HIV and Tuberculosis in Atlanta, GA: Antiretroviral Therapy Uptake and Factors Associated with Unfavorable Outcomes Open Access

Bizune, Destani J. (2017)

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HIV and Tuberculosis in Atlanta, GA: Antiretroviral Therapy Uptake and Factors Associated with Unfavorable Outcomes

By Destani J. Bizune

Background: We investigated antiretroviral therapy (ART) uptake and the association of HIV and unfavorable treatment outcomes among patients with culture-confirmed tuberculosis at Grady Memorial Hospital (GMH), a safety net hospital in Atlanta, GA.

Methods: Retrospective cohort study of patients with culture-confirmed TB admitted to GMH from 2008-15. We compared baseline characteristics between HIV-positive and negative patients. Factors associated with unfavorable outcomes during TB treatment were analyzed using multivariate logistic regression.

Results: Among 271 patients, 95 (35%) were HIV-positive; 23 (24%) of whom were newly diagnosed at the time of TB diagnosis. The 72 patients with known HIV were diagnosed a median of 6 years prior to developing TB, and only 11 (15%) were receiving ART at presentation. Most HIV patients (67%) had a baseline CD4 count ≤ 200 cells/mm3. Fifty-six (67%) of eligible HIV-infected patients were started on ART after TB diagnosis and median days from TB treatment to ART initiation was 81 days (IQR 34 - 118). Most patients were male (75%), black (81%), and median age was 47 years. Almost half the patients (44%) had a history of homelessness. Patients with HIV were more likely to have disseminated disease and complications during treatment, including a higher rate of isoniazid resistance, extrapulmonary involvement, adverse side effects, and hospital readmissions. Overall, 36 (14%) patients died during TB treatment, 17 (47%) of whom were HIV-positive. While the death rate was higher in HIV (19%) vs. non-HIV (11%) TB patients, the difference was non-significant (p = 0.26). In multivariate analysis, disseminated and CNS disease were associated with unfavorable outcome while HIV was not (aOR 1.31, 95% CI 0.63 - 2.74, p = 0.47).

Conclusions: The majority of patients with TB/HIV co-infection in this cohort had known HIV infection before TB diagnosis and were not receiving ART. Additionally, a substantial proportion of co-infected patients did not start ART within a recommended time period. There was no significant association with HIV infection and mortality, but HIV-infected patients had more complications during treatment and higher rates of disseminated disease. Interventions to increase linkage to HIV care are needed and could contribute to TB control in Atlanta.

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Figure 1: Study Population diagram

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Figure 2:

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Figure 3: Survival Probability Plot

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Table 1: Baseline characteristics by HIV status

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Table 2: HIV descriptive statistics

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Table 3: Outcomes

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Table 4: Bivariate analysis for culture conversion

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Table 5: Univariate and multivariate analysis

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Table 6 - Univariate associations with unfavorable outcome

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Table 7 - Multivariate associations with unfavorable outcome

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Supplemental Table 1: Alternative model

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