Impact of the human immunodeficiency virus epidemic on mortality among adults with tuberculosis in rural South Africa, 1991-1995.

SETTING: In the Hlabisa district tuberculosis programme, South Africa, the prevalence of human immunodeficiency virus (HIV) infection among adults with tuberculosis increased from 36.0% in 1993 to 65.9% in 1997, and the annual tuberculosis caseload increased from 321 in 1991 to 1250 in 1996.
OBJECTIVE: To examine the impact of the HIV epidemic on mortality among adults with tuberculosis from 1991 to 1995.
METHODS: Data were extracted from the control programme database. As the programme started in July 1991, data for this year were combined with those for 1992.
RESULTS: All-cause mortality among all those diagnosed with tuberculosis increased by 45.6%, from 9.2% (55/599) in 1991/92 to 13.4% (96/714) in 1995 (P = 0.02). Among smear-positive patients only, mortality increased by 134%, from 4.4% to 10.3% (P = 0.003). The case-fatality rate (CFR) increased in most age groups of both sexes, the largest increase (157.5%) being among women aged 15-34 years. CFR was highest among those with smear-negative disease (24.7% in 1995). In multifactorial analysis, independent risk factors for mortality were increasing age (P = 0.0001), HIV infection (odds ratio [OR] 3.5, 95 % confidence interval [CI] 2.3-5.4), smear-negative disease (OR 2.5, 95%CI 1.8-3.5), and diagnosis in 1995 vs 1991/92 (OR 1.8, 95%CI 1.2-2.7). Mortality among the HIV infected continued to accrue throughout treatment, whereas non-HIV-infected patients that died did so early in treatment.
CONCLUSION: The HIV epidemic is increasing tuberculosis all-cause mortality. As well as having a direct effect on individuals, increased caseloads due to HIV may also contribute to increased mortality by reducing the health system's ability to provide adequate care.