Abstract
ObjectivesPeople living with HIV/AIDS (PLWHA) who develop tuberculosis disease are at greater mortality-risk. This study aimed to assess tuberculosis disease incidence among all PLWHA in Israel and identify populations at high-risk for developing tuberculosis.Design and MethodsRetrospective cohort-study based on the National HIV and Tuberculosis Registries, which were cross-matched and followed for the last 28-years. PLWHA who developed tuberculosis were compared to those who did not by the Cox-proportional analysis to generate hazard-ratios, and survival-analysis was performed by Log-Rank test.ResultsOf all the 6579 PLWHA reported between 1983 and 2010, corresponding to 55737 person-years, 384 (5.8%) developed tuberculosis. Of those, 14 were Israeli-born and 370 were non-Israeli born. The overall tuberculosis incidence-density was 6.9 cases/1000 person-years (95% CI 1.8–12.0). The cumulative tuberculosis-incidence among PLWHA in 2010 was 586 times higher than in HIV-negative individuals (3400 and 5.8 cases per 100000 population, respectively). Higher hazard-ratios to developing tuberculosis were found in migrant citizens PLWHA who were males, non-Israeli born, those who were diagnosed with HIV/AIDS after 1997, those who originated in high-tuberculosis prevalence country and those who acquired HIV by heterosexual or drug-injection transmission. PLWHA who developed tuberculosis had higher odds of dying than other PLWHA (36.5% and 16.6%, respectively, p<0.001, odds ratio = 2.8, 95% confidence-interval 2.3–3.6). In survival-analysis, time to develop tuberculosis was shorter among males than females, in PLWHA who were reported with HIV after 1997, in heterosexual who originated in high-tuberculosis countries, followed by injecting drug-users, heterosexual from low-tuberculosis burden countries and men who have sex with men.ConclusionTuberculosis-incidence is higher among non-Israeli born PLWHA, with decreasing trends from 1991. Despite the moderate TB-rate disease among PLWHA, it remains an important cause for severe morbidity and mortality. Tuberculosis in PLWHA reflects mainly the tuberculosis-burden in the originating country and possibly also the mode of HIV-transmission.
Highlights
Entering the fourth decade of the AIDS epidemic, it is estimated that there are 33.3 million individuals who are infected with HIV, mostly in low and middle income countries [1,2]
Higher hazard-ratios to developing tuberculosis were found in migrant citizens People living with HIV/AIDS (PLWHA) who were males, non-Israeli born, those who were diagnosed with HIV/AIDS after 1997, those who originated in high-tuberculosis prevalence country and those who acquired HIV by heterosexual or drug-injection transmission
In survival-analysis, time to develop tuberculosis was shorter among males than females, in PLWHA who were reported with HIV after 1997, in heterosexual who originated in high-tuberculosis countries, followed by injecting drug-users, heterosexual from low-tuberculosis burden countries and men who have sex with men
Summary
Entering the fourth decade of the AIDS epidemic, it is estimated that there are 33.3 million individuals who are infected with HIV, mostly in low and middle income countries [1,2]. For the year 2010, it was estimated that 1.1 million individuals infected with HIV were diagnosed with tuberculosis (TB) disease [1,4]. The risk of developing active TB among all individuals who have latent TB infection is estimated to be 21–34 times higher in individuals who are co-infected with HIV than among those without HIV infection [1]. People who are infected with HIV who have active TB are more likely to have negative sputum smears results than others, and up to one-third may demonstrate unremarkable chestradiographs [1], and their diagnosis may be delayed. TB disease in people infected with HIV is more likely to be extra-pulmonary than among HIV-negative individuals, evading traditional respiratory-based diagnostic tests, such as chest X-ray and sputum for smear and culture [5,6]
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