*The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa; †City Health Directorate, City of Cape Town, South Africa; and ‡Department of Medicine, University of Cape Town, Cape Town, South Africa.
J Acquir Immune Defic Syndr. 2014 Aug 15;66(5):487-94. doi: 10.1097/QAI.0000000000000201.
To identify determinants of tuberculosis (TB) case fatality including the impact of antiretroviral therapy (ART) at different CD4 thresholds for HIV-positive adult and adolescent TB patients.
Through a retrospective analysis of the electronic TB database, we identified the HIV status of newly registered patients aged ≥15 years. Multivariable Cox proportional hazard models were used to determine the risk factors for TB case fatality in these patients.
In 2009, 2010, and 2011, 25,841, 26,104, and 25,554 newly registered adult TB patients were treated in primary health care clinics in Cape Town, of whom 49.7%, 50.4%, and 50.9% were HIV positive. ART uptake increased over 3 years from 43% to 64.9%, and case fatality of the HIV-positive patients decreased from 7.0% to 5.8% (P < 0.001). Female gender, increasing age, retreatment TB, low CD4 counts, and extrapulmonary TB were associated with increased case fatality, whereas patients on ART had a substantial decrease in case fatality. The difference in case fatality between patients on ART and not on ART was most pronounced at low CD4 counts with the positive influence of ART noted up to a CD4 count threshold of 350 cells per cubic millimeter (P < 0.001). Despite improvements in ART uptake, in 2011, 21% of the patients with CD4 counts <350 cells per cubic millimeter did not start ART during TB treatment.
This study showed a relatively poor uptake of ART among severely immune-compromised TB patients. Patients with CD4 counts <350 cells per cubic millimeter were shown to clearly benefit from ART during TB treatment, and ART initiation should be prioritized for this category of patients.
确定结核病（TB）病死率的决定因素，包括针对 HIV 阳性成人和青少年结核病患者不同 CD4 阈值的抗逆转录病毒治疗（ART）的影响。
通过对电子结核病数据库的回顾性分析，我们确定了新登记的≥15 岁患者的 HIV 状态。使用多变量 Cox 比例风险模型确定这些患者中结核病病死率的危险因素。
2009 年、2010 年和 2011 年，在开普敦的基层医疗诊所治疗了 25841、26104 和 25554 例新登记的成年结核病患者，其中 49.7%、50.4%和 50.9%为 HIV 阳性。ART 使用率在 3 年内从 43%增加到 64.9%，HIV 阳性患者的病死率从 7.0%下降到 5.8%（P < 0.001）。女性、年龄增长、复治结核病、低 CD4 计数和肺外结核病与病死率增加相关，而接受 ART 的患者病死率显著降低。在低 CD4 计数时，接受 ART 和未接受 ART 的患者病死率差异最大，ART 的积极影响在 CD4 计数达到 350 个细胞/立方毫米的阈值时即可被观察到（P < 0.001）。尽管 ART 使用率有所提高，但在 2011 年，仍有 21%的 CD4 计数<350 个细胞/立方毫米的患者在结核病治疗期间未开始接受 ART。
本研究显示，严重免疫抑制的结核病患者中 ART 的使用率相对较低。CD4 计数<350 个细胞/立方毫米的患者在结核病治疗期间明显受益于 ART，应优先为这一类患者启动 ART。
