing treatment. HIV infection increased the recurrence rate [rate ratio adjusted for age, sex, period and TB type 2.69, 95% confidence interval (CI) 1.69-4.26], but with less effect in the first year (adjusted rate ratio 1.71, 95% CI 0.87-3.35) than subsequently (adjusted rate ratio 4.2, 95% CI 2.16-8.15). Recurrence rates on ART were intermediate between those of HIV-negative individuals and HIV-positive individuals without ART. Compared with HIV-positive individuals without ART, the adjusted rate ratio was 0.74 (95% CI 0.27-2.06) in the first year, and 0.43 (95% CI 0.11-1.73) later., Conclusion: The increased incidence of TB recurrence observed in HIV-positive patients appeared to be reduced by ART. The effects are mostly on later (likely reinfection) disease so the impact of ART on reducing recurrence will be highest in high TB incidence settings.

Published
2012
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