Mortality in adults with multidrug-resistant tuberculosis and HIV by antiretroviral therapy and tuberculosis drug use: an individual patient data meta-analysis.
Journal
Lancet (London, England)
ISSN: 1474-547X
Titre abrégé: Lancet
Pays: England
ID NLM: 2985213R
Informations de publication
Date de publication:
08 08 2020
08 08 2020
Historique:
received:
08
04
2020
revised:
14
05
2020
accepted:
21
05
2020
entrez:
11
8
2020
pubmed:
11
8
2020
medline:
19
8
2020
Statut:
ppublish
Résumé
HIV-infection is associated with increased mortality during multidrug-resistant tuberculosis treatment, but the extent to which the use of antiretroviral therapy (ART) and anti-tuberculosis medications modify this risk are unclear. Our objective was to evaluate how use of these treatments altered mortality risk in HIV-positive adults with multidrug-resistant tuberculosis. We did an individual patient data meta-analysis of adults 18 years or older with confirmed or presumed multidrug-resistant tuberculosis initiating tuberculosis treatment between 1993 and 2016. Data included ART use and anti-tuberculosis medications grouped according to WHO effectiveness categories. The primary analysis compared HIV-positive with HIV-negative patients in terms of death during multidrug-resistant tuberculosis treatment, excluding those lost to follow up, and was stratified by ART use. Analyses used logistic regression after exact matching on country World Bank income classification and drug resistance and propensity-score matching on age, sex, geographic site, year of multidrug-resistant tuberculosis treatment initiation, previous tuberculosis treatment, directly observed therapy, and acid-fast-bacilli smear-positivity to obtain adjusted odds ratios (aORs) and 95% CIs. Secondary analyses were conducted among those with HIV-infection. We included 11 920 multidrug-resistant tuberculosis patients. 2997 (25%) were HIV-positive and on ART, 886 (7%) were HIV-positive and not on ART, and 1749 (15%) had extensively drug-resistant tuberculosis. By use of HIV-negative patients as reference, the aOR of death was 2·4 (95% CI 2·0-2·9) for all patients with HIV-infection, 1·8 (1·5-2·2) for HIV-positive patients on ART, and 4·2 (3·0-5·9) for HIV-positive patients with no or unknown ART. Among patients with HIV, use of at least one WHO Group A drug and specific use of moxifloxacin, levofloxacin, bedaquiline, or linezolid were associated with significantly decreased odds of death. Use of ART and more effective anti-tuberculosis drugs is associated with lower odds of death among HIV-positive patients with multidrug-resistant tuberculosis. Access to these therapies should be urgently pursued. American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.
Sections du résumé
BACKGROUND
HIV-infection is associated with increased mortality during multidrug-resistant tuberculosis treatment, but the extent to which the use of antiretroviral therapy (ART) and anti-tuberculosis medications modify this risk are unclear. Our objective was to evaluate how use of these treatments altered mortality risk in HIV-positive adults with multidrug-resistant tuberculosis.
METHODS
We did an individual patient data meta-analysis of adults 18 years or older with confirmed or presumed multidrug-resistant tuberculosis initiating tuberculosis treatment between 1993 and 2016. Data included ART use and anti-tuberculosis medications grouped according to WHO effectiveness categories. The primary analysis compared HIV-positive with HIV-negative patients in terms of death during multidrug-resistant tuberculosis treatment, excluding those lost to follow up, and was stratified by ART use. Analyses used logistic regression after exact matching on country World Bank income classification and drug resistance and propensity-score matching on age, sex, geographic site, year of multidrug-resistant tuberculosis treatment initiation, previous tuberculosis treatment, directly observed therapy, and acid-fast-bacilli smear-positivity to obtain adjusted odds ratios (aORs) and 95% CIs. Secondary analyses were conducted among those with HIV-infection.
FINDINGS
We included 11 920 multidrug-resistant tuberculosis patients. 2997 (25%) were HIV-positive and on ART, 886 (7%) were HIV-positive and not on ART, and 1749 (15%) had extensively drug-resistant tuberculosis. By use of HIV-negative patients as reference, the aOR of death was 2·4 (95% CI 2·0-2·9) for all patients with HIV-infection, 1·8 (1·5-2·2) for HIV-positive patients on ART, and 4·2 (3·0-5·9) for HIV-positive patients with no or unknown ART. Among patients with HIV, use of at least one WHO Group A drug and specific use of moxifloxacin, levofloxacin, bedaquiline, or linezolid were associated with significantly decreased odds of death.
INTERPRETATION
Use of ART and more effective anti-tuberculosis drugs is associated with lower odds of death among HIV-positive patients with multidrug-resistant tuberculosis. Access to these therapies should be urgently pursued.
FUNDING
American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.
Identifiants
pubmed: 32771107
pii: S0140-6736(20)31316-7
doi: 10.1016/S0140-6736(20)31316-7
pmc: PMC8094110
mid: NIHMS1693435
pii:
doi:
Substances chimiques
Anti-HIV Agents
0
Antitubercular Agents
0
Types de publication
Journal Article
Meta-Analysis
Langues
eng
Sous-ensembles de citation
IM
Pagination
402-411Subventions
Organisme : Intramural CDC HHS
ID : CC999999
Pays : United States
Organisme : FIC NIH HHS
ID : D43 TW010062
Pays : United States
Commentaires et corrections
Type : CommentIn
Type : ErratumIn
Informations de copyright
Copyright © 2020 Elsevier Ltd. All rights reserved.
Références
Int J Tuberc Lung Dis. 2005 Jun;9(6):640-5
pubmed: 15971391
PLoS One. 2012;7(10):e46943
pubmed: 23115633
Clin Infect Dis. 2018 Apr 3;66(8):1246-1253
pubmed: 29293906
PLoS One. 2018 Aug 22;13(8):e0202469
pubmed: 30133504
N Engl J Med. 2011 Oct 20;365(16):1482-91
pubmed: 22010914
BMC Infect Dis. 2019 Aug 16;19(1):723
pubmed: 31420021
N Engl J Med. 2010 Feb 25;362(8):697-706
pubmed: 20181971
Lancet. 2018 Sep 8;392(10150):821-834
pubmed: 30215381
PLoS One. 2012;7(10):e47542
pubmed: 23094059
Eur Respir J. 2009 May;33(5):1085-94
pubmed: 19164345
BMC Infect Dis. 2015 Oct 28;15:478
pubmed: 26511616
Int J Tuberc Lung Dis. 2012 Jan;16(1):90-7
pubmed: 22236852
Lancet Respir Med. 2018 Sep;6(9):699-706
pubmed: 30001994
PLoS One. 2018 Mar 8;13(3):e0193491
pubmed: 29518098
Lancet. 2010 May 22;375(9728):1798-807
pubmed: 20488525
Lancet. 2014 Apr 5;383(9924):1230-9
pubmed: 24439237
J Clin Epidemiol. 2006 Oct;59(10):1102-9
pubmed: 16980151
PLoS Med. 2018 Jul 11;15(7):e1002591
pubmed: 29995958
Tuberculosis (Edinb). 2012 Sep;92(5):397-403
pubmed: 22789497
PLoS One. 2015 Dec 30;10(12):e0145380
pubmed: 26716686
N Engl J Med. 2011 Oct 20;365(16):1492-501
pubmed: 22010915
PLoS One. 2016 Mar 07;11(3):e0144249
pubmed: 26950554
PLoS One. 2012;7(11):e47370
pubmed: 23144818
Lancet Infect Dis. 2013 Aug;13(8):690-7
pubmed: 23743044
N Engl J Med. 2011 Oct 20;365(16):1471-81
pubmed: 22010913
Braz J Infect Dis. 2018 Jul - Aug;22(4):305-310
pubmed: 30086258