O412 Factors associated with poor clinical outcome among HIV-infected patients with tuberculosis (TB) in Europe and Argentina. The HIV/TB collaborative study
D Podlekareva*1, A Mocroft2, FA Post3, V Riekstina4, JM Miro5, H Furrer6, M Bruyand7, A Panteleev8, E Girardi9, JJ Toibaro10, J Caylá11, R Miller12, NObel13, A Skrahin14, E Malashenkov15, JD Lundgren16, O Kirk16 and HIV/ TB study group16
Address: 1Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark, 2Royal Free and University College Medical School, London, UK, 3King's College London School of Medicine, London, UK, 4State Agency of TB and Lung Diseases, Riga, Latvia, 5Hosp. Clinic – IDIBAPS, University of Barcelona, Barcelona, Spain, 6University Hospital of Bern, Bern, Switzerland, 7INSERM, U 897, "epidemiology and biostatistics", Bordeaux, France, 8TB Hospital #2, St. Petersburg, Russian Federation, 9Instituto Nazionale Malattie Infettive L Spallanzani, Rome, Italy, 10Hospital JM Ramos Mejia, Buenos Aires, Argentina, 11Barcelona TB Research Unit, Barcelona, Spain, 12Mortimer Market Centre, London, UK, 13Dept of Infectious Diseases; Rigshospitalet, Copenhagen, Denmark, 14Research Institute of Pulmonology and Pulmonary Tuberculosis, Minsk, Belarus, 15Botkin Hospital of Infectious Diseases, St. Petersburg, Russian Federation and 16University of Copenhagen, Copenhagen HIV Programme, Faculty of Health Science, Copenhagen, Denmark
* Corresponding author
from Ninth International Congress on Drug Therapy in HIV Infection Glasgow, UK. 9–13 November 2008
Published: 10 November 2008
Journal of the International AIDS Society 2008, 11(Suppl 1):O39 doi:10.1186/1758-2652-11-S1-O39
Purpose of the study
TB is a common and potentially fatal co-infection among
HIV-infected patients worldwide. We aimed to evaluate
potential regional differences in patient characteristics
and clinical management and their influence on the oneyear
mortality rate after a TB diagnosis in HIV-infected
patients across Europe and Argentina
Methods
1,075 consecutive HIV-patients who started treatment for
TB between January 2004 and December 2006 in 47 clinics
across Europe and Argentina were identified. Patients
were stratified according to region of residence: Argentina
(A), Southern Europe (S), Central/Northern Europe (CN),
or Eastern Europe (E). Deaths among HIV/TB co-infected
patients within 12 months of TB diagnosis, and factors
associated with death, were analysed
Summary of results
At TB diagnosis, there were profound differences in
patient characteristics, usage of anti-TB and combination
antiretroviral therapy (cART), and anti-TB drug resistance
in E compared with the other regions (Table 1). Significantly
fewer patients in E initiated cART within the first
year after TB diagnosis (Table 1), and multi-drug resistant
TB was more common in E (12% [31 of 252 patients with
data on anti-TB resistance]) compared to A, S and CN
(3%, 2% and 3% respectively, p = 0.0002). Progression to
death was significantly faster in E compared to other
regions (Figure 1). In multivariable Cox models, the
adjusted relative hazard of death (RH, compared with E)
was 0.44 (95% CI 0.22–0.88), 0.33 (0.17–0.66), 0.46
(0.20–1.05) in A, S and CN, respectively. Other factors significantly
associated with increased mortality were: CD4
count <200 cells/mm3 vs. >200 cells/mm3 [2.27
(1.52–3.40)], prior AIDS vs. no AIDS [1.84 (1.29–2.62)],
and disseminated TB vs. not disseminated TB [2.01
(1.14–3.56)]. Patients who started anti-TB treatment with at least four first-line drugs had a significantly lower risk
of death [0.50 (0.31–0.81)], as did patients with no resistance
to anti-TB drugs [0.48 (0.28–0.79)].
Table 1:
A (n = 115)
S (n = 210)
CN (n = 168)
E (n = 582)
P-value
Caucasians (%)
23
56
33
83
<0.0001
Injecting drug use (%)
37
35
14
80
<0.0001
>4 1st line anti-TB drugs in initial regimen (%)
83
63
77
25
<0.0001
>1 2nd line anti-TB drug in initial regimen (%)
12
15
10
64
<0.0001
Resistance to any anti-TB drug (%, 513 tests)
7
13
7
50
<0.0001
CD4 count at TB diagnosis (cells/mm3, median, inter-quartile range)
92 (41–228)
146 (55–291)
145 (54–284)
212 (89–463)
<0.0001
On cART at TB diagnosis (%)
26
25
34
8
<0.0001
On cART 12 months after TB diagnosis (%)
77
71
75
31
<0.0001
Conclusion
In conclusion, there were substantial differences in the
clinical management of HIV-TB co-infected patients
across Europe and Argentina, including less use of cART
and more extensive use of second-line anti-TB drugs, presumably
partly due to widespread TB drug resistance in
populations from E. These factors may partly explain the
3–4 fold higher one-year mortality rate after a TB diagnosis
in this region, and deserve immediate public health
attention.
Figure 1
Progression to death within 1 year of TB diagnosis.