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Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

Efsen AM, Schultze A, Post FA, Panteleev A, Furrer H, Miller RF, Losso MH, Toibaro J, Skrahin A, Miro JM, Caylà JA, Girardi E, Bruyand M, Obel N, Podlekareva DN, Lundgren JD, Mocroft A, Kirk O, TB:HIV study group in EuroCoo - PLoS ONE (2015)

Bottom Line: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE).Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

View Article: PubMed Central - PubMed

Affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

ABSTRACT

Objectives: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE). We aimed to study clinical characteristics, factors associated with MDR-TB and predicted activity of empiric anti-TB treatment at time of TB diagnosis among TB/HIV coinfected patients in EE, Western Europe (WE) and Latin America (LA).

Design and methods: Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.

Results: Significant differences were observed between EE (N = 844), WE (N = 152), SE (N = 164), and LA (N = 253) in the proportion of patients with a definite TB diagnosis (47%, 71%, 72% and 40%, p<0.0001), MDR-TB (40%, 5%, 3% and 15%, p<0.0001), and use of combination antiretroviral therapy (cART) (17%, 40%, 44% and 35%, p<0.0001). Injecting drug use (adjusted OR (aOR) = 2.03 (95% CI 1.00-4.09), prior anti-TB treatment (3.42 (1.88-6.22)), and living in EE (7.19 (3.28-15.78)) were associated with MDR-TB. Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

Conclusions: In EE, TB/HIV patients were less likely to receive a definite TB diagnosis, more likely to house MDR-TB and commonly received empiric anti-TB treatment with reduced activity. Improved management of TB/HIV patients in EE requires better access to TB diagnostics including DSTs, empiric anti-TB therapy directed at both susceptible and MDR-TB, and more widespread use of cART.

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Related in: MedlinePlus

Susceptibility of empiric anti-TB treatment (a)1 and hypothetical susceptibility presuming RHZE had been initiated (b)2.1The number of active drugs for a patient was calculated based on initial anti-TB therapy and DST results within the first month of therapy (available for 585/1396 patients). 2The number of active drugs in the initial anti-TB treatment regimen, assuming RHZE had been initiated in all subjects (available for 585/1396 patients).
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pone.0145380.g003: Susceptibility of empiric anti-TB treatment (a)1 and hypothetical susceptibility presuming RHZE had been initiated (b)2.1The number of active drugs for a patient was calculated based on initial anti-TB therapy and DST results within the first month of therapy (available for 585/1396 patients). 2The number of active drugs in the initial anti-TB treatment regimen, assuming RHZE had been initiated in all subjects (available for 585/1396 patients).

Mentions: For patients with DST results available, we next calculated the average number of active drugs used in the empiric anti-TB treatment regimen in relation to the subsequent DST results. The proportion of participants who received treatment with at least three active drugs ranged from 66% in EE to 90–96% in the other regions, p<0.0001, Fig 3a). Worryingly, the empiric regimen contained one or two active drugs in 25% of patients in EE, and no active drugs at all in 9%. These results did not change in sensitivity analyses restricted to individuals with full resistance profiles available. We next assumed resistance to all drugs for which no DST data were available, and the proportion receiving empiric therapy with at least three active drugs ranged from 32% and 39% in LA and EE to 75–80% in the other regions, p<0.0001, underlining that a full DST report was not available for many patients in EE and LA. Routine use of RHZE as the empiric anti-TB regimen would have had minimal impact on the proportion of patients who received at least three active drugs in all regions (Fig 3b).


Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

Efsen AM, Schultze A, Post FA, Panteleev A, Furrer H, Miller RF, Losso MH, Toibaro J, Skrahin A, Miro JM, Caylà JA, Girardi E, Bruyand M, Obel N, Podlekareva DN, Lundgren JD, Mocroft A, Kirk O, TB:HIV study group in EuroCoo - PLoS ONE (2015)

Susceptibility of empiric anti-TB treatment (a)1 and hypothetical susceptibility presuming RHZE had been initiated (b)2.1The number of active drugs for a patient was calculated based on initial anti-TB therapy and DST results within the first month of therapy (available for 585/1396 patients). 2The number of active drugs in the initial anti-TB treatment regimen, assuming RHZE had been initiated in all subjects (available for 585/1396 patients).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4696866&req=5

pone.0145380.g003: Susceptibility of empiric anti-TB treatment (a)1 and hypothetical susceptibility presuming RHZE had been initiated (b)2.1The number of active drugs for a patient was calculated based on initial anti-TB therapy and DST results within the first month of therapy (available for 585/1396 patients). 2The number of active drugs in the initial anti-TB treatment regimen, assuming RHZE had been initiated in all subjects (available for 585/1396 patients).
Mentions: For patients with DST results available, we next calculated the average number of active drugs used in the empiric anti-TB treatment regimen in relation to the subsequent DST results. The proportion of participants who received treatment with at least three active drugs ranged from 66% in EE to 90–96% in the other regions, p<0.0001, Fig 3a). Worryingly, the empiric regimen contained one or two active drugs in 25% of patients in EE, and no active drugs at all in 9%. These results did not change in sensitivity analyses restricted to individuals with full resistance profiles available. We next assumed resistance to all drugs for which no DST data were available, and the proportion receiving empiric therapy with at least three active drugs ranged from 32% and 39% in LA and EE to 75–80% in the other regions, p<0.0001, underlining that a full DST report was not available for many patients in EE and LA. Routine use of RHZE as the empiric anti-TB regimen would have had minimal impact on the proportion of patients who received at least three active drugs in all regions (Fig 3b).

Bottom Line: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE).Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

View Article: PubMed Central - PubMed

Affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

ABSTRACT

Objectives: Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE). We aimed to study clinical characteristics, factors associated with MDR-TB and predicted activity of empiric anti-TB treatment at time of TB diagnosis among TB/HIV coinfected patients in EE, Western Europe (WE) and Latin America (LA).

Design and methods: Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.

Results: Significant differences were observed between EE (N = 844), WE (N = 152), SE (N = 164), and LA (N = 253) in the proportion of patients with a definite TB diagnosis (47%, 71%, 72% and 40%, p<0.0001), MDR-TB (40%, 5%, 3% and 15%, p<0.0001), and use of combination antiretroviral therapy (cART) (17%, 40%, 44% and 35%, p<0.0001). Injecting drug use (adjusted OR (aOR) = 2.03 (95% CI 1.00-4.09), prior anti-TB treatment (3.42 (1.88-6.22)), and living in EE (7.19 (3.28-15.78)) were associated with MDR-TB. Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).

Conclusions: In EE, TB/HIV patients were less likely to receive a definite TB diagnosis, more likely to house MDR-TB and commonly received empiric anti-TB treatment with reduced activity. Improved management of TB/HIV patients in EE requires better access to TB diagnostics including DSTs, empiric anti-TB therapy directed at both susceptible and MDR-TB, and more widespread use of cART.

Show MeSH
Related in: MedlinePlus