Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa
Identifieur interne : 005225 ( Main/Exploration ); précédent : 005224; suivant : 005226Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa
Auteurs : Stephen D. Lawn [Afrique du Sud, Royaume-Uni] ; Landon Myer [Afrique du Sud, États-Unis] ; David Edwards [Afrique du Sud] ; Linda-Gail Bekker [Afrique du Sud] ; Robin Wood [Afrique du Sud]Source :
- AIDS (London, England) [ 0269-9370 ] ; 2009.
Abstract
To determine the short-term and long-term risks of tuberculosis (TB) associated with CD4 cell recovery during antiretroviral therapy (ART).
Observational community-based ART cohort in South Africa.
TB incidence was determined among patients (n = 1480) receiving ART for up to 4.5 years in a South African community-based service. Updated CD4 cell counts were measured 4-monthly. Person-time accrued within a range of CD4 cell count strata (CD4 cell strata) was calculated and used to derive CD4 cell-stratified TB rates. Factors associated with incident TB were identified using Poisson regression models.
Two hundred and three cases of TB were diagnosed during 2785 person-years of observation (overall incidence, 7.3 cases/100 person-years). During person-time accrued within CD4 cell strata 0–100, 101–200, 201–300, 301–400, 401–500 and more than 500 cells/µl unadjusted TB incidence rates were 16.8, 9.3, 5.5, 4.6, 4.2 and 1.5 cases/100 person-years, respectively (P < 0.001). During early ART (first 4 months), adjusted TB rates among those with CD4 cell counts 0–200 cells/µl were 1.7-fold higher than during long-term ART (P = 0.026). Updated CD4 cell counts were the only patient characteristic independently associated with long-term TB risk.
Updated CD4 cell counts were the dominant predictor of TB risk during ART in this low-resource setting. Among those with baseline CD4 cell counts less than 200 cells/µl, the excess adjusted risk of TB during early ART was consistent with ‘unmasking’ of disease missed at baseline screening. TB incidence rates at CD4 cell counts of 200–500 cells/µl remained high and adjunctive interventions are required. TB prevention would be improved by ART policies that minimized the time patients spend with CD4 cell counts below a threshold of 500 cells/µl.
Url:
DOI: 10.1097/QAD.0b013e32832d3b6d
PubMed: 19461502
PubMed Central: 3801095
Affiliations:
- Afrique du Sud, Royaume-Uni, États-Unis
- Angleterre, Grand Londres, État de New York
- Londres, New York
- Université Columbia
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Lawn</name><affiliation wicri:level="1"><nlm:aff id="A1">The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town</wicri:regionArea><wicri:noRegion>Cape Town</wicri:noRegion></affiliation><affiliation wicri:level="3"><nlm:aff id="A2">Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London</wicri:regionArea><placeName><settlement type="city">Londres</settlement><region type="country">Angleterre</region><region type="région" nuts="1">Grand 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Lawn</name><affiliation wicri:level="1"><nlm:aff id="A1">The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town</wicri:regionArea><wicri:noRegion>Cape Town</wicri:noRegion></affiliation><affiliation wicri:level="3"><nlm:aff id="A2">Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London</wicri:regionArea><placeName><settlement type="city">Londres</settlement><region type="country">Angleterre</region><region type="région" nuts="1">Grand Londres</region></placeName></affiliation></author><author><name sortKey="Myer, Landon" sort="Myer, Landon" uniqKey="Myer L" first="Landon" last="Myer">Landon Myer</name><affiliation wicri:level="1"><nlm:aff id="A3">Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town</wicri:regionArea><wicri:noRegion>Cape Town</wicri:noRegion></affiliation><affiliation wicri:level="4"><nlm:aff id="A4">Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA</nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York</wicri:regionArea><placeName><region type="state">État de New York</region><settlement type="city">New York</settlement></placeName><orgName type="university">Université Columbia</orgName></affiliation></author><author><name sortKey="Edwards, David" sort="Edwards, David" uniqKey="Edwards D" first="David" last="Edwards">David Edwards</name><affiliation wicri:level="1"><nlm:aff id="A1">The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town</wicri:regionArea><wicri:noRegion>Cape Town</wicri:noRegion></affiliation></author><author><name sortKey="Bekker, Linda Gail" sort="Bekker, Linda Gail" uniqKey="Bekker L" first="Linda-Gail" last="Bekker">Linda-Gail Bekker</name><affiliation wicri:level="1"><nlm:aff id="A1">The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town</wicri:regionArea><wicri:noRegion>Cape Town</wicri:noRegion></affiliation></author><author><name sortKey="Wood, Robin" sort="Wood, Robin" uniqKey="Wood R" first="Robin" last="Wood">Robin Wood</name><affiliation wicri:level="1"><nlm:aff id="A1">The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town</wicri:regionArea><wicri:noRegion>Cape Town</wicri:noRegion></affiliation></author></analytic><series><title level="j">AIDS (London, England)</title><idno type="ISSN">0269-9370</idno><idno type="eISSN">1473-5571</idno><imprint><date when="2009">2009</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="S1"><title>Objective</title><p id="P1">To determine the short-term and long-term risks of tuberculosis (TB) associated with CD4 cell recovery during antiretroviral therapy (ART).</p></sec><sec id="S2"><title>Design</title><p id="P2">Observational community-based ART cohort in South Africa.</p></sec><sec id="S3"><title>Methods</title><p id="P3">TB incidence was determined among patients (n = 1480) receiving ART for up to 4.5 years in a South African community-based service. Updated CD4 cell counts were measured 4-monthly. Person-time accrued within a range of CD4 cell count strata (CD4 cell strata) was calculated and used to derive CD4 cell-stratified TB rates. Factors associated with incident TB were identified using Poisson regression models.</p></sec><sec id="S4"><title>Results</title><p id="P4">Two hundred and three cases of TB were diagnosed during 2785 person-years of observation (overall incidence, 7.3 cases/100 person-years). During person-time accrued within CD4 cell strata 0–100, 101–200, 201–300, 301–400, 401–500 and more than 500 cells/µl unadjusted TB incidence rates were 16.8, 9.3, 5.5, 4.6, 4.2 and 1.5 cases/100 person-years, respectively (P < 0.001). During early ART (first 4 months), adjusted TB rates among those with CD4 cell counts 0–200 cells/µl were 1.7-fold higher than during long-term ART (P = 0.026). Updated CD4 cell counts were the only patient characteristic independently associated with long-term TB risk.</p></sec><sec id="S5"><title>Conclusion</title><p id="P5">Updated CD4 cell counts were the dominant predictor of TB risk during ART in this low-resource setting. Among those with baseline CD4 cell counts less than 200 cells/µl, the excess adjusted risk of TB during early ART was consistent with ‘unmasking’ of disease missed at baseline screening. TB incidence rates at CD4 cell counts of 200–500 cells/µl remained high and adjunctive interventions are required. TB prevention would be improved by ART policies that minimized the time patients spend with CD4 cell counts below a threshold of 500 cells/µl.</p></sec></div></front></TEI><affiliations><list><country><li>Afrique du Sud</li><li>Royaume-Uni</li><li>États-Unis</li></country><region><li>Angleterre</li><li>Grand Londres</li><li>État de New York</li></region><settlement><li>Londres</li><li>New York</li></settlement><orgName><li>Université Columbia</li></orgName></list><tree><country name="Afrique du Sud"><noRegion><name sortKey="Lawn, Stephen D" sort="Lawn, Stephen D" uniqKey="Lawn S" first="Stephen D" last="Lawn">Stephen D. Lawn</name></noRegion><name sortKey="Bekker, Linda Gail" sort="Bekker, Linda Gail" uniqKey="Bekker L" first="Linda-Gail" last="Bekker">Linda-Gail Bekker</name><name sortKey="Edwards, David" sort="Edwards, David" uniqKey="Edwards D" first="David" last="Edwards">David Edwards</name><name sortKey="Myer, Landon" sort="Myer, Landon" uniqKey="Myer L" first="Landon" last="Myer">Landon Myer</name><name sortKey="Wood, Robin" sort="Wood, Robin" uniqKey="Wood R" first="Robin" last="Wood">Robin Wood</name></country><country name="Royaume-Uni"><region name="Angleterre"><name sortKey="Lawn, Stephen D" sort="Lawn, Stephen D" uniqKey="Lawn S" first="Stephen D" last="Lawn">Stephen D. Lawn</name></region></country><country name="États-Unis"><region name="État de New York"><name sortKey="Myer, Landon" sort="Myer, Landon" uniqKey="Myer L" first="Landon" last="Myer">Landon Myer</name></region></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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