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Lancet HIV. 2015 Jun;2(6):e243-51. doi: 10.1016/S2352-3018(15)00063-6. Epub 2015 May 17.

Does antiretroviral therapy reduce HIV-associated tuberculosis incidence to background rates? A national observational cohort study from England, Wales, and Northern Ireland.

Author information

1
Division of Medicine, University College London, London, UK; HIV/STI Department, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK. Electronic address: rishi.gupta@doctors.org.uk.
2
HIV/STI Department, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.
3
TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.
4
TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; Centre for Infectious Disease Epidemiology, University College London, London, UK.
5
TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
6
Chelsea & Westminster Hospitals NHS Foundation Trust, London, UK.
7
TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; MRC Clinical Trials Unit and Centre for Infectious Disease Epidemiology, University College London, London, UK.
8
Division of Medicine, University College London, London, UK.

Abstract

BACKGROUND:

Whether the incidence of tuberculosis in HIV-positive people receiving long-term antiretroviral therapy (ART) remains above background population rates is unclear. We compared tuberculosis incidence in people receiving ART with background rates in England, Wales, and Northern Ireland.

METHODS:

We analysed a national cohort of HIV-positive individuals linked to the national tuberculosis register. Tuberculosis incidence in the HIV-positive cohort (2007-11) was stratified by ethnic origin and time on ART and compared with background rates (2009). Ethnic groups were defined as follows: the black African group included all individuals of black African origin, including those born in the UK and overseas; the white ethnic group included all white individuals born in the UK and overseas; the south Asian group included those of Indian, Pakistani, and Bangladeshi origin, born in the UK and overseas; and the other ethnic group included all other ethnic origins, including black Afro-Caribbeans.

FINDINGS:

The HIV-positive cohort comprised 79 919 individuals, in whom there were 1550 incident cases in 231 664 person-years of observation (incidence 6·7 cases per 1000 person-years). Incidence of tuberculosis in the HIV-positive cohort was 13·6 per 1000 person-years in black Africans and 1·7 per 1000 person-years in white individuals. Incidence of tuberculosis during long-term ART (≥5 years) in black Africans with HIV was 2·4 per 1000 person-years, similar to background rates of 1·9 per 1000 person-years in this group (rate ratio 1·2, 95% CI 0·96-1·6; p=0·083); but in white individuals with HIV on long-term ART the incidence of 0·5 per 1000 person-years was higher than the background rate of 0·04 per 1000 person-years (rate ratio 14·5, 9·4-21·3; p<0·0001). The increased incidence relative to background in white HIV-positive individuals persisted when analysis was restricted to person-time accrued on ART with CD4 counts of at least 500 cells per μL and when white HIV-positive individuals born abroad were excluded.

INTERPRETATION:

Tuberculosis incidence is unacceptably high irrespective of HIV status in black Africans. In white individuals with HIV, tuberculosis incidence is significantly higher than background rates in white people despite long-term ART. Expanded testing and treatment for latent tuberculosis infection to all HIV-infected adults, irrespective of ART status and CD4 cell count, might be warranted.

FUNDING:

Public Health England.

PMID:
26423197
DOI:
10.1016/S2352-3018(15)00063-6
[Indexed for MEDLINE]

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