Abstract
In HIV hyperendemic sub-Saharan African communities, particularly in southern Africa, the likelihood of achieving the Sustainable Development Goal of ending the tuberculosis (TB) epidemic by 2030 is low, due to lack of cost-effective and practical interventions in population settings. We used one of Africa’s largest population-based prospective cohorts from rural KwaZulu-Natal Province, South Africa, to measure the spatial variations in the prevalence of recently-diagnosed TB disease, and to quantify the impact of community coverage of antiretroviral therapy (ART) on recently-diagnosed TB disease. We collected data on TB disease episodes from a population-based sample of 41,812 adult individuals between 2009 and 2015. Spatial clusters (‘hotspots’) of recently-diagnosed TB were identified using a space-time scan statistic. Multilevel logistic regression models were fitted to investigate the relationship between community ART coverage and recently-diagnosed TB. Spatial clusters of recently-diagnosed TB were identified in a region characterized by a high prevalence of HIV and population movement. Every percentage increase in ART coverage was associated with a 2% decrease in the odds of recently-diagnosed TB (aOR = 0.98, 95% CI:0.97–0.99). We identified for the first time the clear occurrence of recently-diagnosed TB hotspots, and quantified potential benefit of increased community ART coverage in lowering tuberculosis, highlighting the need to prioritize the expansion of such effective population interventions targeting high-risk areas.
Highlights
Tuberculosis (TB) is the leading cause of death from infectious disease in the world[1], with epidemics being spatially heterogeneous, as indicated by evidence of geographic clustering at different resolution levels[2,3]
In this analysis of data from a well-characterized rural South African population with high HIV prevalence and TB incidence, we have demonstrated considerable spatial heterogeneity in people with recently-diagnosed TB, and have shown that every percentage increase in antiretroviral therapy (ART) coverage was associated with a 2% decrease in the odds of recently-diagnosed TB
This study was conducted in a population with an extremely high TB case notification rate, where the epidemic is fueled by the high prevalence of HIV
Summary
Tuberculosis (TB) is the leading cause of death from infectious disease in the world[1], with epidemics being spatially heterogeneous, as indicated by evidence of geographic clustering at different resolution levels[2,3]. National-level analyses in Kenya, Malawi, South Africa and Zimbabwe have demonstrated reductions in TB notifications coincident with increasing ART coverage[14,15,16,17,18,19,20] These findings have been consolidated in a recent systematic review, which reported consistent declines in TB notification rates in most SSA countries between 2010 and 201521. While this can be partially attributed to differences in TB detection rates, there is a need to better understand the factors that influence the spatial heterogenity of TB This understanding and the population-level associations between HIV, ART coverage and TB, might provide important insight that could guide precision public health approaches to ending TB in high HIV prevalence communities. We use data from one of the world’s largest longitudinal population health surveillance systems to characterize the spatial distribution of TB in a high HIV prevalence rural South African community and quantify the impact of community ART coverage scale-up on recently-diagnosed TB disease
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