HIV-associated extrapulmonary tuberculosis in Thailand: epidemiology and risk factors for death

SummaryBackgroundWe conducted a prospective, multicenter observational cohort study in Thailand to characterize the epidemiology of extrapulmonary tuberculosis (TB) in HIV-infected persons and to identify risk factors for death.MethodsFrom May 2005 to September 2006, we enrolled, interviewed, examined, and performed laboratory tests on HIV-infected adult TB patients and followed them from TB treatment initiation until the end of TB treatment. We conducted multivariate proportional hazards analysis to identify factors associated with death.ResultsOf the 769 patients, pulmonary TB only was diagnosed in 461 (60%), both pulmonary and extrapulmonary TB in 78 (10%), extrapulmonary TB at one site in 223 (29%), and extrapulmonary TB at more than one site in seven (1%) patients. Death during TB treatment occurred in 59 of 308 patients (19%) with any extrapulmonary involvement. In a proportional hazards model, patients with extrapulmonary TB had an increased risk of death if they had meningitis, and a CD4+ T-lymphocyte count <200 cells/μl. Patients who received co-trimoxazole, fluconazole, and antiretroviral therapy during TB treatment had a lower risk of death.ConclusionsAmong HIV-infected patients with TB, extrapulmonary disease occurred in 40% of the patients, particularly in those with advanced immune suppression. Death during TB treatment was common, but the risk of death was reduced in patients who took co-trimoxazole, fluconazole, and antiretroviral therapy

Viral hepatitis and HIV-associated tuberculosis: Risk factors and TB treatment outcomes in Thailand

<p>Abstract</p> <p>Background</p> <p>The occurrence of tuberculosis (TB), human immunodeficiency virus (HIV), and viral hepatitis infections in the same patient poses unique clinical and public health challenges, because medications to treat TB and HIV are hepatotoxic. We conducted an observational study to evaluate risk factors for HBsAg and/or anti-HCV reactivity and to assess differences in adverse events and TB treatment outcomes among HIV-infected TB patients.</p> <p>Methods</p> <p>Patients were evaluated at the beginning, during, and at the end of TB treatment. Blood samples were tested for aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (BR), complete blood count, and CD4+ T lymphocyte cell count. TB treatment outcomes were assessed at the end of TB treatment according to international guidelines.</p> <p>Results</p> <p>Of 769 enrolled patients, 752 (98%) had serologic testing performed for viral hepatitis: 70 (9%) were reactive for HBsAg, 237 (31%) for anti-HCV, and 472 (63%) non-reactive for both markers. At the beginning of TB treatment, 18 (26%) patients with HBsAg reactivity had elevated liver function tests compared with 69 (15%) patients non-reactive to any viral marker (p = 0.02). At the end of TB treatment, 493 (64%) were successfully treated. Factors independently associated with HBsAg reactivity included being a man who had sex with men (adjusted odds ratio [AOR], 2.1; 95% confidence interval [CI], 1.1–4.3) and having low TB knowledge (AOR, 1.8; CI, 1.0–3.0). Factors most strongly associated with anti-HCV reactivity were having injection drug use history (AOR, 12.8; CI, 7.0–23.2) and living in Bangkok (AOR, 15.8; CI, 9.4–26.5). The rate of clinical hepatitis and death during TB treatment was similar in patients HBsAg reactive, anti-HCV reactive, both HBsAg and anti-HCV reactive, and non-reactive to any viral marker.</p> <p>Conclusion</p> <p>Among HIV-infected TB patients living in Thailand, markers of viral hepatitis infection, particularly hepatitis C virus infection, were common and strongly associated with known behavioral risk factors. Viral hepatitis infection markers were not strongly associated with death or the development of clinical hepatitis during TB treatment.</p

Social Stigma and Knowledge of Tuberculosis and HIV among Patients with Both Diseases in Thailand

INTRODUCTION: Disease-related stigma and knowledge are believed to be associated with patients' willingness to seek treatment and adherence to treatment. HIV-associated tuberculosis (TB) presents unique challenges, because TB and HIV are both medically complex and stigmatizing diseases. In Thailand, we assessed knowledge and beliefs about these diseases among HIV-infected TB patients. METHODS: We prospectively interviewed and examined HIV-infected TB patients from three provinces and one national referral hospital in Thailand from 2005-2006. At the beginning of TB treatment, we asked patients standardized questions about TB stigma, TB knowledge, and HIV knowledge. Responses were grouped into scores; scores equal to or greater than the median score of study population were considered high. Multiple logistic regression analysis was used to identify factors associated with scores. RESULTS: Of 769 patients enrolled, 500 (65%) reported high TB stigma, 177 (23%) low TB knowledge, and 379 (49%) low HIV knowledge. Patients reporting high TB stigma were more likely to have taken antibiotics before TB treatment, to have first visited a traditional healer or private provider, to not know that monogamy can reduce the risk of acquiring HIV infection, and to have been hospitalized at enrollment. Patients with low TB knowledge were more likely to have severe TB disease, to be hospitalized at enrollment, to be treated at the national infectious diseases referral hospital, and to have low HIV knowledge. Patients with low HIV knowledge were more likely to know a TB patient and to have low TB knowledge. DISCUSSION: We found that stigma and low disease-specific knowledge were common among HIV-infected TB patients and associated with similar factors. Further research is needed to determine whether reducing stigma and increasing TB and HIV knowledge among the general community and patients reduces diagnostic delay and improves patient outcomes

HIV care and treatment factors associated with improved survival during TB treatment in Thailand: an observational study

<p>Abstract</p> <p>Background</p> <p>In Southeast Asia, HIV-infected patients frequently die during TB treatment. Many physicians are reluctant to treat HIV-infected TB patients with anti-retroviral therapy (ART) and have questions about the added value of opportunistic infection prophylaxis to ART, the optimum ART regimen, and the benefit of initiating ART early during TB treatment.</p> <p>Methods</p> <p>We conducted a multi-center observational study of HIV-infected patients newly diagnosed with TB in Thailand. Clinical data was collected from the beginning to the end of TB treatment. We conducted multivariable proportional hazards analysis to identify factors associated with death.</p> <p>Results</p> <p>Of 667 HIV-infected TB patients enrolled, 450 (68%) were smear and/or culture positive. Death during TB treatment occurred in 112 (17%). In proportional hazards analysis, factors strongly associated with reduced risk of death were ART use (Hazard Ratio [HR] 0.16; 95% confidence interval [CI] 0.07–0.36), fluconazole use (HR 0.34; CI 0.18–0.64), and co-trimoxazole use (HR 0.41; CI 0.20–0.83). Among 126 patients that initiated ART after TB diagnosis, the risk of death increased the longer that ART was delayed during TB treatment. Efavirenz- and nevirapine-containing ART regimens were associated with similar rates of adverse events and death.</p> <p>Conclusion</p> <p>Among HIV-infected patients living in Thailand, the single most important determinant of survival during TB treatment was use of ART. Controlled clinical trials are needed to confirm our findings that early ART initiation improves survival and that the choice of non-nucleoside reverse transcriptase inhibitor does not.</p

Baseline TB stigma, TB knowledge, and HIV knowledge among HIV-infected TB patients in Thailand.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome.</p>a<p>Those with available answers.</p>b<p>Five hundred patients had high TB stigma; 75 did not respond to one or more TB stigma questions.</p>c<p>One hundred and seventy-seven had low TB knowledge; 171 did not respond to one or more TB knowledge questions.</p>d<p>Three hundred and seventy-nine patients had low HIV knowledge; 69 did not respond to one or more HIV knowledge questions.</p

Patient characteristics stratified by TB stigma, TB knowledge, and HIV knowledge.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; CD4, CD4+ T-lymphocyte.</p>a<p>Those with available results only.</p>b<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p>c<p>Patients who reported having a cough lasting greater than one month before TB diagnosis or had other symptoms that lasted longer than 14 days and self-assessed these symptoms as being severe.</p>d<p>High TB stigma defined as TB stigma score ≥1; low TB knowledge defined as TB knowledge score<5; and low HIV knowledge defined as HIV knowledge score<5.</p

Bivariable and multiple logistic regression analyses of predictors for having low TB knowledge^a among HIV-infected TB patients.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; CD4, CD4+ T-lymphocyte; variables for which p≤0.20 in bivariable analyses and potential confounders were included in multiple logistic regression analysis.</p>a<p>TB knowledge score<5; TB knowledge score is a summary score of the number of TB knowledge questions (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0006360#pone-0006360-t002" target="_blank">table 2</a> - each question is worth 1 point) that a patient correctly answered.</p>b<p>Compared with being treated in Bangkok.</p>c<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p

Bivariable and multiple logistic regression analyses of predictors for having low HIV knowledge^a among HIV-infected TB patients.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; variables for which p≤0.20 in bivariable analyses and potential confounders were included in multiple logistic regression analysis.</p>a<p>HIV knowledge score<5; HIV knowledge score is a summary score of the number of HIV knowledge questions (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0006360#pone-0006360-t002" target="_blank">table 2</a> - each question is worth 1 point) that a patient correctly answered.</p>b<p>Compared with being treated in Bangkok.</p>c<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p

Bivariable and multiple logistic regression analyses of predictors for having high TB stigma^a among HIV-infected TB patients.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; variables for which p≤0.20 in bivariable analyses and potential confounders were included in multiple logistic regression analysis.</p>a<p>TB stigma score ≥1; TB stigma score is a summary score of the number of TB stigma questions (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0006360#pone-0006360-t001" target="_blank">Table 1</a>; each question was worth 1 point) that a patient answered consistent with stigma.</p>b<p>Compared with being treated in Bangkok.</p>c<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p