Abstract
ObjectivesTo explore changes over time in the epidemiology of tuberculosis (TB) in Denmark in people living with human immunodeficiency virus (HIV) (PLWH). MethodsIn this nationwide, population-based cohort study we included all adult PLWH from the Danish HIV Cohort Study (1995–2017) without previous TB. We estimated TB incidence rate (IR), all-cause mortality rate (MR), associated risk and prognostic factors using Poisson regression. ResultsAmong 6982 PLWH (73 596 person-years (PY)), we observed 217 TB events (IR 2.9/1000 PY, 95% CI 2.6–3.4: IR 6.7, 95% CI 5.7–7.9 among migrants and IR 1.4, 95% CI 1.1–1.7 among Danish-born individuals; p < 0.001). The IR of concomitant HIV/TB remained high and unchanged over time. The IR of TB diagnosed >3 months after HIV diagnosis declined with calendar time, longer time from HIV diagnosis, and CD4 cell recovery. Independent TB risk factors were African/Asian/Greenland origin (adjusted incidence rate ratio (aIRR) 5.2, 95% CI 3.5–7.6, aIRR 6.5, 95% CI 4.2–10.0, aIRR 7.0, 95% CI 3.4–14.6, respectively), illicit drug use (aIRR 6.9, 95% CI 4.2–11.2), CD4 <200 cells/μL (aIRR 2.7, 95% CI 2.0–3.6) and not receiving antiretroviral therapy (aIRR 3.7, 95% CI 2.5–5.3). Fifty-five patients died (MR 27.9/1000 PY, 95% CI 21.4–36.3), with no improvement in mortality over time. Mortality prognostic factors were Danish-origin (adjusted mortality rate ratio (aMRR) 2.3, 95% CI 1.3–4.3), social burden (aMRR 3.9, 95% CI 2.2–7.0), CD4 <100 cells/μL at TB diagnosis (aMRR 2.6, 95% CI 1.3–4.9), TB diagnosed >3 months after HIV versus concomitant diagnosis (aMRR 4.3, 95% CI 2.2–8.7) and disseminated TB (aMRR 3.3, 95% CI 1.1–9.9). ConclusionLate HIV presentation with concomitant TB remains a challenge. Declining TB rates in PLWH were observed over time and with CD4 recovery, highlighting the importance of early and successful antiretroviral therapy. However, MR remained high. Our findings highlight the importance of HIV and TB screening strategies and treatment of latent TB in high-risk groups.
Highlights
The use of antiretroviral therapy (ART) has sharply reduced the incidence of tuberculosis (TB) in people living with human immunodeficiency virus (HIV) (PLWH)
From the Danish HIV Cohort Study (DHCS), we identified 6982 PLWH followed for HIV care during 1995e2017, giving rise to 73 596 PY (median follow-up time 9.6 years; interquartile range (IQR) 3.8e16.9 years)
In the group of patients co-infected with TB and HIV, there were fewer males compared with mono-infected individuals (58.5% versus 75.9%), and a higher percentage of heterosexuals (58.5% versus 34.9%) and non-European individuals (57.6% versus 20.4%, mainly from Africa (39.2%) and Asia (16.1%))
Summary
The use of antiretroviral therapy (ART) has sharply reduced the incidence of tuberculosis (TB) in people living with human immunodeficiency virus (HIV) (PLWH). Identifying risk factors for TB development, treatment failure and death in PLWH is pivotal to achieve the goals of the End TB Strategy [3]. Previous studies have identified immigration from high-burden TB countries and HIV-related immunosuppression as risk factors for development of active TB in low-incidence countries [2,4]. Improved ART coverage and changing migration dynamics over the last decade may have influenced TB epidemiology in countries with a low TB incidence. We conducted a Danish nationwide cohort study from 1995 to 2017 among PLWH to estimate the incidence rate (IR) of TB, the associated mortality rates (MR) and the associated predictive and prognostic factors
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