Abstract
BackgroundDespite rapid scale up of antiretroviral therapy (ART), Tuberculosis (TB) remains the commonest opportunistic infection and cause of death among HIV infected individuals in resource limited settings like India. Incidence of TB in individuals on ART in private healthcare sector in India is infrequently studied.MethodsThis retrospective cohort study conducted between 1st March 2009 and 1st March 2017 aimed to evaluate rate of incident TB in individuals initiated on ART at 3 private sector ART clinics in Pune, India. Individuals more than 12 years of age with ART duration of atleast 6 months were included. Patients were classified as having prevalent TB if they had a TB episode within the year prior to ART initiation or if they developed TB within 6 months of starting ART. Individuals who were diagnosed with TB after 6 months of starting ART were classified as incident TB cases. A recurrent episode of TB after treatment completion or cure of prevalent TB was also regarded as incident TB. Patients were classified as definitive TB if Mycobacterium tuberculosis was grown in culture from a biological sample or a positive rapid molecular test. Patients were classified as probable TB if there was radiologic evidence of TB in absence of confirmatory culture or PCR.Results1904 patients with a median duration of follow up on ART of 57 (IQR = 32.0, 84.0) months were included. Of these, 182 developed incident TB (22% definitive TB, 38% recurrent cases). TB incidence at 6–12 months, 13–24 months, 25–60 months and > 60 months of ART was 24.32, 5.46, 2.54 and 0.75 cases per 100 person years respectively. Current time updated CD4 count < 500 cells/mm3 (p < 0.0001), virologic failure on ART (adjusted Hazard Ratio (aHR): 3.05 (95% CI: 2.094, 4.454), p < 0.0001) and receipt of ART without IPT (aHR: 8.24 (95% CI, 3.358, 20.204), p < 0.0001) were associated with higher risk of incident TB.ConclusionStarting ART early in treatment naïve individuals, prompt detection of virologic failure on ART and providing IPT along with ART will be useful in reducing incident TB. Efforts from private sector are crucial in achieving Sustainable Development Goals set by Government of India and attaining the vision of a TB free India.
Highlights
Despite rapid scale up of antiretroviral therapy (ART), Tuberculosis (TB) remains the commonest opportunistic infection and cause of death among HIV infected individuals in resource limited settings like India
First line ART regimens comprised of 2 nucleoside reverse transcriptase inhibitors (NRTI) plus 1 non-nucleoside reverse transcriptase inhibitor (NNRTI))
Comparison with TB incidence studies from India We found 2 studies which reported the occurrence of ART associated TB from the Indian public health sector with a follow-up period of 6 months to 4 years [25, 26]
Summary
Despite rapid scale up of antiretroviral therapy (ART), Tuberculosis (TB) remains the commonest opportunistic infection and cause of death among HIV infected individuals in resource limited settings like India. Incidence of TB in individuals on ART in private healthcare sector in India is infrequently studied. There are more than a million cases of TB each year which escape surveillance and are not notified to public health authorities in India. Majority of these individuals seek care in the private healthcare sector where they are not properly diagnosed and treated [2, 3]. 5% of the incident TB cases in India have co-morbidity with HIV [2, 3]. An estimated 87,000 HIV associated TB cases were reported in India in 2016 and 12,000 patients died among them [2, 3]
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