Abstract
BackgroundHIV is a major driver of the tuberculosis epidemic in sub-Saharan Africa. The population-level impact of antiretroviral therapy (ART) scale-up on tuberculosis rates in this region has not been well studied. We conducted a descriptive analysis to examine evidence of population-level effect of ART on tuberculosis by comparing trends in estimated tuberculosis notification rates, by HIV status, for countries in sub-Saharan Africa.MethodsWe estimated annual tuberculosis notification rates, stratified by HIV status during 2010–2015 using data from WHO, the Joint United Nations Programme on HIV/AIDS, and the United Nations Population Division. Countries were included in this analysis if they had ≥4 years of HIV prevalence estimates and ≥ 75% of tuberculosis patients with known HIV status. We compared tuberculosis notification rates among people living with HIV (PLHIV) and people without HIV via Wilcoxon rank sum test.ResultsAmong 23 included countries, the median annual average change in tuberculosis notification rates among PLHIV during 2010–2015 was -5.7% (IQR -6.9 to -1.7%), compared to a median change of -2.3% (IQR -4.2 to -0.1%) among people without HIV (p-value = 0.0099). Among 11 countries with higher ART coverage, the median annual average change in TB notification rates among PLHIV was -6.8% (IQR -7.6 to -5.7%) compared to a median change of -2.1% (IQR -6.0 to 0.7%) for PLHIV in 12 countries with lower ART coverage (p = 0.0106).ConclusionTuberculosis notification rates declined more among PLHIV than people without HIV, and have declined more in countries with higher ART coverage. These results are consistent with a population-level effect of ART on decreasing TB incidence among PLHIV. To further reduce TB incidence among PLHIV, additional scale-up of ART as well as greater use of isoniazid preventive therapy and active case-finding will be necessary.
Highlights
Human immunodeficiency virus (HIV) is a major driver of the tuberculosis epidemic in sub-Saharan Africa
Nowhere has this convergence of epidemics been more pronounced than in sub-Saharan Africa where HIV remains a major driver of the TB epidemic [7,8,9]
Because of the potential error introduced by the assumptions we made in estimating TB case notification rates stratified by HIV status, we focused our analysis on assessment of trends over time, reasoning that even if the estimates for a country were inaccurate in a systematic way, the relationship between estimates in different years would remain robust
Summary
HIV is a major driver of the tuberculosis epidemic in sub-Saharan Africa. The population-level impact of antiretroviral therapy (ART) scale-up on tuberculosis rates in this region has not been well studied. The increased risk of TB among people living with HIV (PLHIV) has resulted in the resurgence of TB epidemics worldwide [5, 6]. Nowhere has this convergence of epidemics been more pronounced than in sub-Saharan Africa where HIV remains a major driver of the TB epidemic [7,8,9]. Successful TB control in this region requires addressing the disproportionate burden of TB among PLHIV
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