Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland.
Institute of Medical Virology, University of Zurich, Zurich, Switzerland.
Clin Infect Dis. 2023 Nov 11;77(9):1303-1311. doi: 10.1093/cid/ciad330.
People with human immunodeficiency virus type 1 (HIV-1) (PWH) are frequently coinfected with Mycobacterium tuberculosis (MTB) and at risk for progressing from asymptomatic latent TB infection (LTBI) to active tuberculosis (TB). LTBI testing and preventive treatment (TB specific prevention) are recommended, but its efficacy in low transmission settings is unclear.
We included PWH enrolled from 1988 to 2022 in the Swiss HIV Cohort study (SHCS). The outcome, incident TB, was defined as TB ≥6 months after SHCS inclusion. We assessed its risk factors using a time-updated hazard regression, modeled the potential impact of modifiable factors on TB incidence, performed mediation analysis to assess underlying causes of time trends, and evaluated preventive measures.
In 21 528 PWH, LTBI prevalence declined from 15.1% in 2001% to 4.6% in 2021. Incident TB declined from 90.8 cases/1000 person-years in 1989 to 0.1 in 2021. A positive LTBI test showed a higher risk for incident TB (hazard ratio [HR] 9.8, 5.8-16.5) but only 10.5% of PWH with incident TB were tested positive. Preventive treatment reduced the risk in LTBI test positive PWH for active TB (relative risk reduction, 28.1%, absolute risk reduction 0.9%). On population level, the increase of CD4 T-cells and reduction of HIV viral load were the main driver of TB decrease.
TB specific prevention is effective in selected patient groups. On a population level, control of HIV-1 remains the most important factor for incident TB reduction. Accurate identification of PWH at highest risk for TB is an unmet clinical need.
人类免疫缺陷病毒 1 型（HIV-1）感染者（PWH）常合并感染结核分枝杆菌（MTB），并存在从无症状潜伏性结核感染（LTBI）发展为活动性结核病（TB）的风险。LTBI 检测和预防治疗（TB 特异性预防）被推荐，但在低传播环境中的疗效尚不清楚。
我们纳入了 1988 年至 2022 年期间瑞士艾滋病毒队列研究（SHCS）中招募的 PWH。结局为 LTBI 后≥6 个月发生的 TB，定义为 TB。我们使用时间更新的风险回归来评估其危险因素，模型化了可改变因素对 TB 发病率的潜在影响，进行了中介分析以评估时间趋势的潜在原因，并评估了预防措施。
在 21528 名 PWH 中，LTBI 的患病率从 2001 年的 15.1%下降到 2021 年的 4.6%。TB 发病率从 1989 年的 90.8 例/1000人年下降到 2021 年的 0.1 例/1000人年。LTBI 检测阳性显示发生 TB 的风险更高（风险比[HR] 9.8，5.8-16.5），但只有 10.5%的 TB 患者 LTBI 检测阳性。在 LTBI 检测阳性的 PWH 中，预防治疗降低了活动性 TB 的风险（相对风险降低 28.1%，绝对风险降低 0.9%）。在人群水平上，CD4 T 细胞增加和 HIV 病毒载量降低是 TB 减少的主要驱动因素。
TB 特异性预防在选定的患者群体中是有效的。在人群水平上，控制 HIV-1 仍然是减少 TB 的最重要因素。准确识别 TB 风险最高的 PWH 是一个未满足的临床需求。
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