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Risk of tuberculosis following HIV seroconversion in low-burden tuberculosis countries

Risk of tuberculosis following HIV seroconversion in low-burden tuberculosis countries

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Risk of tuberculosis following HIV seroconversion in low-burden tuberculosis countries

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  1. Risk of tuberculosis following HIV seroconversion in low-burden tuberculosis countries Sara Lodi, Antonella d’Arminio Monforte, Julia del Amo, Sophie Abgrall, Caroline Sabin, Charles Morrison, Hansjakob Furrer, Roberto Muga, Kholoud Porter, Enrico Girardi on behalf of the CASCADE collaboration in EuroCoord

  2. Objectives and methods Knowledge of clinical epidemiology of TB risk at all stages of HIV infection is needed to inform on time for TB preventive interventions in low-burden TB countries We used CASCADE data from patients with well known date of HIV seroconversion in low-burden TB countries to: • Estimate TB incidence rates following HIV seroconversion in the pre-cART era • Establish if TB risk after cART differs from post-seroconversion risk • Explore role of immunosuppression on the risk of TB following cART initiation

  3. N TB 24 29 18 38 33 28 25 16 7 9 5 PY 4075 5803 5611 4993 4221 3415 2618 1923 1311 852 509 Risk of TB in pre-cART era 24 • 9175individuals at risk of TB • 243 TB diagnoses at a median CD4 cell count of 125 cells/mm3 • 50% MSM, 26% IDU 22 20 18 16 14 12 Incidence rate/1000 PY 10 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 Years following seroconversion

  4. 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 Risk of TB after cART initiation 16 • 11178individuals at risk of TB • 120 TB diagnoses at a median CD4 cell count of 195 cells/mm3 TB rate in general population: 0.05-0.2/1000 PY (WHO 2009) 15 14 13 12 11 10 9 Incidence rate/1000 PY 8 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 Years following cART initiation N 8 13 21 10 8 3 10 4 4 16 9 5 8 PY 4309 2652 7751 6733 5794 4923 4087 3275 2462 2577 2495 2427 4309

  5. Predictors of TB after cART IRR 95 % CI P Risk group 0.001 Sex between men 1 Sex between men and women 1.62 0.80 3.28 Injecting drug users 3.76 1.95 7.24 Other/unknown 1.07 0.25 4.67 Country of origin 0.054 Low-burden TB country 1 Mid-burden TB country 2.45 0.86 6.96 Sub-saharan Africa 1.81 0.65 5.07 Unknown 0.42 0.17 1.07 Age at cART initiation (10-year increase) 1.03 1.00 1.07 0.071 Current CD4 count <0.001 >=500 1 350-499 1.60 0.71 3.62 200-349 1.94 0.85 4.40 <200 8.76 4.44 17.25 Duration of cART> 1 year 0.87 0.51 1.47 0.590 HIV RNA at cART (1 log increase) 1.16 1.03 1.30 0.012 IRR IRR 95 % CI 95 % CI P P Risk group Risk group 0.001 0.001 Sex between men 1 1 Sex between men and women 1.62 1.62 0.80 0.80 3.28 3.28 Injecting drug users 3.76 3.76 1.95 1.95 7.24 7.24 1.07 1.07 0.25 0.25 4.67 4.67 Other/unknown Country of origin Country of origin 0.054 0.054 - burden TB country 1 1 Low Mid- burden TB country 2.45 2.45 0.86 0.86 6.96 6.96 1.81 1.81 0.65 0.65 5.07 5.07 Sub-Saharan Africa Unknown 0.42 0.42 0.17 0.17 1.07 1.07 Age at cART initiation (10 Age at cART initiation (10 - - year increase) year increase) 1.03 1.03 1.00 1.00 1.07 1.07 0.071 0.071 Current CD4 count Current CD4 count <0.001 <0.001 ≥500 1 1 350-499 1.60 1.60 0.71 0.71 3.62 3.62 200-349 1.94 1.94 0.85 0.85 4.40 4.40 <200 8.76 8.76 4.44 4.44 17.25 17.25 Duration of cART> 1 year Duration of cART> 1 year 0.87 0.87 0.51 0.51 1.47 1.47 0.590 0.590 HIV RNA at cART (1 log increase) HIV RNA at cART (1 log increase) 1.16 1.16 1.03 1.03 1.30 1.30 0.012 0.012

  6. Implications • Risk of TB increases with time since HIV seroconversion. Prevention should be implemented in early HIV infection. • Both post-seroconversion and post-cART TB rates are higher than those recorded in general population (WHO 2009). HIV infected patients are still at high risk of TB. • Current CD4 cell level is the dominant predictor of TB risk after cART initiation. TB prevention would be improved by antiretroviral treatment policies that minimise the time patients spend with low CD4 count.

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