Abstract
BackgroundSouth Africa remains the country with the greatest burden of HIV-infected individuals and the second highest estimated TB incidence per capita worldwide. Within South Africa, KwaZulu-Natal has one of the highest rates of TB incidence and an emerging epidemic of drug-resistant tuberculosis.MethodsReview of records of consecutive HIV-infected people initiated onto ART between 1st January 2005 and 31st March 2006. Patients were screened for TB at initiation and incident episodes recorded. CD4 counts, viral loads and follow-up status were recorded; data was censored on 5th August 2008. Geographic cluster analysis was performed using spatial scanning.Results801 patients were initiated. TB prevalence was 25.3%, associated with lower CD4 (AHR 2.61 p = 0.01 for CD4 <50 cells/μl) and prior TB (AHR 1.58 p = 0.02). Incidence was 6.89 per 100 person-years from 81 cases over 1175 person-years analysis time and was highest in the first 3 months after ART initiation; associated with male sex and higher log HIV RNA. Prevalent and incident TB were significantly associated with mortality (OR 1.81 p = 0.01 and 2.02 p = 0.01 respectively). Incident TB was associated with a non-significant trend towards viral load >25 copies/ml (OR 1.75 p = 0.11). A low-risk cluster for incident TB was identified for patients living near the local hospital in the geospatial analysis.ConclusionThere is a large burden of TB in this population. Rate of incident TB stabilises at a rate higher than that of the overall population. These data highlight the need for greater research on strategies for active case finding in rural settings and the need to focus on strengthening primary health care.
Highlights
South Africa remains the country with the greatest burden of HIV positive individuals [1] and the second highest estimated TB incidence per capita worldwide [2]
Transfers from GP or non-governmental programmes (n = 8) were included for TB prevalence analysis but removed before incidence and survival analysis because of unknown previous ART regimens
The extremely high TB prevalence in our study demonstrate that South Africa’s dual HIV and TB challenge is not confined to urban settings; this rural cohort had a TB prevalence of 25.3%, similar to urban South Africa [8,17] and higher than figures reported elsewhere in sub-Saharan Africa [7,18,19]
Summary
South Africa remains the country with the greatest burden of HIV-infected individuals and the second highest estimated TB incidence per capita worldwide. Within South Africa, KwaZulu-Natal has one of the highest rates of TB incidence and an emerging epidemic of drug-resistant tuberculosis. South Africa remains the country with the greatest burden of HIV positive individuals [1] and the second highest estimated TB incidence per capita worldwide [2]. Within South Africa, the province of KwaZulu-Natal has the greatest number of HIV positive individuals (an estimated 1.2 million people), with a sustained high incidence of new adult HIV infections [3]. We further used novel geospatial clustering analysis to define areas where incident TB rates are higher or lower than might be expected; such areas could be used for targeted behavioural analysis, to aid our understanding of the TB epidemic in HIV infected individuals, and measure the impact of interventions to curb it
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