Malawi/SA Study highlights need for better management of TB and HIV co-infection

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A study from South Africa and Malawi highlights the urgent need for better management of people with TB and HIV co-infection, reports Aidsmap. It shows how suboptimal implementation of TB and HIV standards of care is causing unnecessary human suffering and untimely deaths in people living with co-infection. This study reinforces the necessity of due diligence in ensuring that every component of the evidence-based model of care for TB and HIV is taken care of.

The report says the study reported an alarmingly high mortality of 31% at the end of two months. One-third of these deaths took place within one week of hospitalisation, while another third occurred after the patient was discharged.

Despite being preventable, treatable and curable, TB still remains the biggest cause of death for people living with HIV, causing 251,000 deaths in 2018. Missed opportunities of diagnosing and treating TB (and latent TB) in outpatient services and community healthcare settings, especially among people living with HIV, can lead to unnecessary hospitalisation and/or untimely deaths. TB continues to be the top cause of hospitalisation in people living with HIV as well as of deaths of those hospitalised.

This study not only points towards our failure to put into practice scientifically robust ways of managing TB and HIV, but also suggests interventions which can potentially improve TB and HIV programme outcomes.

The report says Dr Ankur Gupta-Wright at the London School of Hygiene and Tropical Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine and colleagues conducted a prospective cohort study, nested within the STAMP randomised controlled trial, in 322 hospitalised patients with TB/HIV co-infection in two hospitals in Malawi and South Africa, between October 2015 and September 2017. The study aimed to describe clinical phenotypes of these patients so as to triage them for intensified care and/or specific interventions to reduce their risk of death.

Background: Tuberculosis (TB) is the major killer of people living with human immunodeficiency virus (HIV) globally, with suboptimal diagnostics and management contributing to high case-fatality rates.
Methods: A prospective cohort of patients with confirmed TB (Xpert MTB/RIF and/or Determine TB-LAM Ag positive) identified through screening HIV-positive inpatients with sputum and urine diagnostics in Malawi and South Africa (Rapid urine-based Screening for Tuberculosis to reduce AIDS Related Mortality in hospitalized Patients in Africa [STAMP] trial). Urine was tested prospectively (intervention) or retrospectively (standard of care arm). We defined baseline clinical phenotypes using hierarchical cluster analysis, and also used Cox regression analysis to identify associations with early mortality (≤56 days).

Results: Of 322 patients with TB confirmed between October 2015 and September 2018, 78.0% had ≥1 positive urine test. Antiretroviral therapy (ART) coverage was 80.2% among those not newly diagnosed, but with median CD4 count 75 cells/µL and high HIV viral loads. Early mortality was 30.7% (99/322), despite near-universal prompt TB treatment. Older age, male sex, ART before admission, poor nutritional status, lower hemoglobin, and positive urine tests (TB-LAM and/or Xpert MTB/RIF) were associated with increased mortality in multivariate analyses. Cluster analysis (on baseline variables) defined 4 patient subgroups with early mortality ranging from 9.8% to 52.5%. Although unadjusted mortality was 9.3% lower in South Africa than Malawi, in adjusted models mortality was similar in both countries (hazard ratio, 0.9; P = .729).
Conclusions: Mortality following prompt inpatient diagnosis of HIV-associated TB remained unacceptably high, even in South Africa. Intensified management strategies are urgently needed, for which prognostic indicators could potentially guide both development and subsequent use.

Ankur Gupta-Wright, Katherine Fielding, Douglas Wilson, Joep J van Oosterhout, Daniel Grint, Henry C Mwandumba, Melanie Alufandika-Moyo, Jurgens A Peters, Lingstone Chiume, Stephen D Lawn, Elizabeth L Corbett

Full Aidsmap report

Clinical Infectious Diseases abstract

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