Articles tagged as "Comorbidity"

TB/ HIV

Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U, Zeller K, Andrews J, Friedland G. Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet 2006;368:1575-80.

The epidemics of HIV-1 and tuberculosis in South Africa are closely related. High mortality rates in co-infected patients have improved with ART, but drug-resistant tuberculosis has emerged as a major cause of death. Gandhi and colleagues assessed the prevalence and consequences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis in a rural area in KwaZulu Natal, South Africa. The authors undertook enhanced surveillance for drug-resistant tuberculosis with sputum culture and drug susceptibility testing in patients with known or suspected tuberculosis. Genotyping was done for isolates resistant to first-line and second-line drugs. From January 2005 to March 2006, sputum was obtained from 1539 patients. The authors detected MDR tuberculosis in 221 patients, of whom 53 had XDR tuberculosis. Prevalence among 475 patients with culture-confirmed tuberculosis was 39% (185 patients) for MDR and 6% (30) for XDR tuberculosis. Only 55% (26 of 47) of patients with XDR tuberculosis had never been previously treated for tuberculosis; 67% (28 of 42) had a recent hospital admission. All 44 patients with XDR tuberculosis who were tested for HIV were co-infected. 52 of 53 patients with XDR tuberculosis died, with median survival of 16 days from time of diagnosis (range 6-37) among the 42 patients with confirmed dates of death. Genotyping of isolates showed that 39 of 46 (85%, 95%CI 74-95) patients with XDR tuberculosis had similar strains. The authors conclude that MDR tuberculosis is more prevalent than previously realised in this setting. XDR tuberculosis has been transmitted to HIV co-infected patients and is associated with high mortality. These observations warrant urgent intervention and threaten the success of treatment programmes for tuberculosis and HIV.

Editors’ note: XDR (extreme or extensive drug-resistant TB) is defined as resistance to at least the 2 most potent anti-TB drugs, isoniazid and rifampicin, in addition to resistance to at least 3 of the 6 classes of second-line drugs. This first outbreak, which occurred among people living with HIV, shows that XDR-TB is clearly highly lethal, leaving patients without treatment options and, as a result, virtually untreatable.


Lawn SD, Myer L, Bekker LG, Wood R. Burden of tuberculosis in an antiretroviral treatment programme in sub-Saharan Africa: impact on treatment outcomes and implications for tuberculosis control. AIDS 2006;20:1605-12.

Lawn and colleagues determined burden and risk factors for tuberculosis in an ART programme and its impact on ART outcomes in a prospective cohort study. Prevalent tuberculosis was assessed at baseline and incident tuberculosis was ascertained prospectively over 3 years among 944 patients accessing a community-based ART programme in South Africa. At enrolment, median CD4 cell count was 96cells/microlitre and 52% of patients had a previous history of tuberculosis. Prevalent tuberculosis was present in 25% and was strongly associated with advanced immunodeficiency. During 782 person-years of ART, 81 cases of tuberculosis were diagnosed. The incidence was 22.1/100 person-years during the first 3 months of ART and decreased to an average of 4.5/100 person-years during the second and third years. In multivariate analysis, risk of incident tuberculosis during follow-up was only associated with the current absolute CD4 cell count at that time point; an increase of 100 cells/ml was associated with a 25% lower risk (P = 0.007). Although prevalent and incident tuberculosis were associated with greater than two-fold increased mortality risk, they did not compromise immunological and virological outcomes among survivors at 48 weeks. The authors conclude that late initiation of ART was associated with a major burden of tuberculosis in this ART programme. Tuberculosis reduced survival but did not impair immuno-virological outcomes. Reductions in tuberculosis incidence during ART were dependent on CD4 cell count; however, after 3 years of treatment, rates were still 5-10 times higher than among non-HIV-infected people. Earlier initiation of ART may reduce this burden of tuberculosis.

Editors’ note: Stephen Lawn’s brown bag seminar in Geneva this week provoked lively discussion, including of the need for active TB case finding and isoniazid (INH) prophylaxis in HIV clinics.

Comorbidity
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TB/ HIV

Bwire R, Nagelkerke NJ, Borgdorff MW. Finding patients eligible for antiretroviral therapy using TB services as entry point for HIV treatment. Trop Med Int Health 2006;11:1567-75.

As we scale up towards universal access to comprehensive HIV prevention, treatment, care and support services it is important to consider the tuberculosis programme as an important partner in identifying those who are HIV infected and eligible for antiretroviral therapy (ART). In a study to assess the proportion of adults (15-49 years) eligible for ART identifiable through tuberculosis services in 18 sub-Saharan African countries, Bwire and colleagues estimated the number of tuberculosis patients needed to screen to identify one adult eligible for ART for each country. The proportion of all adults eligible for ART that could be identified through the tuberculosis programme ranged from 2-18% (10% on average). The number of tuberculosis patients needed to be screened to identify one patient eligible for ART ranged from 1.4 to 4.2, compared to 8.6 to 65.4 if adults aged 15-49 are randomly screened. Tuberculosis services are thus an important entry point for identifying people who are eligible for ART.

Editors’ note: TB services have been considered to be ‘low hanging fruit’ in terms of access to HIV-positive patients who may be in need of antiretroviral treatment. The findings of this study strongly support this belief.

Comorbidity, HIV Treatment
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TB/ HIV

Sinanovic E, Kumaranayake L. Sharing the burden of TB/HIV? Costs and financing of public-private partnerships for tuberculosis treatment in South Africa. Trop Med Int Health 2006;11:1466-74. http://www.blackwell-synergy.com/doi/full/10.1111/j.1365-3156.2006.01686.x

Sinanovic and Kumaranayake explored the economic costs and sources of financing for different public-private partnership (PPP) arrangements for tuberculosis (TB) service provision involving both workplace and non-profit private providers in South Africa. The financing required for the different models from the perspective of the provincial TB programme, provider, and the patient were considered. Two models of TB provider partnerships were evaluated, relative to sole public provision: public-private workplace (PWP) and public-private non-government (PNP). The cost analysis was undertaken from a societal perspective. Costs were collected retrospectively to consider both the financial and economic costs. Patient costs were estimated using a retrospective structured patient interview. Expansion of PPPs could potentially lead to reduced government sector financing requirements for new patients: government financing would require $609-690 per new patient treated in the purely public model, in contrast to PNP sites which would only need to $130-139 per patient and $36-46 with the PWP model. Moreover, there are no patient costs associated with the treatment in the employer-based facilities and the cost to the patient supervised in the community is, on average, three times lower than in public sector facilities. The results suggest that there is a strong economic case for expanding PPP involvement in TB treatment in the process of scaling up. The cost to the government per new patient treated could be reduced by enhanced partnership between the private and public sectors.

Editors’ note: As TB continues to rise in sub-Saharan Africa and reports of the virtually untreatable XDR-TB (extremely drug resistant TB) surface worldwide the need for creative cost-effective service delivery models is ever more evident. These models would mean lower costs for both governments and patients.

Comorbidity
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Care and Support (Anxiety and Depression pre- ARV Initiation)

Nogueira Campos L, De Fatima Bonolo P, et al. Anxiety and depression assessment prior to initiating antiretroviral treatment in Brazil. AIDS Care 2006;18:529-36

Nogueira Campos carried out a cross-sectional study with 386 patients who received their first anti-retroviral prescription between May 2001 and May 2002 in public AIDS referral centers in Belo Horizonte, Brazil. The main objective was to assess the prevalence and factors associated with anxiety and depression among HIV-infected patients initiating ART using the Hospital Anxiety and Depression Scale. The authors collected clinical, behavioural and demographic data from interviews and medical charts, and conducted multivariate analysis by logistic regression. Prevalence of moderate to severe anxiety and depression were 35.8% and 21.8%, respectively. Female gender, low schooling, lack of health insurance, attendance to psychotherapy, difficulty in accessing health services and exposure category were independently associated with anxiety. On the other hand, female gender, lack of health insurance, low income, living alone, and lacking a sexual partner in the last month were independently associated with depression. The authors conclude that this study highlights the importance of detecting psychological distress by simple screening methods in the HIV setting, where the prevalence of anxiety and depression is considerably high, so proper intervention can be established soon in the treatment course.

Comorbidity, HIV Treatment
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Tuberculosis and other mycobacterial Infections

Kali PB, Gray GE, et al. Combining PMTCT with active case finding for tuberculosis. J Acquir Immune Defic Syndr 2006 Apr 24 [Epub ahead of print]. http://gateway.ut.ovid.com/gw2/ovidweb.cgi

Tuberculosis (TB) has become a leading cause of maternal mortality and morbidity in high HIV prevalence settings. Active TB in pregnant women has potentially serious consequences for foetuses and newborns. In Soweto (South Africa) there is more than 90% uptake of voluntary counselling and HIV testing during routine antenatal care, and almost one third of pregnant women are found to have HIV- infection. The post-test counselling session in the prevention of mother-to-child transmission programme provides an opportunity to screen HIV-infected pregnant women for TB. In this study, 370 HIV-infected pregnant women were screened for symptoms of active TB by lay counsellors at the post-test counselling session. If symptomatic, they were referred to nurses who investigated them further. Eight women were found to have previously undiagnosed, smear-negative, culture-confirmed TB (that is an incidence of 21.6/1000). The mean CD4 count in those with active TB was significantly lower than in those without TB. Symptoms most associated with active TB were haemoptysis and fever. The authors conclude that the incidence of TB in HIV-infected pregnant women is high, and screening for TB during routine antenatal care should be implemented in high HIV prevalence settings.

 


Ustianowski AP, Lawn SD, Lockwood DN. Interactions between HIV infection and leprosy: a paradox. Lancet Infect Dis 2006;6:350-360.http://www.thelancet.com/journals/laninf/article/PIIS1473309906704935/fulltextEarly in the HIV epidemic it was feared that HIV would undermine leprosy control, as has occurred with TB. It was predicted that patients with leprosy and HIV co-infection would have an increased risk of lepromatous disease and a faster clinical evolution, and that the leprosy would be more difficult to treat. None of these concerns have materialised and the interaction between HIV and Mycobacterium leprae seems to be far more subtle than that between HIV and TB. Ustianowski and colleagues reviewed the epidemiological, clinical, and pathological data relating to leprosy/HIV co-infection. The published epidemiological data are limited in quality but show neither an increased HIV prevalence among leprosy cases nor an alteration in clinical spectrum of leprosy among co-infected patients. Some data suggest that immune-mediated reactions that complicate leprosy occur at a higher frequency in co-infected patients. Leprosy has now been reported presenting as immune reconstitution disease among patients commencing HAART. Histopathological observations reveal a normal spectrum of appearances in biopsies of leprosy lesions from co-infected patients, even among those with advanced immunodeficiency. These observations suggest that cell-mediated immune responses to Mycobacterium leprae are preserved at the site of disease despite evidence that these responses are abrogated systemically, in contrast to TB where host granulomatous responses are impaired by HIV co-infection. The authors speculate that this paradox may relate to differences within leprosy and TB granulomas between the activation state and rates of cell turnover that differentially affect the susceptibility of granulomas to HIV. The authors conclude that the interactions between leprosy and HIV have been little studied and further research on the clinical, pathological, and management aspects of this co-infection is warranted.

 

Comorbidity
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