Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low- and middle-income countries: a multicohort study

the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium

Research output: Contribution to journalArticle

Abstract

Introduction: Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under-resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV-positive adults in antiretroviral therapy (ART) programmes in low- and middle-income countries (LMIC). Methods: We collected data from HIV-positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub-Saharan Africa, Asia-Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes. Results and Discussion: We analysed 2695 HIV-positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/μL (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result. Conclusions: Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.

Original languageEnglish (US)
Article numbere25392
JournalJournal of the International AIDS Society
Volume22
Issue number9
DOIs
StatePublished - Sep 1 2019
Externally publishedYes

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Tuberculosis
Pulmonary Tuberculosis
Therapeutics
Odds Ratio
HIV
Nucleic Acid Amplification Techniques
Central America
Meninges
Meningeal Tuberculosis
Mortality
Pleura
South America
Africa South of the Sahara
CD4 Lymphocyte Count
Routine Diagnostic Tests
Abdomen
Microscopy
Acquired Immunodeficiency Syndrome
Epidemiology
Logistic Models

Keywords

  • diagnostics
  • extrapulmonary tuberculosis
  • HIV-positive patients
  • lost to follow-up
  • low- and middle-income countries
  • mortality
  • pulmonary tuberculosis
  • tuberculosis

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Infectious Diseases

Cite this

Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low- and middle-income countries : a multicohort study. / the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium.

In: Journal of the International AIDS Society, Vol. 22, No. 9, e25392, 01.09.2019.

Research output: Contribution to journalArticle

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title = "Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low- and middle-income countries: a multicohort study",
abstract = "Introduction: Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under-resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV-positive adults in antiretroviral therapy (ART) programmes in low- and middle-income countries (LMIC). Methods: We collected data from HIV-positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub-Saharan Africa, Asia-Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes. Results and Discussion: We analysed 2695 HIV-positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41{\%}), and the median CD4 count at TB treatment start was 114 cells/μL (IQR 40 to 248). Overall, 1930 had PTB (72{\%}), and 765 EPTB (28{\%}). Among EPTB patients, the most frequently involved sites were the lymph nodes (24{\%}), pleura (15{\%}), abdomen (11{\%}) and meninges (6{\%}). The majority of PTB (1123 of 1930, 58{\%}) and EPTB (582 of 765, 76{\%}) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52{\%}) and 183 of 438 EPTB (42{\%}) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95{\%} CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95{\%} CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95{\%} CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95{\%} CI 0.1 to 0.8) compared to TB patients with a negative test result. Conclusions: Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.",
keywords = "diagnostics, extrapulmonary tuberculosis, HIV-positive patients, lost to follow-up, low- and middle-income countries, mortality, pulmonary tuberculosis, tuberculosis",
author = "{the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium} and Kathrin Z{\"u}rcher and Marie Ballif and Sasisopin Kiertiburanakul and Henri Chenal and Marcel Yotebieng and Beatriz Grinsztejn and Denna Michael and Sterling, {Timothy R.} and Ngonyani, {Kapella M.} and Mandalakas, {Anna M.} and Matthias Egger and Pettit, {April C.} and Lukas Fenner and Valdilea Veloso and Paula Luz and {de Boni}, Raquel and Wagner, {Sandra Cardoso} and Ruth Friedman and Ronaldo Moreira and Madero, {Juan Sierra} and Ramirez, {Brenda Crabtree} and Paco Belaunzaran and Vega, {Yanink Caro} and Eduardo Gotuzzo and Fernando Mejia and Gabriela Carriquiry and McGowan, {Catherine C.} and Shepherd, {Bryan E.} and Timothy Sterling and Karu Jayathilake and Person, {Anna K.} and Rebeiro, {Peter F.} and Mark Giganti and Jessica Castilho and Duda, {Stephany N.} and Fernanda Maruri and Hilary Vansell and E. Uy and R. Bantique and A. vihingsanon and S. Gatechompol and P. Phanuphak and C. Phadungphon and S. Kiertiburanakul and A. Phuphuakrat and L. Chumla and N. Sanmeema and Nguyen, {K. V.} and Bui, {H. V.} and Nguyen, {D. T.H.}",
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TY - JOUR

T1 - Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low- and middle-income countries

T2 - a multicohort study

AU - the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium

AU - Zürcher, Kathrin

AU - Ballif, Marie

AU - Kiertiburanakul, Sasisopin

AU - Chenal, Henri

AU - Yotebieng, Marcel

AU - Grinsztejn, Beatriz

AU - Michael, Denna

AU - Sterling, Timothy R.

AU - Ngonyani, Kapella M.

AU - Mandalakas, Anna M.

AU - Egger, Matthias

AU - Pettit, April C.

AU - Fenner, Lukas

AU - Veloso, Valdilea

AU - Luz, Paula

AU - de Boni, Raquel

AU - Wagner, Sandra Cardoso

AU - Friedman, Ruth

AU - Moreira, Ronaldo

AU - Madero, Juan Sierra

AU - Ramirez, Brenda Crabtree

AU - Belaunzaran, Paco

AU - Vega, Yanink Caro

AU - Gotuzzo, Eduardo

AU - Mejia, Fernando

AU - Carriquiry, Gabriela

AU - McGowan, Catherine C.

AU - Shepherd, Bryan E.

AU - Sterling, Timothy

AU - Jayathilake, Karu

AU - Person, Anna K.

AU - Rebeiro, Peter F.

AU - Giganti, Mark

AU - Castilho, Jessica

AU - Duda, Stephany N.

AU - Maruri, Fernanda

AU - Vansell, Hilary

AU - Uy, E.

AU - Bantique, R.

AU - vihingsanon, A.

AU - Gatechompol, S.

AU - Phanuphak, P.

AU - Phadungphon, C.

AU - Kiertiburanakul, S.

AU - Phuphuakrat, A.

AU - Chumla, L.

AU - Sanmeema, N.

AU - Nguyen, K. V.

AU - Bui, H. V.

AU - Nguyen, D. T.H.

PY - 2019/9/1

Y1 - 2019/9/1

N2 - Introduction: Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under-resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV-positive adults in antiretroviral therapy (ART) programmes in low- and middle-income countries (LMIC). Methods: We collected data from HIV-positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub-Saharan Africa, Asia-Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes. Results and Discussion: We analysed 2695 HIV-positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/μL (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result. Conclusions: Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.

AB - Introduction: Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under-resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV-positive adults in antiretroviral therapy (ART) programmes in low- and middle-income countries (LMIC). Methods: We collected data from HIV-positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub-Saharan Africa, Asia-Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes. Results and Discussion: We analysed 2695 HIV-positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/μL (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result. Conclusions: Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.

KW - diagnostics

KW - extrapulmonary tuberculosis

KW - HIV-positive patients

KW - lost to follow-up

KW - low- and middle-income countries

KW - mortality

KW - pulmonary tuberculosis

KW - tuberculosis

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DO - 10.1002/jia2.25392

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VL - 22

JO - Journal of the International AIDS Society

JF - Journal of the International AIDS Society

SN - 1758-2652

IS - 9

M1 - e25392

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