Joanna d’Arc Lyra Batista

Smoking increases the risk of relapse after successful tuberculosis treatment

Background Recent tobacco smoking has been identified as a risk factor for developing tuberculosis, and two studies which have investigated its association with relapse of tuberculosis after completion of treatment had conflicting results (and did not control for confounding). The objective of this study was to investigate risk factors for tuberculosis relapse, with emphasis on smoking. Methods A cohort of newly diagnosed TB cases was followed up from their discharge after completion of treatment (in 2001–2003) until October 2006 and relapses of tuberculosis ascertained during that period. A case of relapse was defined as a patient who started a second treatment during the follow up. Results Smoking (OR 2.53, 95% CI 1.23–5.21) and living in an area where the family health program was not implemented (OR 3.61, 95% CI 1.46–8.93) were found to be independently associated with relapse of tuberculosis. Conclusions Our results establish that smoking is associated with relapse of tuberculosis even after adjustment for the socioeconomic variables. Smoking cessation support should be incorporated in the strategies to improve effectiveness of Tuberculosis Control Programs.

Risk factors associated with death in patients who initiate treatment for tuberculosis after two different follow-up periods

INTRODUCTION: Mortality from tuberculosis, which should be a rare event, still affects a large portion of the population of developing countries. In this context, Recife, a city in the northeast of Brazil where this study was developed, has the highest tuberculosis mortality rates of the Brazilian capitals. OBJECTIVE: To analyze survival probability and identify risk factors for death from tuberculosis in a cohort of patients living in Recife who started treatment for tuberculosis. METHODOLOGY: A cohort of newly diagnosed TB cases was followed up from the beginning of treatment (in 2001-2003) until June 2007. Survival probability was estimated by Kaplan-Meier method; and Cox Regression analysis was used to identify risk factors. RESULTS: At the end of the follow-up period, the survival probability after beginning TB treatment was 95.9%. Older ages, positivity for HIV and late initial treatment were statistically associated with death from TB in one year follow-up. When the analysis was done considering the total period of follow-up, older ages, positivity serology for HIV, late initial treatment, weight loss, and history of previous treatment remained in the multivariate Cox regression model. CONCLUSION: A more comprehensive analysis, specifically for deaths from tuberculosis as the underlying and non-underlying cause, allowed identification of a greater number of predictive factors that would otherwise not be detected if follow-up had lasted only until the end of treatment. These results can guide feasible interventions for health services aiming to reduce case-fatality from tuberculosis.

Incidence and risk factors for tuberculosis in people living with HIV: cohort from HIV referral health centers in Recife, Brazil.

Objective To identify the incidence of and risk factors for tuberculosis in people living with HIV (PLHIV). Design Observational, prospective cohort study. Methods A total of 2069 HIV-infected patients was observed between July 2007 and December 2010. The Kaplan-Meier method was used to estimate the probability of survival free of tuberculosis, and Cox regression analysis to identify risk factors associated with the development of tuberculosis. Results Survival free of tuberculosis (TB) was 91%. The incidence rate of tuberculosis was 2.8 per 100 persons/years. Incidence of tuberculosis was higher when subjects had CD4 cell count <200 cells/mm3; were not on antiretroviral therapy; in those who had, a body mass index <18.5 kg/m2, anemia (or were not tested for it), were illiterate or referred previous tuberculosis treatment at entry into the cohort. Those not treated for latent TB infection had a much higher risk (HR = 7.9) of tuberculosis than those with a negative tuberculin skin test (TST). Having a TST≥5 mm but not being treated for latent TB infection increased the risk of incident tuberculosis even in those with a history of previous tuberculosis. Conclusions Preventive actions to reduce the risk of TB in people living with HIV should include an appropriate HAART and treatment for latent TB infection in those with TST≥5 mm. The actions towards enabling rigorous implementation of treatment of latent TB infection and targeting of PLHIV drug users both at the individual and in public health level can reduce substantially the incidence of TB in PLHIV.

Survival of HIV-infected patients after starting tuberculosis treatment: a prospective cohort study.

OBJECTIVES To estimate the probability of survival and to evaluate risk factors for death in a cohort of persons living with human immunodeficiency virus (PLHIV) who had started tuberculosis (TB) treatment. METHODS A prospective cohort study was conducted between June 2007 and December 2009 with HIV-infected patients who had started anti-tuberculosis treatment in the State of Pernambuco, Brazil. Survival data were analysed using the Kaplan-Meier estimator, the log-rank test and the Cox model. Hazard ratios and their respective 95%CIs were estimated. RESULTS Of a cohort of 2310 HIV-positive individuals, 333 patients who had commenced treatment for TB were analysed. The mortality rate was 5.25 per 10,000 person-years (95%CI 4.15-6.63). The probability of survival at 30 months was 74%. Risk factors for death in the study population were being female, age ≥30 years, having anaemia, not using highly active antiretroviral therapy (HAART) during treatment for TB and disseminated TB. Protective factors for death were a CD4 lymphocyte count >200 cells/mm(3) and treatment for TB having started in an out-patient clinic. CONCLUSIONS The use of HAART can prevent deaths among HIV-TB patients, corroborating the efficacy of starting HAART early in individuals with TB.

Prevalence and socioeconomic factors associated with smoking in people living with HIV by sex, in Recife, Brazil

INTRODUCTION Smoking is the leading cause of preventable death in the world. The prevalence of smoking is higher in people infected with HIV than in the general population. Although it is biologically plausible that smoking increases the morbidity and mortality of people living with HIV/AIDS, few studies in developing countries have analyzed the determinants and consequences of smoking in HIV infected people. OBJECTIVE To estimate the prevalence of smoking and identify the socioeconomic factors associated with smoking and smoking cessation in patients with HIV by sex. METHODS A cross-sectional study was conducted with baseline data, obtained from an ongoing prospective cohort study of patients with HIV attending two referral centers in Recife, Northeast Region of Brazil, between July 2007 and October 2009. RESULTS The prevalence of current smoking was 28.9%. For both sexes, smoking was independently associated with heavy alcohol drinking and marijuana use. Among women, smoking was associated with living alone, not being married and illiteracy; and among men, being 40 years or older, low income and using crack. Compared with ex-smokers, current smokers were younger and more likely to be unmarried, heavy drinkers and marijuana users. CONCLUSIONS It is important to incorporate smoking cessation interventions for the treatment of heavy alcohol drinkers and marijuana users with HIV/AIDS, which may increase life expectancy and quality of life, as smoking is related to risk of death, relapse of tuberculosis, and non communicable diseases.

ASSOCIATION BETWEEN SMOKING, CRACK COCAINE ABUSE AND THE DISCONTINUATION OF COMBINATION ANTIRETROVIRAL THERAPY IN RECIFE, PERNAMBUCO, BRAZIL

Despite the effectiveness of combination antiretroviral therapy in the treatment of people living with HIV/AIDS (PLWHA), nonadherence to medication has become a major threat to its effectiveness. This study aimed to estimate the prevalence of self-reported irregular use of antiretroviral therapy and the factors associated with such an irregularity in PLWHA. A cross-sectional study of PLWHA who attended two referral centers in the city of Recife, in Northeastern Brazil, between June 2007 and October 2009 was carried out. The study analyzed socioeconomic factors, social service support and personal habits associated with nonadherence to antiretroviral therapy, adjusted by multivariable logistic regression analysis. The prevalence of PLWHA who reported irregular use of combination antiretroviral therapy (cART) was 25.7%. In the final multivariate model, the irregular use of cART was associated with the following variables: being aged less than 40 years (OR = 1.66, 95%-CI: 1.29-2.13), current smokers (OR = 1.76, 95%-CI: 1.31-2.37) or former smokers (OR = 1.43, 95%-CI: 1.05-1.95), and crack cocaine users (OR = 2.79, 95%-CI: 1.24-6.32). Special measures should be directed towards each of the following groups: individuals aged less than 40 years, smokers, former smokers and crack cocaine users. Measures for giving up smoking and crack cocaine should be incorporated into HIV-control programs in order to promote greater adherence to antiretroviral drugs and thus improve the quality of life and prolong life expectancy.

An evaluation of factors associated with taking and responding positive to the tuberculin skin test in individuals with HIV/AIDS.

BackgroundThe tuberculin skin test (TST) is still the standard test for detecting latent infection by M tuberculosis (LTBI). Given that the Brazilian Health Ministry recommends that the treatment of latent tuberculosis (LTBI) should be guided by the TST results, the present study sets out to describe the coverage of administering the TST in people living with HIV at two referral health centers in the city of Recife, where TST is offered to all patients. In addition, factors associated with the non-application of the test and with positive TST results were also analyzed.MethodsA cross-sectional study was carried out with HIV patients, aged 18 years or over, attending outpatient clinics at the Correia Picanço Hospital/SES/PE and the Oswaldo Cruz/UPE University Hospital, who had been recommended to take the TST, in the period between November 2007 and February 2010. Univariate and multivariate logistic regression analyses were carried out to establish associations between the dependent variable - taking the TST (yes/no), at a first stage analysis, and the independent variables, followed by a second stage analysis considering a positive TST as the dependent variable. The odds ratio was calculated as the measure of association and the confidence interval (CI) at 95% as the measure of accuracy of the estimate.ResultsOf the 2,290 patients recruited, 1087 (47.5%) took the TST. Of the 1,087 patients who took the tuberculin skin test, the prevalence of TST ≥ 5 mm was 21.6% among patients with CD4 ≥ 200 and 9.49% among those with CD4 < 200 (p = 0.002). The patients most likely not to take the test were: men, people aged under 39 years, people with low educational levels and crack users. The risk for not taking the TST was statiscally different for health service. Patients who presented better immunity (CD4 ≥ 200) were more than two and a half times more likely to test positive that those with higher levels of immunodeficiency (CD4 < 200).ConclusionsConsidering that the TST is recommended by the Brazilian health authorities, coverage for taking the test was very low. The most serious implication of this is that LTBI treatment was not carried out for the unidentified TST-positive patients, who may consequently go on to develop TB and eventually die.

Validating a Scoring System for the Diagnosis of Smear-Negative Pulmonary Tuberculosis in HIV-Infected Adults

Background The challenge of diagnosing smear-negative pulmonary TB (tuberculosis) in people living with HIV justifies the use of instruments other than the smear test for diagnosing the disease. Considering the clinical-radiological similarities of TB amongst HIV-infected adults and children, the proposal of this study was to assess the accuracy of a scoring system used to diagnose smear-negative pulmonary TB in children and adolescents, in HIV-infected adults suspected of having smear-negative pulmonary TB. Methods A Phase III validation study aiming to assess the diagnostic accuracy of a scoring system for diagnosing smear-negative pulmonary TB in HIV-infected adults. The study assessed sensitivity, specificity, positive and negative likelihood ratios, and positive and negative predictive values of the scoring system. Three versions of the scoring system were tested. Results From a cohort of 2,382 (HIV-infected adults), 1276 were investigated and 128 were diagnosed with pulmonary TB. Variables associated with the diagnosis of TB were: coughing, weight loss, fever, malnutrition, chest X-ray, and positive tuberculin test. The best diagnostic performance occurred with the scoring system with new scores, with sensitivity = 81.2% (95%-CI 74.5% –88%), specificity = 78% (75.6% –80.4%), PPV = 29.2% (24.5% –33.9%) and NPV = 97.4% (96.4% –98.4%), LR+ = 3.7 (3.4–4.0) and LR− = 0.24 (0.2–0.4). Conclusion The proposed scoring system (with new scores) presented a good capacity for discriminating patients who did not have pulmonary TB, in the studied population. Further studies are necessary in order to validate it, thus permitting the assessment of its use in diagnosing smear-negative pulmonary TB in HIV-infected adults.

Fatores associados à subnotificação de tuberculose com base no Sinan Aids e Sinan Tuberculose

INTRODUCTION Tuberculosis (TB) is one of the worlds major public health problems. Epidemiological surveillance has proved to be an important tool to assist in the control and prevention of communicable diseases such as TB and AIDS. This study aimed to estimate the rate and factors associated with the underreporting of TB among cases of coinfection with human immunodeficiency virus (HIV)/AIDS in the state of Pernambuco, based on data from the TB and Aids Notifiable Diseases Information System (Sinan TB and Sinan AIDS). METHODS A cross-sectional study was carried out based on the records of the TB and AIDS Notification System to identify cases of TB underreporting in the study period. In order to identify underreporting, a probabilistic linkage was undertaken using RecLink III software. RESULTS The rate of TB underreporting was 29%, and the factors associated were: presenting a clinical form of TB as cavitary or unspecified pulmonary TB or having both kinds of TB at the same time; being treated outside the municipality of Recife; and being treated at health services not specialized for HIV/AIDS. DISCUSSION The proportion of underreporting found in our study was lower than that observed in other Brazilian studies that took into account underreporting from mortality data. CONCLUSION The variables associated with underreporting of TB were mostly related to the healthcare system rather than to individual characteristics, which points to the need for training of health professionals in order to notify the information systems correctly.

Índice de massa corporal em pacientes co-infectados pela tuberculose-HIV em hospital de referência da cidade de Recife, estado de Pernambuco, Brasil

Summary The objective of this study was to evaluate the body mass index (BMI) and the main biological, social, clinical and immunological characteristics of patients infected with HIV/AIDS and tuberculosis disease, compared to those HIV infected but with no tuberculosis, in a reference hospital for HIV/AIDS patients in the City of Recife, State of Pernam-buco, Brazil. The study population consisted of 80 HIV/AIDS patients, of whom 40 were co-infected with tuberculosis. The patients had their weight and height measured, and answered a structured questionnaire designed specifically for the purpose of the study. The association between a BMI below 18.5 kg/m 2 (underweight) and tuberculosis disease-HIV co-infection was statistically significant. That association may be a sentinel sign in health services attended by HIV infected patients, aiming to provide them adequate caloric intake. Prospective studies should be carried out to obtain a better understanding of malnutrition as expression of tuberculosis-HIV co-infection, and as an aggravating factor to clinical conditions of their patients.