Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa
Identifieur interne : 001D39 ( Pmc/Corpus ); précédent : 001D38; suivant : 001D40Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa
Auteurs : Stephen D. Lawn ; Landon Myer ; David Edwards ; Linda-Gail Bekker ; Robin WoodSource :
- 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
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Lawn</name><affiliation><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></affiliation><affiliation><nlm:aff id="A2">Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author><author><name sortKey="Myer, Landon" sort="Myer, Landon" uniqKey="Myer L" first="Landon" last="Myer">Landon Myer</name><affiliation><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></affiliation><affiliation><nlm:aff id="A4">Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA</nlm:aff></affiliation></author><author><name sortKey="Edwards, David" sort="Edwards, David" uniqKey="Edwards D" first="David" last="Edwards">David Edwards</name><affiliation><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></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><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></affiliation></author><author><name sortKey="Wood, Robin" sort="Wood, Robin" uniqKey="Wood R" first="Robin" last="Wood">Robin Wood</name><affiliation><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></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">19461502</idno><idno type="pmc">3801095</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801095</idno><idno type="RBID">PMC:3801095</idno><idno type="doi">10.1097/QAD.0b013e32832d3b6d</idno><date when="2009">2009</date><idno type="wicri:Area/Pmc/Corpus">001D39</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001D39</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa</title><author><name sortKey="Lawn, Stephen D" sort="Lawn, Stephen D" uniqKey="Lawn S" first="Stephen D" last="Lawn">Stephen D. Lawn</name><affiliation><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></affiliation><affiliation><nlm:aff id="A2">Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author><author><name sortKey="Myer, Landon" sort="Myer, Landon" uniqKey="Myer L" first="Landon" last="Myer">Landon Myer</name><affiliation><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></affiliation><affiliation><nlm:aff id="A4">Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA</nlm:aff></affiliation></author><author><name sortKey="Edwards, David" sort="Edwards, David" uniqKey="Edwards D" first="David" last="Edwards">David Edwards</name><affiliation><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></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><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></affiliation></author><author><name sortKey="Wood, Robin" sort="Wood, Robin" uniqKey="Wood R" first="Robin" last="Wood">Robin Wood</name><affiliation><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></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><pmc article-type="research-article"><pmc-comment>The publisher of this article does not allow downloading of the full text in XML form.</pmc-comment>
<pmc-dir>properties manuscript</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-journal-id">8710219</journal-id><journal-id journal-id-type="pubmed-jr-id">1493</journal-id><journal-id journal-id-type="nlm-ta">AIDS</journal-id><journal-id journal-id-type="iso-abbrev">AIDS</journal-id><journal-title-group><journal-title>AIDS (London, England)</journal-title></journal-title-group><issn pub-type="ppub">0269-9370</issn><issn pub-type="epub">1473-5571</issn></journal-meta><article-meta><article-id pub-id-type="pmid">19461502</article-id><article-id pub-id-type="pmc">3801095</article-id><article-id pub-id-type="doi">10.1097/QAD.0b013e32832d3b6d</article-id><article-id pub-id-type="manuscript">NIHMS514764</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Short-term and long-term risk of tuberculosis associated with CD4 cell recovery during antiretroviral therapy in South Africa</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Lawn</surname><given-names>Stephen D</given-names></name><xref ref-type="aff" rid="A1">a</xref><xref ref-type="aff" rid="A2">b</xref></contrib><contrib contrib-type="author"><name><surname>Myer</surname><given-names>Landon</given-names></name><xref ref-type="aff" rid="A3">c</xref><xref ref-type="aff" rid="A4">d</xref></contrib><contrib contrib-type="author"><name><surname>Edwards</surname><given-names>David</given-names></name><xref ref-type="aff" rid="A1">a</xref></contrib><contrib contrib-type="author"><name><surname>Bekker</surname><given-names>Linda-Gail</given-names></name><xref ref-type="aff" rid="A1">a</xref></contrib><contrib contrib-type="author"><name><surname>Wood</surname><given-names>Robin</given-names></name><xref ref-type="aff" rid="A1">a</xref></contrib></contrib-group><aff id="A1"><label>a</label>The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</aff><aff id="A2"><label>b</label>Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK</aff><aff id="A3"><label>c</label>Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa</aff><aff id="A4"><label>d</label>Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA</aff><author-notes><corresp id="cor1">Correspondence to Stephen D. Lawn, Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa. Tel: +27 21 650 6957; fax: +27 21 650 6963; <email>stevelawn@yahoo.co.uk</email></corresp></author-notes><pub-date pub-type="nihms-submitted"><day>4</day><month>9</month><year>2013</year></pub-date><pub-date pub-type="ppub"><day>24</day><month>8</month><year>2009</year></pub-date><pub-date pub-type="pmc-release"><day>21</day><month>10</month><year>2013</year></pub-date><volume>23</volume><issue>13</issue><fpage>1717</fpage><lpage>1725</lpage><abstract><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></abstract><kwd-group><kwd>Africa</kwd><kwd>antiretroviral</kwd><kwd>CD4 cell</kwd><kwd>HIV</kwd><kwd>immune reconstitution</kwd><kwd>resource-limited country</kwd><kwd>tuberculosis</kwd></kwd-group><funding-group><award-group><funding-source country="United States">National Institute of Allergy and Infectious Diseases Extramural Activities : NIAID</funding-source><award-id>U19 AI053217 || AI</award-id></award-group><award-group><funding-source country="United States">National Institute of Allergy and Infectious Diseases Extramural Activities : NIAID</funding-source><award-id>R01 AI058736 || AI</award-id></award-group></funding-group></article-meta></front></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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