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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Factors Associated With Tuberculosis as an AIDS-Defining Disease in an Immigration Setting</title><author><name sortKey="Martin, Vicente" sort="Martin, Vicente" uniqKey="Martin V" first="Vicente" last="Martín">Vicente Martín</name><affiliation><nlm:aff id="aff01">IBIOMED. Área de Medicina Preventiva y Salud Pública. Universidad de León. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Garcia De Olalla, Patricia" sort="Garcia De Olalla, Patricia" uniqKey="Garcia De Olalla P" first="Patricia" last="García De Olalla">Patricia García De Olalla</name><affiliation><nlm:aff id="aff02">Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Orcau, Angels" sort="Orcau, Angels" uniqKey="Orcau A" first="Angels" last="Orcau">Angels Orcau</name><affiliation><nlm:aff id="aff02">Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Cayla, Joan A" sort="Cayla, Joan A" uniqKey="Cayla J" first="Joan A" last="Caylà">Joan A. Caylà</name><affiliation><nlm:aff id="aff02">Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">21325728</idno><idno type="pmc">3899502</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899502</idno><idno type="RBID">PMC:3899502</idno><idno type="doi">10.2188/jea.JE20100072</idno><date when="2011">2011</date><idno type="wicri:Area/Pmc/Corpus">002625</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002625</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Factors Associated With Tuberculosis as an AIDS-Defining Disease in an Immigration Setting</title><author><name sortKey="Martin, Vicente" sort="Martin, Vicente" uniqKey="Martin V" first="Vicente" last="Martín">Vicente Martín</name><affiliation><nlm:aff id="aff01">IBIOMED. Área de Medicina Preventiva y Salud Pública. Universidad de León. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Garcia De Olalla, Patricia" sort="Garcia De Olalla, Patricia" uniqKey="Garcia De Olalla P" first="Patricia" last="García De Olalla">Patricia García De Olalla</name><affiliation><nlm:aff id="aff02">Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Orcau, Angels" sort="Orcau, Angels" uniqKey="Orcau A" first="Angels" last="Orcau">Angels Orcau</name><affiliation><nlm:aff id="aff02">Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Cayla, Joan A" sort="Cayla, Joan A" uniqKey="Cayla J" first="Joan A" last="Caylà">Joan A. Caylà</name><affiliation><nlm:aff id="aff02">Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Epidemiology</title><idno type="ISSN">0917-5040</idno><idno type="eISSN">1349-9092</idno><imprint><date when="2011">2011</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Immigration can affect the evolution of TB as an AIDS-defining disease (AIDS–TB).</p></sec><sec><title>Methods</title><p>The Barcelona AIDS register for 1994–2005 was analyzed, and the global characteristics of AIDS–TB and AIDS–non-TB cases were compared. The Mantel-Haenszel test was used in the trend analysis, and logistic regression was used in the multivariate analysis.</p></sec><sec><title>Results</title><p>Of the 3600 cases studied, 1130 had both AIDS and TB. A declining trend in AIDS–TB rates was observed in both sexes among both immigrants and native residents. The percentage of AIDS–TB was significantly higher among immigrants (<italic>P</italic> = 0.02). The number of cases among immigrants remained constant over the period of study, but decreased among native residents. The sociodemographic and immunological characteristics associated with TB were male sex, age younger than 36 years, inner city residence, a record of incarceration, greater than 200 CD4+ T-cells/mm<sup>3</sup>, injecting drug use, heterosexual sex, and immigration from Latin America, the Caribbean, or sub-Saharan Africa.</p></sec><sec><title>Conclusions</title><p>The incidence of TB as an AIDS-defining disease decreased in Barcelona during a recent 10-year period in both native and immigrant populations. However, immigrants remain a high-risk group for AIDS–TB and should be targeted for surveillance and control of both diseases.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Epidemiol</journal-id><journal-id journal-id-type="iso-abbrev">J Epidemiol</journal-id><journal-id journal-id-type="publisher-id">JE</journal-id><journal-title-group><journal-title>Journal of Epidemiology</journal-title></journal-title-group><issn pub-type="ppub">0917-5040</issn><issn pub-type="epub">1349-9092</issn><publisher><publisher-name>Japan Epidemiological Association</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">21325728</article-id><article-id pub-id-type="pmc">3899502</article-id><article-id pub-id-type="doi">10.2188/jea.JE20100072</article-id><article-id pub-id-type="publisher-id">JE20100072</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group><subj-group subj-group-type="mainclass"><subject>Infectious Disease</subject></subj-group></article-categories><title-group><article-title>Factors Associated With Tuberculosis as an AIDS-Defining Disease in an Immigration Setting</article-title><alt-title alt-title-type="verso-running-head">Tuberculosis, AIDS, and Immigration</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Martín</surname><given-names>Vicente</given-names></name><xref ref-type="aff" rid="aff01"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>García de Olalla</surname><given-names>Patricia</given-names></name><xref ref-type="aff" rid="aff02"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Orcau</surname><given-names>Angels</given-names></name><xref ref-type="aff" rid="aff02"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Caylà</surname><given-names>Joan A</given-names></name><xref ref-type="aff" rid="aff02"><sup>2</sup></xref></contrib><on-behalf-of>for the Barcelona AIDS and Tuberculosis Working Group</on-behalf-of><aff id="aff01"><label>1</label>IBIOMED. Área de Medicina Preventiva y Salud Pública. Universidad de León. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></aff><aff id="aff02"><label>2</label>Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. CIBER Epidemiología y Salud Pública (CIBERESP),<addr-line>Spain</addr-line></aff></contrib-group><author-notes><corresp id="fn01">Address for correspondence. Joan A. Caylà, Servicio de Epidemiología. Agencia de Salud Pública de Barcelona. Plaza Lesseps 1, 08023 Barcelona (e-mail: <email>jcayla@aspb.es</email>).</corresp></author-notes><pub-date pub-type="epub"><day>5</day><month>3</month><year>2011</year></pub-date><pub-date pub-type="epreprint"><day>12</day><month>2</month><year>2011</year></pub-date><pub-date pub-type="collection"><year>2011</year></pub-date><volume>21</volume><issue>2</issue><fpage>108</fpage><lpage>113</lpage><history><date date-type="received"><day>10</day><month>5</month><year>2010</year></date><date date-type="accepted"><day>9</day><month>11</month><year>2010</year></date></history><permissions><copyright-statement>© 2011 Japan Epidemiological Association.</copyright-statement><copyright-year>2011</copyright-year><copyright-holder>Japan Epidemiological Association</copyright-holder><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/3.0/"><license-p>This is an open access article distributed under the terms of Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><abstract><sec><title>Background</title><p>Immigration can affect the evolution of TB as an AIDS-defining disease (AIDS–TB).</p></sec><sec><title>Methods</title><p>The Barcelona AIDS register for 1994–2005 was analyzed, and the global characteristics of AIDS–TB and AIDS–non-TB cases were compared. The Mantel-Haenszel test was used in the trend analysis, and logistic regression was used in the multivariate analysis.</p></sec><sec><title>Results</title><p>Of the 3600 cases studied, 1130 had both AIDS and TB. A declining trend in AIDS–TB rates was observed in both sexes among both immigrants and native residents. The percentage of AIDS–TB was significantly higher among immigrants (<italic>P</italic> = 0.02). The number of cases among immigrants remained constant over the period of study, but decreased among native residents. The sociodemographic and immunological characteristics associated with TB were male sex, age younger than 36 years, inner city residence, a record of incarceration, greater than 200 CD4+ T-cells/mm<sup>3</sup>, injecting drug use, heterosexual sex, and immigration from Latin America, the Caribbean, or sub-Saharan Africa.</p></sec><sec><title>Conclusions</title><p>The incidence of TB as an AIDS-defining disease decreased in Barcelona during a recent 10-year period in both native and immigrant populations. However, immigrants remain a high-risk group for AIDS–TB and should be targeted for surveillance and control of both diseases.</p></sec></abstract><kwd-group kwd-group-type="author"><title>Key words: </title><kwd>epidemiology</kwd><kwd>AIDS</kwd><kwd>tuberculosis</kwd><kwd>immigration</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>The human immunodeficiency virus (HIV) is the strongest risk factor for the development of tuberculosis (TB) among individuals infected with <italic>Mycobacterium tuberculosis</italic>.<sup><xref ref-type="bibr" rid="r01">1</xref></sup> The high prevalence of co-infection by these 2 microorganisms in many geographical areas and in specific population groups has made TB the most common AIDS-diagnostic disease in the world.<sup><xref ref-type="bibr" rid="r02">2</xref></sup> For these reasons, the HIV pandemic has modified the epidemiology of TB and necessitated a review of the strategies for TB prevention and control.<sup><xref ref-type="bibr" rid="r03">3</xref></sup> One method for evaluating such strategies is to analyze trends in the incidence of TB as an AIDS-defining disease in AIDS registers.<sup><xref ref-type="bibr" rid="r04">4</xref></sup><sup>–</sup><sup><xref ref-type="bibr" rid="r06">6</xref></sup></p><p>In Spain, TB has been the most common AIDS-defining disease (Centro Nacional de Epidemiología, 2009) since pulmonary tuberculosis was introduced as a diagnostic criterion for AIDS in 1994.<sup><xref ref-type="bibr" rid="r07">7</xref></sup> Antiretroviral therapy (ART) and trends in immigration have influenced the epidemiology of these diseases in a number of countries and regions.<sup><xref ref-type="bibr" rid="r08">8</xref></sup><sup>–</sup><sup><xref ref-type="bibr" rid="r10">10</xref></sup></p><p>The aim of the present study was to examine the factors associated with TB as an AIDS-defining disease in a context where ART is free and universally available and where more than 4 million immigrants have arrived in recent years (Instituto Nacional de Estadística, 2008).</p></sec><sec sec-type="methods"><title>METHODS</title><p>Barcelona, the second largest city in Spain (1 605 602 inhabitants in 2006), is located in the northern part of the east coast of the country. The city AIDS register includes all patients diagnosed with AIDS who were recorded in the Epidemiological Surveillance System, which is an active system for gathering data provided by doctors, hospital discharges, and mortality databases. The register is linked to the registers of TB patients and drug users and thus provides a comprehensive data source.</p><p>In this observational, retrospective study of prevalence, we analyzed AIDS cases among city residents older than 13 years who were included in the register between 1994 and 2005. The variables studied were sex, age at AIDS diagnosis, geographical region of origin (Spain, Latin America, and Caribbean; North America and Western Europe; Middle East and North Africa; Sub-Saharan Africa; Rest of Europe and Central Asia; East and South Asia and Pacific), place of residence (inner city or other), period in prison, route of HIV infection (intravenous drug users [IDUs], male non-IDUs who have sex with males, non-IDU heterosexual males, and females and unknown), AIDS-defining disease (AIDS–TB for tuberculosis and AIDS–non-TB for other),<sup><xref ref-type="bibr" rid="r07">7</xref></sup> CD4 cell count/mL at diagnosis (≥200, <200, unknown), and date of diagnosis, which was grouped into the periods 1994–1996, 1997–2000, and 2001–2005, which corresponded to the most widely used antiretroviral treatments, ie, pre-HAART, HAART with protease inhibitors, and HAART with non-nucleoside reverse transcriptase inhibitors, respectively. The collected data for AIDS–TB cases were then compared with those for AIDS–non-TB cases. Univariate analysis for categorical and continuous variables was conducted using the chi-square test and the <italic>t</italic> test, respectively. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analysis that included variables associated with AIDS–TB cases with a <italic>P</italic>-value less than 0.2, according to a maximized log-likelihood procedure.</p><p>TB rates and 95% CIs for the periods 1994–1998, 1999–2001, 2002–2004, and 2005 were calculated from information provided by the Barcelona City Department of Statistics. The data were obtained from the municipal censuses of, respectively, 1996, 2001, 2004 and 2005 (Ayuntamiento de Barcelona, 2007) and were subdivided by age group, sex, and nationality. Trends were analyzed using the Mantel-Haenszel test for trend.</p><p>All data were systematically collected by the AIDS Registry of Barcelona City and were handled in a strictly confidential manner according to the principles of the Declaration of Helsinki, 1964, reviewed and updated by the World Medical Organisation (Edinburgh, 2000). This study also fulfilled the requirements of law 15/1999 on the protection of data, which stipulates that the approval of an ethics committee is not required for this type of analysis.</p></sec><sec sec-type="results"><title>RESULTS</title><p>A total of 3600 AIDS cases were detected, including 1130 (31.4%) AIDS–TB cases. Localization of TB was exclusively pulmonary in 60.9% of cases (688/1130), exclusively extrapulmonary in 15.0% (169/1130), and mixed in the remaining 24.2% (273/1130). The proportion of cases with smear-positive pulmonary localization was 39.5% (380/961). The time between HIV infection and a diagnosis of AIDS was less than 1 month in 38.4% of native Spaniards and 54.2% of immigrants (<italic>P</italic> < 0.001). Regarding time spent in Spain, 6.2% of immigrants developed AIDS within the 1st year, 46.1% between the 1st and 5th year, 25.9% between the 6th and 10th year, and 21.8% after 10 years. The corresponding distribution was 7.7%, 52.8%, 19.0%, and 20.4% among Latin Americans, and 0%, 52.4%, 21.4%, and 26.2% among sub-Saharans.</p><p>The total number of detected cases of AIDS decreased over time among both AIDS–TB and AIDS–non-TB subjects, mainly due to the marked decrease observed among native Spaniards (Table <xref ref-type="table" rid="tbl01">1</xref>).</p><table-wrap id="tbl01" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Numbers and rates of AIDS cases among residents of Barcelona city by AIDS-defining disease status and place of birth (1994–2005)</title></caption><table frame="hsides" rules="groups"><thead><tr><td rowspan="5" align="center" valign="middle" colspan="1">Year</td><td colspan="6" align="center" valign="middle" rowspan="1">Cases</td><td rowspan="3" colspan="3" align="center" valign="middle">% AIDS–TB</td><td rowspan="3" colspan="3" align="center" valign="middle">AIDS–TB rate per 100 000<break></break>inhabitants</td></tr><tr><td colspan="6" rowspan="1"><hr></hr></td></tr><tr><td colspan="3" align="center" valign="middle" rowspan="1">AIDS–TB</td><td colspan="3" align="center" valign="middle" rowspan="1">AIDS–non-TB</td></tr><tr><td colspan="3" rowspan="1"><hr></hr></td><td colspan="3" rowspan="1"><hr></hr></td><td colspan="3" rowspan="1"><hr></hr></td><td colspan="3" rowspan="1"><hr></hr></td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">Native</td><td align="center" valign="middle" rowspan="1" colspan="1">Immigrant</td><td align="center" valign="middle" rowspan="1" colspan="1">Total</td><td align="center" valign="middle" rowspan="1" colspan="1">Native</td><td align="center" valign="middle" rowspan="1" colspan="1">Immigrant</td><td align="center" valign="middle" rowspan="1" colspan="1">Total</td><td align="center" valign="middle" rowspan="1" colspan="1">Native</td><td align="center" valign="middle" rowspan="1" colspan="1">Immigrant</td><td align="center" valign="middle" rowspan="1" colspan="1">Total</td><td align="center" valign="middle" rowspan="1" colspan="1">Native</td><td align="center" valign="middle" rowspan="1" colspan="1">Immigrant</td><td align="center" valign="middle" rowspan="1" colspan="1">Total</td></tr></thead><tbody><tr><td align="center" valign="middle" rowspan="1" colspan="1">1994</td><td align="center" valign="middle" rowspan="1" colspan="1">230</td><td align="center" valign="middle" rowspan="1" colspan="1">15</td><td align="center" valign="middle" rowspan="1" colspan="1">245</td><td align="center" valign="middle" rowspan="1" colspan="1">425</td><td align="center" valign="middle" rowspan="1" colspan="1">32</td><td align="center" valign="middle" rowspan="1" colspan="1">457</td><td align="center" valign="middle" rowspan="1" colspan="1">35.1</td><td align="center" valign="middle" rowspan="1" colspan="1">31.9</td><td align="center" valign="middle" rowspan="1" colspan="1">34.9</td><td align="center" valign="middle" rowspan="1" colspan="1">18.0</td><td align="center" valign="middle" rowspan="1" colspan="1">30.1</td><td align="center" valign="middle" rowspan="1" colspan="1">18.5</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">1995</td><td align="center" valign="middle" rowspan="1" colspan="1">178</td><td align="center" valign="middle" rowspan="1" colspan="1">11</td><td align="center" valign="middle" rowspan="1" colspan="1">189</td><td align="center" valign="middle" rowspan="1" colspan="1">421</td><td align="center" valign="middle" rowspan="1" colspan="1">27</td><td align="center" valign="middle" rowspan="1" colspan="1">448</td><td align="center" valign="middle" rowspan="1" colspan="1">29.7</td><td align="center" valign="middle" rowspan="1" colspan="1">28.9</td><td align="center" valign="middle" rowspan="1" colspan="1">29.7</td><td align="center" valign="middle" rowspan="1" colspan="1">14.0</td><td align="center" valign="middle" rowspan="1" colspan="1">20.7</td><td align="center" valign="middle" rowspan="1" colspan="1">14.2</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">1996</td><td align="center" valign="middle" rowspan="1" colspan="1">141</td><td align="center" valign="middle" rowspan="1" colspan="1">6</td><td align="center" valign="middle" rowspan="1" colspan="1">147</td><td align="center" valign="middle" rowspan="1" colspan="1">348</td><td align="center" valign="middle" rowspan="1" colspan="1">14</td><td align="center" valign="middle" rowspan="1" colspan="1">362</td><td align="center" valign="middle" rowspan="1" colspan="1">28.8</td><td align="center" valign="middle" rowspan="1" colspan="1">30.0</td><td align="center" valign="middle" rowspan="1" colspan="1">28.9</td><td align="center" valign="middle" rowspan="1" colspan="1">11.1</td><td align="center" valign="middle" rowspan="1" colspan="1">11.3</td><td align="center" valign="middle" rowspan="1" colspan="1">11.1</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">1997</td><td align="center" valign="middle" rowspan="1" colspan="1">112</td><td align="center" valign="middle" rowspan="1" colspan="1">9</td><td align="center" valign="middle" rowspan="1" colspan="1">121</td><td align="center" valign="middle" rowspan="1" colspan="1">243</td><td align="center" valign="middle" rowspan="1" colspan="1">16</td><td align="center" valign="middle" rowspan="1" colspan="1">259</td><td align="center" valign="middle" rowspan="1" colspan="1">31.5</td><td align="center" valign="middle" rowspan="1" colspan="1">36.0</td><td align="center" valign="middle" rowspan="1" colspan="1">31.8</td><td align="center" valign="middle" rowspan="1" colspan="1">8.8</td><td align="center" valign="middle" rowspan="1" colspan="1">16.9</td><td align="center" valign="middle" rowspan="1" colspan="1">9.1</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">1998</td><td align="center" valign="middle" rowspan="1" colspan="1">78</td><td align="center" valign="middle" rowspan="1" colspan="1">7</td><td align="center" valign="middle" rowspan="1" colspan="1">85</td><td align="center" valign="middle" rowspan="1" colspan="1">160</td><td align="center" valign="middle" rowspan="1" colspan="1">7</td><td align="center" valign="middle" rowspan="1" colspan="1">167</td><td align="center" valign="middle" rowspan="1" colspan="1">32.8</td><td align="center" valign="middle" rowspan="1" colspan="1">50.0</td><td align="center" valign="middle" rowspan="1" colspan="1">33.7</td><td align="center" valign="middle" rowspan="1" colspan="1">6.1</td><td align="center" valign="middle" rowspan="1" colspan="1">13.2</td><td align="center" valign="middle" rowspan="1" colspan="1">6.4</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">1999</td><td align="center" valign="middle" rowspan="1" colspan="1">60</td><td align="center" valign="middle" rowspan="1" colspan="1">8</td><td align="center" valign="middle" rowspan="1" colspan="1">68</td><td align="center" valign="middle" rowspan="1" colspan="1">125</td><td align="center" valign="middle" rowspan="1" colspan="1">9</td><td align="center" valign="middle" rowspan="1" colspan="1">134</td><td align="center" valign="middle" rowspan="1" colspan="1">32.4</td><td align="center" valign="middle" rowspan="1" colspan="1">47.1</td><td align="center" valign="middle" rowspan="1" colspan="1">33.7</td><td align="center" valign="middle" rowspan="1" colspan="1">4.7</td><td align="center" valign="middle" rowspan="1" colspan="1">12.5</td><td align="center" valign="middle" rowspan="1" colspan="1">5.1</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">2000</td><td align="center" valign="middle" rowspan="1" colspan="1">49</td><td align="center" valign="middle" rowspan="1" colspan="1">11</td><td align="center" valign="middle" rowspan="1" colspan="1">60</td><td align="center" valign="middle" rowspan="1" colspan="1">122</td><td align="center" valign="middle" rowspan="1" colspan="1">9</td><td align="center" valign="middle" rowspan="1" colspan="1">131</td><td align="center" valign="middle" rowspan="1" colspan="1">28.7</td><td align="center" valign="middle" rowspan="1" colspan="1">55.0</td><td align="center" valign="middle" rowspan="1" colspan="1">31.4</td><td align="center" valign="middle" rowspan="1" colspan="1">3.9</td><td align="center" valign="middle" rowspan="1" colspan="1">17.1</td><td align="center" valign="middle" rowspan="1" colspan="1">4.5</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">2001</td><td align="center" valign="middle" rowspan="1" colspan="1">45</td><td align="center" valign="middle" rowspan="1" colspan="1">7</td><td align="center" valign="middle" rowspan="1" colspan="1">52</td><td align="center" valign="middle" rowspan="1" colspan="1">103</td><td align="center" valign="middle" rowspan="1" colspan="1">19</td><td align="center" valign="middle" rowspan="1" colspan="1">122</td><td align="center" valign="middle" rowspan="1" colspan="1">30.4</td><td align="center" valign="middle" rowspan="1" colspan="1">26.9</td><td align="center" valign="middle" rowspan="1" colspan="1">29.9</td><td align="center" valign="middle" rowspan="1" colspan="1">3.5</td><td align="center" valign="middle" rowspan="1" colspan="1">10.9</td><td align="center" valign="middle" rowspan="1" colspan="1">3.9</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">2002</td><td align="center" valign="middle" rowspan="1" colspan="1">44</td><td align="center" valign="middle" rowspan="1" colspan="1">10</td><td align="center" valign="middle" rowspan="1" colspan="1">54</td><td align="center" valign="middle" rowspan="1" colspan="1">80</td><td align="center" valign="middle" rowspan="1" colspan="1">12</td><td align="center" valign="middle" rowspan="1" colspan="1">92</td><td align="center" valign="middle" rowspan="1" colspan="1">35.5</td><td align="center" valign="middle" rowspan="1" colspan="1">45.5</td><td align="center" valign="middle" rowspan="1" colspan="1">37.0</td><td align="center" valign="middle" rowspan="1" colspan="1">3.6</td><td align="center" valign="middle" rowspan="1" colspan="1">5.5</td><td align="center" valign="middle" rowspan="1" colspan="1">3.9</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">2003</td><td align="center" valign="middle" rowspan="1" colspan="1">30</td><td align="center" valign="middle" rowspan="1" colspan="1">15</td><td align="center" valign="middle" rowspan="1" colspan="1">45</td><td align="center" valign="middle" rowspan="1" colspan="1">98</td><td align="center" valign="middle" rowspan="1" colspan="1">21</td><td align="center" valign="middle" rowspan="1" colspan="1">119</td><td align="center" valign="middle" rowspan="1" colspan="1">23.4</td><td align="center" valign="middle" rowspan="1" colspan="1">41.7</td><td align="center" valign="middle" rowspan="1" colspan="1">27.4</td><td align="center" valign="middle" rowspan="1" colspan="1">2.5</td><td align="center" valign="middle" rowspan="1" colspan="1">8.3</td><td align="center" valign="middle" rowspan="1" colspan="1">3.2</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">2004</td><td align="center" valign="middle" rowspan="1" colspan="1">22</td><td align="center" valign="middle" rowspan="1" colspan="1">13</td><td align="center" valign="middle" rowspan="1" colspan="1">35</td><td align="center" valign="middle" rowspan="1" colspan="1">89</td><td align="center" valign="middle" rowspan="1" colspan="1">16</td><td align="center" valign="middle" rowspan="1" colspan="1">105</td><td align="center" valign="middle" rowspan="1" colspan="1">19.8</td><td align="center" valign="middle" rowspan="1" colspan="1">44.8</td><td align="center" valign="middle" rowspan="1" colspan="1">25.0</td><td align="center" valign="middle" rowspan="1" colspan="1">1.8</td><td align="center" valign="middle" rowspan="1" colspan="1">7.2</td><td align="center" valign="middle" rowspan="1" colspan="1">2.5</td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">2005</td><td align="center" valign="middle" rowspan="1" colspan="1">22</td><td align="center" valign="middle" rowspan="1" colspan="1">7</td><td align="center" valign="middle" rowspan="1" colspan="1">29</td><td align="center" valign="middle" rowspan="1" colspan="1">54</td><td align="center" valign="middle" rowspan="1" colspan="1">20</td><td align="center" valign="middle" rowspan="1" colspan="1">74</td><td align="center" valign="middle" rowspan="1" colspan="1">28.9</td><td align="center" valign="middle" rowspan="1" colspan="1">25.9</td><td align="center" valign="middle" rowspan="1" colspan="1">28.2</td><td align="center" valign="middle" rowspan="1" colspan="1">1.8</td><td align="center" valign="middle" rowspan="1" colspan="1">3.2</td><td align="center" valign="middle" rowspan="1" colspan="1">2.0</td></tr><tr><td colspan="10" rowspan="1"><hr></hr></td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">Total</td><td align="center" valign="middle" rowspan="1" colspan="1">1011</td><td align="center" valign="middle" rowspan="1" colspan="1">119</td><td align="center" valign="middle" rowspan="1" colspan="1">1130</td><td align="center" valign="middle" rowspan="1" colspan="1">2268</td><td align="center" valign="middle" rowspan="1" colspan="1">202</td><td align="center" valign="middle" rowspan="1" colspan="1">2470</td><td align="center" valign="middle" rowspan="1" colspan="1">30.8</td><td align="center" valign="middle" rowspan="1" colspan="1">37.1</td><td align="center" valign="middle" rowspan="1" colspan="1">31.4</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr></tbody></table><table-wrap-foot><p>Abbreviations: AIDS–TB, tuberculosis as diagnostic disease; AIDS–non-TB, diagnostic disease was not TB; % AIDS–TB, percentage of AIDS–TB with respect to total number of AIDS cases.</p></table-wrap-foot></table-wrap><p>AIDS–TB cases accounted for approximately 30% of all cases, and no significant change in this rate was observed during the study period. The percentage of AIDS–TB was 30.8% among native Spaniards and 37.1% among immigrants (<italic>P</italic> = 0.02; Table <xref ref-type="table" rid="tbl01">1</xref>). A significant decreasing trend in the percentage of TB was observed among native Spaniards (<italic>P</italic> =0.03), but not among immigrants (Table <xref ref-type="table" rid="tbl01">1</xref>). In 1994, 6.5% of AIDS–TB cases were immigrants, which rose to 37.1% in 2004 (<italic>P</italic> < 0.001). This increase was mainly accounted for by males: 5.5% of AIDS–TB cases in 1994–1996 were male immigrants, which rose to 27.5% in 2001–2005 (Figure <xref ref-type="fig" rid="fig01">1</xref>), while the proportion of female immigrants with AIDS remained between 6.1% and 7.8% (Figure <xref ref-type="fig" rid="fig01">1</xref>).</p><fig id="fig01" fig-type="figure" orientation="portrait" position="float"><label>Figure 1.</label><caption><title>(a) Rates of AIDS–TB cases and immigrant AIDS–TB cases among men, by period and nationality. Error bars represent 95% confidence intervals. Bars: Rate per 100 000 inhabitants. Line: %immigrant TB cases. Native: A person born in or a citizen of Spain. (b) Rates of AIDS–TB cases and immigrant AIDS–TB cases among women, by period and nationality. Error bars represent 95% confidence intervals. Bars: Rate per 100 000 inhabitants. Line: %immigrant TB cases. Native: A person born in or a citizen of Spain. </title></caption><graphic xlink:href="je-21-108-g001"></graphic></fig><p>Among both the native and immigrant groups, AIDS rates also tended to decrease. In 1994, 52.7 AIDS cases per 100 000 inhabitants were registered (18.5 AIDS–TB; 34.2 AIDS–non-TB), which decreased to 7.2 per 100 000 in 2005 (2.0 AIDS–TB; 5.2 AIDS–non-TB). The decrease in AIDS–TB rates was constant throughout the study period: on average, the rate decreased by 20% per year among both natives and immigrants (Table <xref ref-type="table" rid="tbl01">1</xref>).</p><p>During the period studied, the average incidence of AIDS–TB declined steadily among males, females, natives, and immigrants, although it remained higher among males and immigrants (Figure <xref ref-type="fig" rid="fig01">1</xref>). The highest AIDS–TB incidence among males was observed in foreign-born men aged 30 to 39 years (Figure <xref ref-type="fig" rid="fig02">2</xref>); among females, the highest incidence was observed in Spanish women aged 30 to 39 years and foreign-born women aged 40 to 49 years (Figure <xref ref-type="fig" rid="fig02">2</xref>).</p><fig id="fig02" fig-type="figure" orientation="portrait" position="float"><label>Figure 2.</label><caption><title>(a) Rates of AIDS–TB cases among men, by age group and nationality. Error bars represent 95% confidence intervals. Native: A person born in or a citizen of Spain. (b) Rates of AIDS–TB cases among women, by age group and nationality. Error bars represent 95% confidence intervals. Native: A person born in or a citizen of Spain. </title></caption><graphic xlink:href="je-21-108-g002"></graphic></fig><p>On multivariate analysis, TB was more common among males, individuals 35 years of age or younger, inner city residents, those with a history of incarceration, those with greater than 200 CD4+ T-cells/mm<sup>3</sup>, IDUs, heterosexuals, and immigrants from Latin America, the Caribbean, and sub-Saharan Africa (Table <xref ref-type="table" rid="tbl02">2</xref>).</p><table-wrap id="tbl02" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Factors associated with tuberculosis as an AIDS-defining disease (Barcelona 1994–2005)</title></caption><table frame="hsides" rules="groups"><thead><tr><td align="center" valign="middle" rowspan="1" colspan="1">Variable</td><td align="center" valign="middle" rowspan="1" colspan="1">No.</td><td align="center" valign="middle" rowspan="1" colspan="1">TB</td><td align="center" valign="middle" rowspan="1" colspan="1">%</td><td align="center" valign="middle" rowspan="1" colspan="1">OR</td><td align="center" valign="middle" rowspan="1" colspan="1">95% CI</td><td align="center" valign="middle" rowspan="1" colspan="1">Adjusted OR</td><td align="center" valign="middle" rowspan="1" colspan="1">95% CI</td></tr></thead><tbody><tr><td align="left" valign="middle" rowspan="1" colspan="1">Sex</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Female</td><td align="center" valign="middle" rowspan="1" colspan="1">757</td><td align="center" valign="middle" rowspan="1" colspan="1">204</td><td align="center" valign="middle" rowspan="1" colspan="1">26.9</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Male</td><td align="center" valign="middle" rowspan="1" colspan="1">2843</td><td align="center" valign="middle" rowspan="1" colspan="1">926</td><td align="center" valign="middle" rowspan="1" colspan="1">32.6</td><td align="center" valign="middle" rowspan="1" colspan="1">1.30</td><td align="center" valign="middle" rowspan="1" colspan="1">1.1–1.6</td><td align="center" valign="middle" rowspan="1" colspan="1">1.49</td><td align="center" valign="middle" rowspan="1" colspan="1">1.2–1.8</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1">Age, yrs</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> >35</td><td align="center" valign="middle" rowspan="1" colspan="1">1743</td><td align="center" valign="middle" rowspan="1" colspan="1">443</td><td align="center" valign="middle" rowspan="1" colspan="1">25.4</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> ≤35</td><td align="center" valign="middle" rowspan="1" colspan="1">1857</td><td align="center" valign="middle" rowspan="1" colspan="1">687</td><td align="center" valign="middle" rowspan="1" colspan="1">37.0</td><td align="center" valign="middle" rowspan="1" colspan="1">1.72</td><td align="center" valign="middle" rowspan="1" colspan="1">1.5–2.0</td><td align="center" valign="middle" rowspan="1" colspan="1">1.30</td><td align="center" valign="middle" rowspan="1" colspan="1">1.1–1.5</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1">Place of residence</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Other districts</td><td align="center" valign="middle" rowspan="1" colspan="1">2859</td><td align="center" valign="middle" rowspan="1" colspan="1">824</td><td align="center" valign="middle" rowspan="1" colspan="1">28.8</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Ciutat Vella (inner city)</td><td align="center" valign="middle" rowspan="1" colspan="1">741</td><td align="center" valign="middle" rowspan="1" colspan="1">306</td><td align="center" valign="middle" rowspan="1" colspan="1">41.3</td><td align="center" valign="middle" rowspan="1" colspan="1">1.74</td><td align="center" valign="middle" rowspan="1" colspan="1">1.5–2.1</td><td align="center" valign="middle" rowspan="1" colspan="1">1.73</td><td align="center" valign="middle" rowspan="1" colspan="1">1.4–2.1</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1">Risk group</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Homosexual</td><td align="center" valign="middle" rowspan="1" colspan="1">881</td><td align="center" valign="middle" rowspan="1" colspan="1">160</td><td align="center" valign="middle" rowspan="1" colspan="1">18.2</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> IDU</td><td align="center" valign="middle" rowspan="1" colspan="1">1832</td><td align="center" valign="middle" rowspan="1" colspan="1">747</td><td align="center" valign="middle" rowspan="1" colspan="1">40.8</td><td align="center" valign="middle" rowspan="1" colspan="1">3.10</td><td align="center" valign="middle" rowspan="1" colspan="1">2.6–3.8</td><td align="center" valign="middle" rowspan="1" colspan="1">2.58</td><td align="center" valign="middle" rowspan="1" colspan="1">2.1–3.2</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Heterosexual</td><td align="center" valign="middle" rowspan="1" colspan="1">746</td><td align="center" valign="middle" rowspan="1" colspan="1">198</td><td align="center" valign="middle" rowspan="1" colspan="1">26.5</td><td align="center" valign="middle" rowspan="1" colspan="1">1.63</td><td align="center" valign="middle" rowspan="1" colspan="1">1.3–2.1</td><td align="center" valign="middle" rowspan="1" colspan="1">1.96</td><td align="center" valign="middle" rowspan="1" colspan="1">1.5–2.6</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Unknown</td><td align="center" valign="middle" rowspan="1" colspan="1">141</td><td align="center" valign="middle" rowspan="1" colspan="1">25</td><td align="center" valign="middle" rowspan="1" colspan="1">17.7</td><td align="center" valign="middle" rowspan="1" colspan="1">0.97</td><td align="center" valign="middle" rowspan="1" colspan="1">0.6–1.6</td><td align="center" valign="middle" rowspan="1" colspan="1">1.01</td><td align="center" valign="middle" rowspan="1" colspan="1">0.6–1.7</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1">History of incarceration</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> No</td><td align="center" valign="middle" rowspan="1" colspan="1">2986</td><td align="center" valign="middle" rowspan="1" colspan="1">780</td><td align="center" valign="middle" rowspan="1" colspan="1">26.1</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Yes</td><td align="center" valign="middle" rowspan="1" colspan="1">614</td><td align="center" valign="middle" rowspan="1" colspan="1">350</td><td align="center" valign="middle" rowspan="1" colspan="1">57.0</td><td align="center" valign="middle" rowspan="1" colspan="1">3.75</td><td align="center" valign="middle" rowspan="1" colspan="1">3.1–4.5</td><td align="center" valign="middle" rowspan="1" colspan="1">2.47</td><td align="center" valign="middle" rowspan="1" colspan="1">2.0–3.0</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1">CD4 lymphocytes</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> <200</td><td align="center" valign="middle" rowspan="1" colspan="1">1815</td><td align="center" valign="middle" rowspan="1" colspan="1">475</td><td align="center" valign="middle" rowspan="1" colspan="1">26.2</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> ≥200</td><td align="center" valign="middle" rowspan="1" colspan="1">481</td><td align="center" valign="middle" rowspan="1" colspan="1">250</td><td align="center" valign="middle" rowspan="1" colspan="1">52.0</td><td align="center" valign="middle" rowspan="1" colspan="1">3.05</td><td align="center" valign="middle" rowspan="1" colspan="1">2.5–3.8</td><td align="center" valign="middle" rowspan="1" colspan="1">3.06</td><td align="center" valign="middle" rowspan="1" colspan="1">2.5–3.8</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Unknown</td><td align="center" valign="middle" rowspan="1" colspan="1">1304</td><td align="center" valign="middle" rowspan="1" colspan="1">405</td><td align="center" valign="middle" rowspan="1" colspan="1">31.1</td><td align="center" valign="middle" rowspan="1" colspan="1">1.27</td><td align="center" valign="middle" rowspan="1" colspan="1">1.1–1.5</td><td align="center" valign="middle" rowspan="1" colspan="1">1.29</td><td align="center" valign="middle" rowspan="1" colspan="1">1.1–1.5</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1">Period</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> 1994–1996</td><td align="center" valign="middle" rowspan="1" colspan="1">1846</td><td align="center" valign="middle" rowspan="1" colspan="1">582</td><td align="center" valign="middle" rowspan="1" colspan="1">31.5</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> 1997–2000</td><td align="center" valign="middle" rowspan="1" colspan="1">1025</td><td align="center" valign="middle" rowspan="1" colspan="1">334</td><td align="center" valign="middle" rowspan="1" colspan="1">32.6</td><td align="center" valign="middle" rowspan="1" colspan="1">1.05</td><td align="center" valign="middle" rowspan="1" colspan="1">0.9–1.2</td><td align="center" valign="middle" rowspan="1" colspan="1">1.14</td><td align="center" valign="middle" rowspan="1" colspan="1">1.0–1.4</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> 2001–2005</td><td align="center" valign="middle" rowspan="1" colspan="1">729</td><td align="center" valign="middle" rowspan="1" colspan="1">214</td><td align="center" valign="middle" rowspan="1" colspan="1">29.4</td><td align="center" valign="middle" rowspan="1" colspan="1">0.90</td><td align="center" valign="middle" rowspan="1" colspan="1">0.7–1.1</td><td align="center" valign="middle" rowspan="1" colspan="1">1.04</td><td align="center" valign="middle" rowspan="1" colspan="1">0.8–1.3</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1">Region of origin</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Spain</td><td align="center" valign="middle" rowspan="1" colspan="1">3279</td><td align="center" valign="middle" rowspan="1" colspan="1">1011</td><td align="center" valign="middle" rowspan="1" colspan="1">30.8</td><td align="center" valign="middle" rowspan="1" colspan="1">1</td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td><td align="left" valign="middle" rowspan="1" colspan="1"> </td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> North America/Western Europe</td><td align="center" valign="middle" rowspan="1" colspan="1">67</td><td align="center" valign="middle" rowspan="1" colspan="1">20</td><td align="center" valign="middle" rowspan="1" colspan="1">29.9</td><td align="center" valign="middle" rowspan="1" colspan="1">0.94</td><td align="center" valign="middle" rowspan="1" colspan="1">0.5–1.6</td><td align="center" valign="middle" rowspan="1" colspan="1">1.06</td><td align="center" valign="middle" rowspan="1" colspan="1">0.6–1.9</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Latin America/Caribbean</td><td align="center" valign="middle" rowspan="1" colspan="1">142</td><td align="center" valign="middle" rowspan="1" colspan="1">45</td><td align="center" valign="middle" rowspan="1" colspan="1">31.7</td><td align="center" valign="middle" rowspan="1" colspan="1">1.02</td><td align="center" valign="middle" rowspan="1" colspan="1">0.7–1.5</td><td align="center" valign="middle" rowspan="1" colspan="1">1.69</td><td align="center" valign="middle" rowspan="1" colspan="1">1.1–2.5</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Middle East/North Africa</td><td align="center" valign="middle" rowspan="1" colspan="1">48</td><td align="center" valign="middle" rowspan="1" colspan="1">24</td><td align="center" valign="middle" rowspan="1" colspan="1">50.0</td><td align="center" valign="middle" rowspan="1" colspan="1">2.20</td><td align="center" valign="middle" rowspan="1" colspan="1">1.2–3.9</td><td align="center" valign="middle" rowspan="1" colspan="1">1.56</td><td align="center" valign="middle" rowspan="1" colspan="1">0.8–2.9</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Sub-Saharan Africa</td><td align="center" valign="middle" rowspan="1" colspan="1">42</td><td align="center" valign="middle" rowspan="1" colspan="1">21</td><td align="center" valign="middle" rowspan="1" colspan="1">50.0</td><td align="center" valign="middle" rowspan="1" colspan="1">2.20</td><td align="center" valign="middle" rowspan="1" colspan="1">1.2–4.0</td><td align="center" valign="middle" rowspan="1" colspan="1">2.39</td><td align="center" valign="middle" rowspan="1" colspan="1">1.2–4.6</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> Rest of Europe/Central Asia</td><td align="center" valign="middle" rowspan="1" colspan="1">11</td><td align="center" valign="middle" rowspan="1" colspan="1">5</td><td align="center" valign="middle" rowspan="1" colspan="1">45.5</td><td align="center" valign="middle" rowspan="1" colspan="1">1.47</td><td align="center" valign="middle" rowspan="1" colspan="1">0.2–8.8</td><td align="center" valign="middle" rowspan="1" colspan="1">0.94</td><td align="center" valign="middle" rowspan="1" colspan="1">0.3–3.4</td></tr><tr><td align="left" valign="middle" rowspan="1" colspan="1"> South Asia/East Asia/Pacific</td><td align="center" valign="middle" rowspan="1" colspan="1">11</td><td align="center" valign="middle" rowspan="1" colspan="1">4</td><td align="center" valign="middle" rowspan="1" colspan="1">36.4</td><td align="center" valign="middle" rowspan="1" colspan="1">1.10</td><td align="center" valign="middle" rowspan="1" colspan="1">0.2–6.0</td><td align="center" valign="middle" rowspan="1" colspan="1">1.17</td><td align="center" valign="middle" rowspan="1" colspan="1">0.3–4.4</td></tr></tbody></table><table-wrap-foot><p>Abbreviations: CI, confidence interval; IDU, intravenous drug user; OR, odds ratio; TB, tuberculosis.</p></table-wrap-foot></table-wrap></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>The 1994 adoption of pulmonary TB as an AIDS-defining disease among individuals infected with HIV<sup><xref ref-type="bibr" rid="r07">7</xref></sup> resulted in the highest number of detected cases in the European Union (93.7 per million inhabitants), Spain (183.5 cases per million), and Barcelona (464.3 cases per million).<sup><xref ref-type="bibr" rid="r14">14</xref></sup> Since that year, there have been consistent decreases in both the number of cases and the incidence of AIDS. As compared with 1994 values, incidence in 2005 was 75% lower (<20 cases per million) in the European Union, 80% lower (36 cases per million) in Spain, and approximately 90% lower (68.7 cases per million) in Barcelona. The marked declines in both AIDS–TB and AIDS–non-TB cases have been attributed to improvement in the immune status of HIV-infected individuals owing to highly active antiretroviral therapies (HAART) and the effectiveness of programs for prevention and control of HIV infection and TB.<sup><xref ref-type="bibr" rid="r11">11</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r12">12</xref></sup> The reduction in AIDS–TB rates observed in our study is likely attributable to the same causes. In Spain, ART has always been widely accessible and free, and, since 1997, approximately 70% of HIV-infected individuals have been receiving HAART.<sup><xref ref-type="bibr" rid="r13">13</xref></sup><sup>–</sup><sup><xref ref-type="bibr" rid="r15">15</xref></sup> HIV prevention and control activities in the city of Barcelona have been effective, especially among IDUs.<sup><xref ref-type="bibr" rid="r16">16</xref></sup> The tuberculosis control program is also effective and may partly explain the decline in AIDS–TB cases that occurred during the pre-HAART period.<sup><xref ref-type="bibr" rid="r17">17</xref></sup></p><p>Regarding TB as an AIDS-defining disease, Barcelona has historically had high incidences of AIDS and TB, with many cases of comorbidity, which explains why more than 30% of AIDS cases had TB as their AIDS-defining disease. This percentage is higher than those observed in Central and Western Europe (20% and 25%, respectively),<sup><xref ref-type="bibr" rid="r18">18</xref></sup> the United States (5%),<sup><xref ref-type="bibr" rid="r19">19</xref></sup> France (10%),<sup><xref ref-type="bibr" rid="r20">20</xref></sup> Brazil (24%),<sup><xref ref-type="bibr" rid="r21">21</xref></sup> London (19%),<sup><xref ref-type="bibr" rid="r04">4</xref></sup> and New York (5.3%),<sup><xref ref-type="bibr" rid="r22">22</xref></sup> and lower than incidences observed in Eastern Europe (50%)<sup><xref ref-type="bibr" rid="r18">18</xref></sup> and Portugal (51%),<sup><xref ref-type="bibr" rid="r18">18</xref></sup> where the incidence of TB is higher and lower, respectively.</p><p>As in previous studies, the factors predicting the presence of TB as an AIDS-defining disease are consistent with the high observed prevalences of co-infection by HIV and <italic>M. tuberculosis</italic> and are associated with the same population groups: males, young people, IDUs, promiscuous heterosexuals, individuals with a history of incarceration, and immigrants from countries with a high prevalence of latent tuberculosis infection (LTBI).<sup><xref ref-type="bibr" rid="r23">23</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r24">24</xref></sup> It should be noted that, in Barcelona, the inner city is the district with the lowest socioeconomic level and the city’s highest incidences of TB and AIDS.<sup><xref ref-type="bibr" rid="r25">25</xref></sup> The present study shows that a level of greater than 200 CD4+ T-cells/mm<sup>3</sup> is associated with the presence of TB, which could be due to the high prevalence of LTBI.<sup><xref ref-type="bibr" rid="r25">25</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r26">26</xref></sup> The absence in the city of outbreaks, which are associated with the presence of individuals with severe immunosuppression, indicates that endogenous reactivation and treatment of LTBI may be important in contexts where the prevalence of co-infection is high.<sup><xref ref-type="bibr" rid="r27">27</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r28">28</xref></sup></p><p>In the present study, immigrants from Latin America, the Caribbean, and sub-Saharan Africa were more likely to develop TB as an AIDS-defining disease—as was observed in previous studies in countries with high levels of immigration from those geographical areas—probably because of the high prevalence of TB-AIDS co-infection in their countries of origin.<sup><xref ref-type="bibr" rid="r08">8</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r29">29</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r30">30</xref></sup> However, the endemic nature of TB-AIDS co-infection in countries of origin may not be sufficient to explain this finding. In the case of immigrants with latent tuberculosis infection (LTI) alone, the social group into which immigrants integrate in the receiving country could determine their risk of HIV infection and, therefore, the occurrence of AIDS–TB cases.<sup><xref ref-type="bibr" rid="r31">31</xref></sup> On arrival in Spain, some immigrants become IDUs or sell sex for money, thereby increasing the risk of HIV infection.<sup><xref ref-type="bibr" rid="r31">31</xref></sup></p><p>AIDS–TB rates observed among immigrants were higher than among native Spaniards, but may be overestimated because of a higher real denominator due to the existence of illegal immigration. Nonetheless, other cohort studies have also found higher rates among immigrants.<sup><xref ref-type="bibr" rid="r30">30</xref></sup> It should also be noted that access to methods of early detection of HIV infection may have been impaired among immigrants, as was observed in the present study and in other Spanish studies, perhaps due to the illegal residence status of some immigrants and the fact that HIV transmission occurred mainly among heterosexuals, a group perceived as less at risk.<sup><xref ref-type="bibr" rid="r14">14</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r15">15</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r30">30</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r34">34</xref></sup> The proportion of AIDS–TB cases increased among immigrants because the number of cases among that population remained constant over time, which was not the case among native Spaniards. A similar tendency was observed in the Spanish HIV infection registry<sup><xref ref-type="bibr" rid="r32">32</xref></sup> and the Lazio TB registry in Italy.<sup><xref ref-type="bibr" rid="r33">33</xref></sup></p><p>Immigration in Spain has increased considerably in recent years: immigrants formed 2.3% of the population in 2000 and 8.5% in 2005 [Instituto Nacional de Estadística, 2008]. In Barcelona, the number of immigrants rose from 29 534 in the 1996 census to 260 058 in 2005 (16% of the population; Ayuntamiento de Barcelona, 2006). The vast majority come from countries with higher TB rates and lower HIV infection rates than Spain (mainly countries in Latin America, Eastern Europe, and North Africa). This could explain the low impact of immigration on the rate of AIDS–TB in Spain, in contrast to trends observed elsewhere, where the decline in AIDS–TB rates has been checked by the arrival of immigrants from areas of high co-infection, particularly sub-Saharan Africa.<sup><xref ref-type="bibr" rid="r12">12</xref></sup><sup>,</sup><sup><xref ref-type="bibr" rid="r29">29</xref></sup> These findings must be interpreted with caution, however, as an immigrant population is not normally representative of its country of origin and does not reflect its epidemiological patterns. Nonetheless, it is not difficult to imagine an exchange of infections that might occur between one group with a high prevalence of LTBI and low HIV infection (immigrants) and another with lower LTBI prevalence but a higher rate of HIV infection (natives).<sup><xref ref-type="bibr" rid="r31">31</xref></sup> This hypothesis is supported by the fact that immigrants who had been in Spain longer had developed HIV infection in that country. It thus seems likely that approximately half the comorbid immigrants arrive in Spain with co-infection, and at least one third become co-infected while living in Spain.<sup><xref ref-type="bibr" rid="r31">31</xref></sup></p></sec><sec sec-type="conclusions"><title>CONCLUSIONS</title><p>The incidence of TB as an AIDS-defining disease decreased in Barcelona during 1994–2005 in both the native and immigrant populations. To ensure that this trend continues in the future, it is essential to intensify HIV infection and TB control programs specifically directed at those immigrant groups most at risk of HIV infection (ie, drug users, sex workers, the promiscuous, etc.).</p></sec></body><back><ack><title>ACKNOWLEDGMENTS</title><p>AIDS and Tuberculosis Working Group—Hospital de Sant Pau: Maria Antonia Sambeat, Mercè Gurgui; Hospital Universitari Vall d’Hebron: Inmaculada Ocaña, Esteve Ribera; Hospital del Mar: Josep Lluis López-Colomés, Hernando Knobel; Hospital Clinic-IDIBAPS, University of Barcelona: Josep Maria Miró, Josep Maria Gatell; Agencia de Salud Pública: Roser Clos, Pilar Gorrindo.</p><p>We express our thanks to all the doctors and nurses of the health care centers in Barcelona who work with people with AIDS and/or TB and who have collaborated all these years with the Barcelona TB Programme. 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<string-name name-style="eastern"><surname>Nicolau</surname><given-names>A</given-names></string-name>, <etal></etal></person-group><article-title>Retraso diagnóstico de la infección por el virus de la inmunodeficiencia humana en España</article-title>. <source>Enferm Infecc Microbiol Clin</source>. <year>2010</year>;<volume>28</volume>(<issue>9</issue>):<fpage>583</fpage>–<lpage>9</lpage><pub-id pub-id-type="doi">10.1016/j.eimc.2010.02.013</pub-id><pub-id pub-id-type="pmid">20541845</pub-id></mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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