Abstract
BackgroundThe occurrence of tuberculosis (TB), human immunodeficiency virus (HIV), and viral hepatitis infections in the same patient poses unique clinical and public health challenges, because medications to treat TB and HIV are hepatotoxic. We conducted an observational study to evaluate risk factors for HBsAg and/or anti-HCV reactivity and to assess differences in adverse events and TB treatment outcomes among HIV-infected TB patients.MethodsPatients were evaluated at the beginning, during, and at the end of TB treatment. Blood samples were tested for aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (BR), complete blood count, and CD4+ T lymphocyte cell count. TB treatment outcomes were assessed at the end of TB treatment according to international guidelines.ResultsOf 769 enrolled patients, 752 (98%) had serologic testing performed for viral hepatitis: 70 (9%) were reactive for HBsAg, 237 (31%) for anti-HCV, and 472 (63%) non-reactive for both markers. At the beginning of TB treatment, 18 (26%) patients with HBsAg reactivity had elevated liver function tests compared with 69 (15%) patients non-reactive to any viral marker (p = 0.02). At the end of TB treatment, 493 (64%) were successfully treated. Factors independently associated with HBsAg reactivity included being a man who had sex with men (adjusted odds ratio [AOR], 2.1; 95% confidence interval [CI], 1.1–4.3) and having low TB knowledge (AOR, 1.8; CI, 1.0–3.0). Factors most strongly associated with anti-HCV reactivity were having injection drug use history (AOR, 12.8; CI, 7.0–23.2) and living in Bangkok (AOR, 15.8; CI, 9.4–26.5). The rate of clinical hepatitis and death during TB treatment was similar in patients HBsAg reactive, anti-HCV reactive, both HBsAg and anti-HCV reactive, and non-reactive to any viral marker.ConclusionAmong HIV-infected TB patients living in Thailand, markers of viral hepatitis infection, particularly hepatitis C virus infection, were common and strongly associated with known behavioral risk factors. Viral hepatitis infection markers were not strongly associated with death or the development of clinical hepatitis during TB treatment.
Highlights
The occurrence of tuberculosis (TB), human immunodeficiency virus (HIV), and viral hepatitis infections in the same patient poses unique clinical and public health challenges, because medications to treat TB and HIV are hepatotoxic
When prescribed anti-retroviral therapy, HIV-infected patients usually receive stavudine, lamivudine, and nevirapine; in patients with TB, efavirenz is recommended as a substitute for nevirapine
Risk factors for hepatitis B surface antigen (HBsAg) and/or anti-HCV reactivity Factors independently associated with HBsAg reactivity included being a man who had sex with men and having low TB knowledge (AOR, 1.8; 95% CI, 1.0–3.0; Table 2.1)
Summary
The occurrence of tuberculosis (TB), human immunodeficiency virus (HIV), and viral hepatitis infections in the same patient poses unique clinical and public health challenges, because medications to treat TB and HIV are hepatotoxic. While most of these cases can safely and effectively be treated, complications can occur during TB treatment, because of anti-TB drug resistance, poor adherence, drug-drug interactions, and toxicity.[1] Liver toxicity is a common side effect that is strongly associated with three of the four anti-TB drugs included in the most widely accepted regimen.[2,3] The burden of TB continues to rise in some regions of the world, because of the human immunodeficiency virus (HIV) epidemic This TB/HIV syndemic has increased the clinical complexity of managing patients. Medications used to prevent opportunistic infections or treat HIV are often hepatotoxic, and opportunistic infections may involve the liver. [4,5,6]
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