Patients with HIV and tuberculosis in Eastern Europe are nearly four times more likely to die than those living in Western Europe and Latin America, according to study data published in The Lancet Infectious Diseases.
Researchers called the mortality rate “alarmingly high” and said it was associated with modifiable risk factors, highlighting the need for improved TB care in HIV-positive patients living in Eastern Europe, where the co-epidemic is being driven by injection drug use.
“The poorer outcome in this region compared with Western Europe and Latin America was associated with a lower availability of tuberculosis culture tests and drug susceptibility tests [DST], suboptimum initial antituberculosis treatment regimens, and patients’ late presentation with severe immune suppression and disseminated tuberculosis disease,” the researchers wrote. “An urgent need therefore exists to improve and restructure the health care approach for patients with HIV and tuberculosis in this region.”
The researchers studied 1,406 patients aged 16 years and older who were diagnosed with TB during a 3-year period ending Dec. 31, 2013, and who were HIV-positive before or up to 3 months after their TB diagnosis. The patients were enrolled in 62 HIV and TB clinics in 19 countries: nine in Eastern Europe, seven in Western Europe and three in Latin America.
The primary endpoint was death within 1 year of starting TB treatment. Mortality rates were analyzed using Kaplan-Meyer estimates, with Western Europe and Latin America data combined because of the low number of deaths in those regions.
Of the 834 patients studied in the Eastern European countries — Belarus, Estonia, Georgia, Latvia, Lithuania, Poland, Romania, Ukraine and Russia — TB cultures were available for 43%, compared with 50% in Western Europe and Latin America combined. The availability of data for baseline drug susceptibility testing was 35% in Eastern Europe compared with 50% in the other two areas.
Multidrug-resistant TB was diagnosed in 39% of the 254 patients for whom data were available in Eastern Europe, compared with 7% in the other areas. Patients in Eastern Europe who underwent a DST were far less likely — 69% to 95% — to receive initial antituberculosis therapy, including at least three active drugs than in the other areas. According to the researchers, those who started treatment with three or more active drugs in Eastern Europe had a substantially lower risk for death at 1 year (13%) than those who started treatment with fewer than three active drugs (34%).
Within 1 year, 264 of the 1,406 patients had died, including 27% of the patients in Eastern Europe compared with 7% in the other two areas. Patients from Western Europe and Latin America had a 68% reduced risk for death vs. those in Eastern Europe (adjusted HR = 0.33; 95% CI, 0.23-0.48).
“In more than two-thirds of those who died in Eastern Europe, the cause of death was considered to be tuberculosis,” the researchers wrote, “and the excess mortality in this region could not be explained by regional differences in other clinical and demographic prognostic factors such as sex, CD4 cell count at time of tuberculosis diagnosis, receipt of ART, disseminated tuberculosis disease, documented multidrug-resistant tuberculosis, or choice of initial antituberculosis regimen.”
Despite a co-epidemic driven by heroin use, opioid substitution therapy is rarely prescribed because it is either illegal or unavailable — and scarcely supported — the researchers said.
“Many of these patients are not engaged with health care services despite awareness of their HIV diagnosis and are therefore not receiving antiretroviral therapy, which allows immunodeficiency to progress and severe tuberculosis disease to develop,” they wrote. “Meanwhile, management of those patients with HIV and tuberculosis who are engaged in health care seems to be suboptimal.” – by Gerard Gallagher
Disclosure: Podlekareva reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.