Abstract
BackgroundIn Cape Town, the roll-out of antiretroviral therapy (ART) has increased over the last decade with an estimated coverage of 63% of HIV- positive patients in 2013. The influence of ART on the characteristics of the population of HIV-positive patients presenting to the primary care TB programme is unknown. In this study, we examined trends in CD4 count distribution, ART usage and treatment outcomes among HIV-positive TB patients in Cape Town from 2009 to 2013.MethodsData from the electronic TB register on all newly registered drug-sensitive TB patients ≥18 years were analyzed retrospectively. Descriptive statistics were used to compare baseline characteristics, the CD4 count distribution and TB treatment outcomes both by year of treatment and ART status at the start of TB treatment. Survival analyses were used to assess the change in mortality risk during TB treatment over time, stratified by ART status at start of TB treatment.Results118,989 patients were treated over 5 years. HIV prevalence among TB patients decreased from 50.9% in 2009 to 49.0% in 2013. The absolute number of HIV-positive TB cases declined by 13.2% between 2010 and 2013. More patients entered the TB programme on ART in 2013 compared to 2009 (30.0% vs 9.9%). Among these, the CD4 count distribution showed a year by year shift to higher CD4 counts. In 2013, over 75% of ART-naïve TB patients still had a CD4 count < 350 cells/mm3. ART initiation among ART-naive patients increased from 37.0 to 77.7% and TB case fatality declined from 7.4 to 5.2% (p < 0.001). In multivariate analysis a decrease in TB mortality was most strongly associated with CD4 count (Adjusted HR 0.82 per increase of 50 cells/mm3, 95% CI: 0.81–0.83, p < 001) and the initiation of ART during TB treatment (Adjusted HR 0.39, 95% CI: 0.35–0.42, p < 0.001).ConclusionComprehensive changes in the ART and TB treatment programmes resulted in incremental increases in ART coverage for HIV-positive TB patients and a subsequent decrease in TB case fatality due to increased ART uptake in HIV-positive ART-naïve patients. However TB still remained a major presenting opportunistic infection with the majority of cases occurring at low CD4 counts.
Highlights
In Cape Town, the roll-out of antiretroviral therapy (ART) has increased over the last decade with an estimated coverage of 63% of Human immunodeficiency virus (HIV)- positive patients in 2013
Previous studies of HIV/TB co-infected patients in sub-Saharan Africa have shown that most patients diagnosed with TB had low CD4 counts and were not receiving ART at the time of TB diagnosis [5,6,7]
While the increase in coverage has been shown to coincide with a decline in the HIV-positive TB epidemic in the city, the influence of ART on the characteristics of the HIV-positive patients presenting with TB is unknown
Summary
In Cape Town, the roll-out of antiretroviral therapy (ART) has increased over the last decade with an estimated coverage of 63% of HIV- positive patients in 2013. The influence of ART on the characteristics of the population of HIV-positive patients presenting to the primary care TB programme is unknown. In sub-Saharan Africa, the increase in the tuberculosis (TB) epidemic has been shown to strongly correlate with the increase in HIV-prevalence [1, 2] This has been driven predominantly by a rise in HIV-positive TB cases among patients with severe immune suppression [2]. In Cape Town with an HIV prevalence of 5.2% in 2013, the roll-out of ART in primary health care clinics was estimated to provide coverage of 63% of HIV-positive patients in that same year [9]. While the increase in coverage has been shown to coincide with a decline in the HIV-positive TB epidemic in the city, the influence of ART on the characteristics of the HIV-positive patients presenting with TB is unknown
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