794
Prevalence, Incidence, and Outcomes of Tuberculosis Treatment in HIV+ Individuals Initiating Home-based ART in Rural Uganda
David Moore*1,2, P Ekwaru1, C Liechty1,3, W Were1, G Mwima1, P Solberg1,4, and J Mermin1
1Global AIDS Prgm, CDC, Entebbe, Uganda; 2BC Ctr for Excellence in HIV/AIDS, Vancouver, Canada; 3Glen Cove Internal Med, Rockport, ME, US; and 4Dartmouth Univ Sch of Med, NH, US
Background: Tuberculosis (TB) is the leading cause of
death for HIV+ individuals in sub-Saharan Africa.
Expanding access to ART may reduce the burden of TB, but to what extent is
unknown.
Methods: We conducted a nested cohort analysis of adults
who initiated ART in a clinical trial designed to compare the effectiveness of 3
ART-monitoring strategies in rural Uganda. At baseline subjects were screened
for active TB by history, clinical examination, sputum examination for
acid-fast bacilli (AFB), and chest X-rays. Those diagnosed were provided with
home-based TB treatment. All participants received ART drug delivery and
monitoring through weekly home visits by field officers. Subjects with chronic
cough or other potential symptoms of TB were offered sputum AFB screening and advised
to visit clinic physicians for assessment. Those subjects with TB at baseline
were compared to those without TB by logistic regression analysis. Cox
proportional hazards modeling was used to examine associations between baseline
variables and TB incidence; and to examine factors associated with mortality in
TB patients.
Results: A total of 75 subjects (7.2%) of 1044
ART-eligible subjects were receiving TB treatment or diagnosed with TB at
baseline. Having TB was associated with having a body mass index of <18 (AOR
= 4.95; 95%CI 2.95 to 8.31), and a past history of TB treatment (AOR = 3.09;
95%CI 1.85 to 5.15). A further 53 subjects were diagnosed with TB in a median
of 1.4 years of follow-up (incidence density 3.6/100 person-years). TB
incidence was associated with a low body mass index at baseline (relative
hazard (RH) = 2.76; 95%CI 1.57 to 4.84) and marginally associated with a prior
history of TB treatment (RH = 1.70; p
= 0.08). Cumulative mortality for those with TB at baseline or follow-up was
17.9/100 person-years, compared to 3.8/100 person-years for those without TB.
Mortality in those diagnosed with TB was associated with low body mass index
(RH = 4.39; 95%CI 1.40 to 13.8) but was not associated with a TB diagnosis
within the first 3 months of ART. Previous TB treatment was associated with a
reduced risk of mortality (RH = 0.34; 95%CI 0.12 to 0.94).
Conclusions: TB incidence and TB-associated mortality
remain high in HIV+ patients in Uganda even after initiating ART. Immune
reconstitution syndrome does not appear to be an important cause of this excess
mortality.
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