Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia; Bordeaux Population Health Centre U1219, Université de Bordeaux, Bordeaux, France.
Service d'Epidémiologie et de Santé Publique, Centre Pasteur du Cameroun, Réseau International des Instituts Pasteur, Yaounde, Cameroon.
Lancet HIV. 2018 Feb;5(2):e87-e95. doi: 10.1016/S2352-3018(17)30206-0. Epub 2017 Nov 23.
Tuberculosis is a major cause of morbidity and mortality in HIV-infected children, but is difficult to diagnose. We studied mortality and its determinants in antiretroviral treatment (ART)-naive HIV-infected children presenting with suspected tuberculosis.
In this observational cohort study, HIV-infected children aged 13 years or younger with suspected tuberculosis were followed up for 6 months as part of the ANRS 12229 PAANTHER 01 cohort in eight hospitals in four countries (Burkina Faso, Cambodia, Cameroon, and Vietnam). Children started ART and antituberculosis treatment at the clinician's discretion and were retrospectively classified into one of three groups by tuberculosis documentation: confirmed by culture or Xpert MTB/RIF, unconfirmed, and unlikely. We assessed mortality and associated factors using Kaplan-Meier methods and Cox proportional hazard models. The ANRS 12229 PAANTHER 01 study is registered at ClinicalTrials.gov, number NCT01331811.
266 (61%) of 438 children enrolled in the study between April 27, 2011, and May 31, 2014, were ART-naive and included in the analysis (40 had confirmed tuberculosis, 119 unconfirmed tuberculosis, and 107 unlikely tuberculosis). 112·5 person-years of follow-up were available. 154 children (58%) started antituberculosis treatment and 212 (80%) started ART. 50 children (19%) died. Mortality by 6 months was higher in children with confirmed tuberculosis (14 deaths; 2 month survival probability 65·0% [95% CI 50·2-79·8]) compared with unconfirmed tuberculosis (19 deaths; 83·5% [76·8-90·3]) and unlikely tuberculosis (17 deaths; 83·5% [76·3-90·7]; log-rank p=0·0141) and was lower in children with confirmed or unconfirmed tuberculosis who started antituberculosis treatment (p<0·0001 for both). In a multivariate analysis, ART started during the first month of follow-up (hazard ratio 0·08; 95% CI 0·01-0·67), confirmed tuberculosis (6·33; 2·15-18·64), young age (5·90; 2·02-17·19), CD4 less than 10% (2·63; 1·25-5·53), miliary features (4·08; 1·56-10·66), and elevated serum transaminases (4·40; 1·82-10·65) were all independently associated with mortality.
In our cohort, mortality was high in the first 6 months after suspicion of tuberculosis in ART-naive children. ART should be started early, particularly in children with factors associated with high mortality. Documented or empirical tuberculosis treatment decision should be accelerated to reduce mortality and allow early ART initiation.
ANRS and Fondation Total.
结核病是导致艾滋病毒感染儿童发病和死亡的主要原因，但难以诊断。我们研究了初治抗逆转录病毒治疗（ART）的艾滋病毒感染儿童出现疑似结核病的死亡率及其决定因素。
在这项观察性队列研究中，年龄在 13 岁或以下、疑似结核病的艾滋病毒感染儿童作为八个国家/地区（布基纳法索、柬埔寨、喀麦隆和越南）的 ANRS 12229 PAANTHER 01 队列的一部分，在 6 个月内接受随访。根据临床医生的判断，儿童开始接受 ART 和抗结核治疗，并通过结核病记录进行回顾性分类为以下三组之一：培养或 Xpert MTB/RIF 确认、未确认和不太可能。我们使用 Kaplan-Meier 方法和 Cox 比例风险模型评估死亡率和相关因素。ANRS 12229 PAANTHER 01 研究在 ClinicalTrials.gov 注册，编号为 NCT01331811。
2011 年 4 月 27 日至 2014 年 5 月 31 日期间，共招募了 438 名儿童，其中 266 名（61%）为初治，纳入分析（40 例确诊结核病，119 例未确诊结核病，107 例不太可能为结核病）。可获得 112.5 人年的随访数据。154 名儿童（58%）开始接受抗结核治疗，212 名儿童（80%）开始接受 ART。有 50 名儿童（19%）死亡。确诊结核病的儿童在 6 个月时的死亡率更高（14 例死亡；2 个月存活率为 65.0%[95%CI 50.2-79.8]），而未确诊结核病的儿童（19 例死亡；83.5%[76.8-90.3]）和不太可能为结核病的儿童（17 例死亡；83.5%[76.3-90.7]；log-rank p=0.0141），确诊或未确诊结核病并开始接受抗结核治疗的儿童死亡率较低（两者均 p<0.0001）。在多变量分析中，在随访的第一个月开始接受 ART（风险比 0.08；95%CI 0.01-0.67）、确诊结核病（6.33；2.15-18.64）、年龄较小（5.90；2.02-17.19）、CD4 小于 10%（2.63；1.25-5.53）、粟粒性特征（4.08；1.56-10.66）和血清转氨酶升高（4.40；1.82-10.65）均与死亡率独立相关。
在我们的队列中，初治 ART 的艾滋病毒感染儿童在疑似结核病后的前 6 个月死亡率较高。ART 应尽早开始，特别是在与高死亡率相关的儿童中。应加速做出有记录或经验性的结核病治疗决策，以降低死亡率并允许尽早开始 ART。
ANRS 和 Total 基金会。
Zotero 插件