HIV as a Risk Factor for Multi-Drug Resistant Tuberculosis: A Systematic Review

Winstone Zulu is featured prominently in a tuberculosis (TB) and HIV awareness campaign sponsored by the Stop TB Partnership, a network of organizations, countries and donors that have made the elimination of tuberculosis a priority. He is a Zambian who contracted HIV and later acquired infection with TB. He managed to survive the coinfection when so many around him, including four of his brothers, died of tuberculosis in the 1990s. This defining experience led him to become a leading advocate for TB and HIV patients worldwide. Like those in his family, many people in sub-Saharan Africa and throughout the world who suffer from TB and HIV do not survive the deadly combination. The terrifying consequences of the two infections have now become even graver- a newer threat of multi-drug resistant TB (MDR-TB) jeopardizes what little control there is now over the dual epidemic. Understanding the relationship between HIV and MDR-TB has profound implications for the many people like Winstone Zulu's brothers, who have all but received a death sentence.Master of Public Healt

Is HIV Infection a Risk Factor for Multi-Drug Resistant Tuberculosis? A Systematic Review

BACKGROUND:Tuberculosis (TB) is an important cause of human suffering and death. Human immunodeficiency virus (HIV), multi-drug resistant TB (MDR-TB), and extensive drug resistant tuberculosis (XDR-TB) have emerged as threats to TB control. The association between MDR-TB and HIV infection has not yet been fully investigated. We conducted a systematic review and meta-analysis to summarize the evidence on the association between HIV infection and MDR-TB. METHODS AND RESULTS:Original studies providing Mycobacterium tuberculosis resistance data stratified by HIV status were identified using MEDLINE and ISI Web of Science. Crude MDR-TB prevalence ratios were calculated and analyzed by type of TB (primary or acquired), region and study period. Heterogeneity across studies was assessed, and pooled prevalence ratios were generated if appropriate. No clear association was found between MDR-TB and HIV infection across time and geographic locations. MDR-TB prevalence ratios in the 32 eligible studies, comparing MDR-TB prevalence by HIV status, ranged from 0.21 to 41.45. Assessment by geographical region or study period did not reveal noticeable patterns. The summary prevalence ratios for acquired and primary MDR-TB were 1.17 (95% CI 0.86, 1.6) and 2.72 (95% CI 2.03, 3.66), respectively. Studies eligible for review were few considering the size of the epidemics. Most studies were not adjusted for confounders and the heterogeneity across studies precluded the calculation of a meaningful overall summary measure. CONCLUSIONS:We could not demonstrate an overall association between MDR-TB and HIV or acquired MDR-TB and HIV, but our results suggest that HIV infection is associated with primary MDR-TB. Future well-designed studies and surveillance in all regions of the world are needed to better clarify the relationship between HIV infection and MDR-TB

Factors Associated with HIV Testing Among Public Sector Clinic Attendees in Johannesburg, South Africa

Uptake of VCT remains low in many sub-Saharan African countries. Men and women aged 15 and older were recruited from a family planning, STI, and VCT clinic in inner-city Johannesburg between 2004 and 2005 to take part in a cross-sectional survey on HIV testing (n = 198). Fourty-eight percent of participants reported previously testing for HIV and, of these, 86.9% reported disclosing their status to their sex partner. In multivariable analyses, individuals whose partners had been tested; for HIV were more likely to have tested (AOR 2.92 95% CI: 1.38–6.20). In addition, those who reported greater blame/shame attitudes towards people living with HIV/AIDS were less likely to have tested (AOR 0.35; 95% CI: 0.16-0.77) while those reporting more equitable attitudes towards people living with HIV/AIDS were more likely to have tested (AOR 2.87; 95% CI: 1.20-6.86). Promotion of and increased access to couples HIV testing should be made available within the South African context

The hidden economic and environmental costs of antimicrobial therapies: a call to action

The overuse and inappropriate use of antimicrobials have led to environmental waste and drug shortages. This challenges the ecological and economical sustainability of our healthcare system and worsens antimicrobial resistance

Forest plot of MDR-TB prevalence ratios by HIV status and corresponding 95% confidence intervals by geographical region^*.

<p>^*Clark O; Djulbegovic B. Forest plots in excel software (Data sheet). 2001. Available at <a href="http://www.evidencias.com" target="_blank">www.evidencias.com</a>.</p

Abstract 030: Aspirin Use and Myocardial Infarction in HIV versus Non-HIV Patients

Introduction: Myocardial infarction (MI) risk is increased among HIV populations, but the use of aspirin (ASA) for primary prevention of MI has not been investigated in this group. Hypothesis: We hypothesized that ASA use would be associated with a decreased risk of incident MI in both HIV and matched control patients. Methods: Patients who received care from the Partners HealthCare System in Boston between 2000 and 2009 without baseline coronary heart disease (CHD) were included. Non-HIV patients were matched to HIV patients by demographic factors, with 33,348 control and 3,698 HIV patients. To ascertain non-episodic ASA use, we developed an algorithm combining medication data and electronic health record free text search and validated it using medical record review. We used a definition of at least two ASA prescriptions, two text strings, or one of each, all occurring more than 30 days prior to MI (sensitivity 73%, specificity 83%, AUC 78%). We used Cox proportional hazard modeling to assess the association between ASA use and first MI within the HIV and control groups. We further assessed the effect of ASA in models stratified by cardiovascular risk (low CHD risk = 0-1 traditional risk factors, high CHD risk = 2 or more risk factors), to minimize potential confounding by indication. Results: ASA use was significantly lower in HIV compared to non-HIV patients in the overall groups (12.4% vs. 15.3%, p&lt;0.001) and among men (13.1% vs. 17.3%, p&lt;0.001) but not among women. The relative difference in the rates of ASA use between HIV and non-HIV was greater among patients at high CHD risk (22.1% vs. 42.4%, p&lt;0.001) compared to patients at low CHD risk (5.5% vs. 6.7%, p=.037). Similar patterns were seen within each gender. In multivariate models adjusting for CHD and HIV-related factors, ASA use was not associated with decreased MI risk among HIV patients overall (HR 0.97, 95% confidence interval [CI] 0.64-1.49, p=0.90), by CHD risk category or by gender. In contrast, ASA use was associated with significantly decreased MI risk in the non-HIV group in models adjusted for traditional CHD risk factors, with a reduced hazard of 71% (95% CI: 66%-76%). Relative risk reduction for MI in the non-HIV group was more pronounced among patients with high underlying CHD risk (71% vs. 57% in low CHD risk) and among males (76% vs. 50% in females). Conclusions: ASA use was relatively lower in HIV compared to matched control patients, particularly among those with high underlying CHD risk. In contrast to non-HIV patients for whom ASA was significantly associated with decreased MI risk, ASA did not show this effect among HIV patients. Further studies will help to establish whether patients with HIV disease may represent a subgroup in which ASA is less effective for primary prevention of MI. </jats:p

MDR-TB Prevalence ratio by HIV prevalence among study participants and by region^*.

<p>^*One outlier from the Latin American region (HIV Prevalence: 0.20, Prevalence Ratio: 45) is not presented.</p