Alvarez-Uria Gerardo, Pakam Raghavakalyan, Midde Manoranjan, Naik Praveen K
Department of Infectious Diseases, Rural Development Trust Hospital, Anantapur, Andhra Pradesh, India;
Department of Infectious Diseases, Rural Development Trust Hospital, Anantapur, Andhra Pradesh, India.
J Int AIDS Soc. 2014 Dec 9;17(1):19251. doi: 10.7448/IAS.17.1.19251. eCollection 2014.
India has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.
We describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.
A total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1-23.6) in the pre-ART group and 17.8% (95% CI, 16.3-19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economical conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9-32.6) in pre-ART TB and 34.9% (95% CI, 31-39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.
The high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.
印度是全球结核病负担最重的国家，但HIV相关结核病的流行病学情况尚不为人所知。
在印度阿南塔布尔开展的一项HIV队列研究中，我们描述了从HIV诊断到开始抗逆转录病毒治疗（ART）（ART治疗前组）以及开始ART治疗后（ART治疗组）结核病的发病率和死亡率。使用竞争风险回归和受限立方样条法对与结核病相关的因素进行多变量分析。
ART治疗前组共纳入4590例患者，随访3133人年（py）；ART治疗组纳入3784例患者，随访4756 py。在ART治疗前组，HIV诊断后的第一个月结核病发病率很高，随后不久下降近四倍。在ART治疗组，开始ART治疗后结核病发病率上升，在第三个月达到峰值。ART治疗前组30个月内发生结核病的概率为22.3%（95%置信区间[CI]，21.1 - 23.6），ART治疗组为17.8%（95% CI，16.3 - 19.3）。在多变量分析中，两组中女性患结核病的风险较低。社会经济条件差与ART治疗前组患结核病风险增加相关，但在ART治疗组中并非如此。虽然在ART治疗前组低CD4细胞计数与结核病之间的关联很强，但在ART治疗组中这种关联较弱，CD4细胞计数约为110个细胞/mm3的患者结核病风险最高。结核病患者12个月时的累积死亡率在ART治疗前结核病患者中为29.6%（95% CI，26.9 - 32.6），在ART治疗后结核病患者中为34.9%（95% CI，31 - 39.1）。ART治疗前死亡的患者占一半，ART治疗后死亡的患者中三分之二患有结核病。
本研究中结核病的高发病率和死亡率凸显了印度迫切需要改善HIV相关结核病的预防和诊断。我们发现开始ART治疗前后结核病存在显著差异。
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