Incidence of Tuberculosis After Initiation of Highly Active Antiretroviral Therapy in Georgia; Survival Rate and Risk Factors of Mortality Among HIV-infected Patients with and without Antiretroviral Therapy Pubblico

Abstract

Background : There is a lack of data on the impact of antiretroviral therapy (ART) on the
incidence of Tuberculosis (TB) and survival of HIV/ TB co-infected patients in high TB burden
countries of Eastern Europe. The study objective was to determine TB incidence rate among
HIV-infected individuals receiving ART and to estimate the independent association between
ART use and mortality among HIV-infected individuals in Georgia in years 2008-2009.
Methods : Retrospective cohort study among all HIV-infected patients entering clinical care at
National AIDS Center, Tbilisi, Georgia between 01/2008-06/2009. Factors associated with
mortality including ART use were assessed utilizing a logistic regression and Cox proportional
hazards model.
Results : Of 410 HIV-infected patients, 110 (26.8%) had TB at initial presentation and 49 (11.9%)
had a prior history of TB. CD4 count at time of HIV diagnosis among the 410 HIV-infected
patients was less than 200 cells/mm3 in 180 (45.9%). The mean baseline CD4 count was lower in
HIV/TB co-infected patients compared with HIV-infected patients without TB (156.9 cells/mm3
vs. 339.9 cells/mm3, P<0.0001).
During a total of 776.6 person-years of observation, 4 new cases of TB were diagnosed. The
overall TB incidence rate was 5.15/1000 person-years (95% CI=1.64-12.42). The overall
mortality rate among HIV/TB co-infected patients was 27.9% in the ART+ group (n=93) and
82.3% in the ART- group (n=17).
HIV/TB co-infected patients who initiated ART after 2 months of TB diagnosis were 2.6 times as
likely to die compared to those who initiated ART within 2 months after TB diagnosis (HR: 2.64,
CI=1.03-6.75, P= 0.0425). Survival rates at 1, 2 and 3 years after TB diagnosis were
approximately 77%, 75% and 75% in ART+ group, compared to 15%, 0% and 0% in ART- group
(long-rank test, p<0.0001). In multivariable analysis "not receiving ART" was associated with a
higher probability of death (HR= 7.71, CI=3.36-17.68);
Conclusion: TB is the presenting opportunistic infection in over a quarter of HIV-infected
patients in Georgia. Recently published randomized trials suggest that starting ART during TB
treatment is associated with significantly increased survival. Implementation of ART during TB
treatment is critical to improve outcomes for HIV/TB co-infected patients.

Table of Contents

Table of Contents

Page
Abstract .......... iv
Table of Contents .......vii
Abbreviations..........x
Chapter I Introduction.....1
International Situation in HIV and TB co-infection.1
Addressing the co-epidemics of TB and HIV...3
Global burden of Tuberculosis...........4
Global burden of HIV/AIDS............5
TB Epidemiology in Georgia...........7
The status of HIV/AIDS Epidemic in Georgia....8
The Policy and Programmatic Response .....10
Rationale ...................12
The specific aims of the study..........12
Chapter II Review of the Literature ...13
Impact of HIV on TB manifestation........14
Screening and Diagnosis of TB in HIV-Infected Patients..15
Complexity of treatment of TB and HIV/AIDS co-infection ...16
Effect of Highly Active Antiretroviral Treatment (HAART) on tuberculosis epidemiology.....17
TB incidence and recurrence in HIV-infected individuals ...19
The timing for the initiation of antiretroviral therapy in HIV-infected patients with TB ..20
Chapter III Methods .........26
Study Population ................26
Data abstraction.................26
Ethical consideration ...............27
Description of ART program in Georgia ........27
Laboratory Assays .................29
Definitions ...................29
Definitions of TB....................30
Definition of prior, prevalent and incident TB......31
Definitions of treatment outcomes (WHO) .....32
Statistical Analysis.................33
Chapter IV Results ..........35
Socio-demographic and Clinical characteristics of

HIV-infected patients...................................................................35
Association between Socio-demographic and clinical

characteristics and ART use among HIV-infected patients ........37
Association between Socio-demographic and clinical

characteristics and mortality among HIV-infected patients ... 37
Multivariable Analysis (Logistic and Cox proportional

hazard regression Analysis) for entire cohort ... 39

Baseline Socio-demographic and clinical characteristics of HIV/TB co-infected patients............40

Association between Socio-demographic and clinical

characteristics and ART use among HIV/TB co-infected patients .. .41

Association between Socio-demographic and clinical characteristics and mortality among HIV/TB co-infected patients ...41

Multivariable Analysis (Logistic and Cox proportional hazard

regression Analysis) for HIV/TB co-infected cohort ....42

Chapter V Discussion ........44

References .............50

Tables and Figures .........54

Appendix .............79

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Parola chiave	HIV/TB co-infection
Committee Chair / Thesis Advisor	Del Rio, Carlos, Emory University
Partnering Agencies	Does not apply (no collaborating organization)

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