Prevalent and incident tuberculosis as risk factors for mortality during eight years of follow-up in a South African antiretroviral treatment service
Background: The association between tuberculosis (TB) and mortality in antiretroviral treatment (ART) programmes in sub-Saharan Africa remains incompletely defined. This study aimed to determine whether prevalent TB at baseline and incident TB diagnosed during ART were independent risk factors for mortality in a community-based South African ART service.
Methods: Deaths from all causes were ascertained among HIV-infected patients receiving ART. Data on TB events and 4-monthly CD4 cell count and viral load measurements were collected from patient records. Mortality rates were calculated and Poisson regression models were used to calculate incidence rate ratios (IRR) and identify risk factors for mortality.
Results: 1544 patients receiving ART for a median of 5.0 years were included in the analysis. 464 (30.0%) patients had a diagnosis of prevalent TB at baseline, 424 (27.5%) developed incident TB during follow-up and there was a total of 208 (13.5%) deaths from all causes. Mortality rates were highest during the first year of ART (8.84 deaths/100 person-years, 95%CI 7.41-10.54), and decreased during the 2nd, 3rd, 4th, 5th and subsequent years of ART to 2.07 (95%CI 7.41-10.54), 1.67 (95%CI 1.06-2.62), 1.86 (95%CI 1.18-2.91), 1.22 (95%CI 068-2.21) and 1.14 (95%CI 0.59-2.19) deaths/100 person-years respectively. Current CD4 cell count was the factor most strongly associated with mortality. However, in multivariate analyses adjusted for baseline and time-updated co-variates, both prevalent and incident TB were independent risk factors for mortality (IRR 2.0 [95% CI 1.5-2.7] and 2.6 [95%CI 1.4-4.7] respectively). Greater mortality risk was also associated with recurrent TB (IRR 4.8, 95% CI 3.0-7.9) and person-time accrued within 6 months of a TB episode (IRR 3.0, 95% CI 2.0-4.4).
Conclusions: Prevalent and incident TB are strongly associated with mortality during ART. Strategies to prevent TB prior to and during ART are needed, as are diagnostic algorithms and new tools to rapidly identify cases and initiate treatment.
19th International AIDS Conference
"A.Gupta, et al.
Prevalent and incident tuberculosis as risk factors for mortality during eight years of follow-up in a South African antiretroviral treatment service.
19th International AIDS Conference: