Peter Bock1, Karen Jennings2, Redwaan Vermaak1, Helen Cox3, Graeme Meintjes3,4, Geoffrey Fatti5, James Kruger6, Virginia De Azevedo7, Leonard Maschilla8, Francoise Louis5, Colette Gunst7,8, Nelis Grobbelaar9, Rory Dunbar1, Mohammed Limbada10, Sian Floyd11, Ashraf Grimwood5, Helen Ayles12, Richard Hayes11, Sarah Fidler13, Nulda Beyers1. 1. Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa. 2. City of Cape Town Health Services, Cape Town, South Africa. 3. Institute of Infectious Disease and Molecular Medicine University of Cape Town, Cape Town, South Africa. 4. Department of Medicine, University of Cape Town, Cape Town, South Africa. 5. Kheth' Impilo. AIDS Free Living, Cape Town, South Africa. 6. Western Cape Department of Health, HIV Treatment & PMTCT Programme, Cape Town, South Africa. 7. Western Cape Department of Health, Cape Winelands District, Worcester, South Africa. 8. Stellenbosch University Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Tygerberg Campus, Western Cape, South Africa. 9. ANOVA Healthcare, Paarl, South Africa. 10. Zambart, University of Zambia, Lusaka, Zambia. 11. Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom. 12. Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom. 13. Department of Medicine, Imperial College London, London, United Kingdom.
Abstract
INTRODUCTION: Antiretroviral treatment (ART) guidelines recommend life-long ART for all HIV-positive individuals. This study evaluated tuberculosis (TB) incidence on ART in a cohort of HIV-positive individuals starting ART regardless of CD4 count in a programmatic setting at 3 clinics included in the HPTN 071 (PopART) trial in South Africa. METHODS: A retrospective cohort analysis of HIV-positive individuals aged ≥18 years starting ART, between January 2014 and November 2015, was conducted. Follow-up was continued until 30 May 2016 or censored on the date of (1) incident TB, (2) loss to follow-up from HIV care or death, or (3) elective transfer out; whichever occurred first. RESULTS: The study included 2423 individuals. Median baseline CD4 count was 328 cells/μL (interquartile range 195-468); TB incidence rate was 4.41/100 person-years (95% confidence interval [CI]: 3.62 to 5.39). The adjusted hazard ratio of incident TB was 0.27 (95% CI: 0.12 to 0.62) when comparing individuals with baseline CD4 >500 and ≤500 cells/μL. Among individuals with baseline CD4 count >500 cells/μL, there were no incident TB cases in the first 3 months of follow-up. Adjusted hazard of incident TB was also higher among men (adjusted hazard ratio 2.16; 95% CI: 1.41 to 3.30). CONCLUSIONS: TB incidence after ART initiation was significantly lower among individuals starting ART at CD4 counts above 500 cells/μL. Scale-up of ART, regardless of CD4 count, has the potential to significantly reduce TB incidence among HIV-positive individuals. However, this needs to be combined with strengthening of other TB prevention strategies that target both HIV-positive and HIV-negative individuals.
INTRODUCTION: Antiretroviral treatment (ART) guidelines recommend life-long ART for all HIV-positive individuals. This study evaluated tuberculosis (TB) incidence on ART in a cohort of HIV-positive individuals starting ART regardless of CD4 count in a programmatic setting at 3 clinics included in the HPTN 071 (PopART) trial in South Africa. METHODS: A retrospective cohort analysis of HIV-positive individuals aged ≥18 years starting ART, between January 2014 and November 2015, was conducted. Follow-up was continued until 30 May 2016 or censored on the date of (1) incident TB, (2) loss to follow-up from HIV care or death, or (3) elective transfer out; whichever occurred first. RESULTS: The study included 2423 individuals. Median baseline CD4 count was 328 cells/μL (interquartile range 195-468); TB incidence rate was 4.41/100 person-years (95% confidence interval [CI]: 3.62 to 5.39). The adjusted hazard ratio of incident TB was 0.27 (95% CI: 0.12 to 0.62) when comparing individuals with baseline CD4 >500 and ≤500 cells/μL. Among individuals with baseline CD4 count >500 cells/μL, there were no incident TB cases in the first 3 months of follow-up. Adjusted hazard of incident TB was also higher among men (adjusted hazard ratio 2.16; 95% CI: 1.41 to 3.30). CONCLUSIONS: TB incidence after ART initiation was significantly lower among individuals starting ART at CD4 counts above 500 cells/μL. Scale-up of ART, regardless of CD4 count, has the potential to significantly reduce TB incidence among HIV-positive individuals. However, this needs to be combined with strengthening of other TB prevention strategies that target both HIV-positive and HIV-negative individuals.
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