Late Diagnosis and Mortality Decrease among HIV Positive People
The rate of death due to tuberculosis (TB) in the
U.S. has decreased by half since the early 1990s,
mostly attributable to a reduction among HIV positive
people, according to a study described in the November
26, 2010 Morbidity and Mortality Weekly Report.
What's more, among people with HIV, the proportion
who were not diagnosed with TB until after they
died also declined, reflecting better access to
for Disease Control and Prevention (CDC) investigators looked
at the effect of HIV infection on the risk of death during
treatment for tuberculosis in
Worldwide, TB incidence increased from 125 cases per 100,000
people in 1990 to 142 cases per 100,000 in 2004, primarily
due to the HIV epidemic, the study authors noted as background.
People with HIV are at increased risk for TB infection and
development of TB disease, and also have a higher risk of
"This is documented most clearly in resource-limited
settings, where limited access to antiretroviral
therapy (ART) and other health care services contribute
to the elevated mortality," they wrote.
The impact of HIV on TB
outcomes is less clear in high-income countries such as the
U.S., however. In this study, investigators analyzed data
from all culture-positive patients with TB documented between
1993 and 2008, as reported to the CDC's National TB Surveillance
proportion of TB patients with documented HIV test results
increased substantially, from 36% in 1993 to 79% in 2008.
proportion of all TB patients who died during TB treatment
decreased from 18% (2445 out of 13,629) in 1993 to 9%
(682 out of 7578) in 2006.
patients coinfected with TB and HIV, 41% (950 out of 2337)
died during treatment in 1993, falling to 20% (131 of
663) in 2006.
HIV negative TB patients, 8% died during treatment in
1993 compared with 5% in 2006.
proportion of HIV/TB coinfected patients who were first
diagnosed with TB after death fell from 7% (191 out of
2927) in 1993 to 4% (32 out of 768) in 2006.
addition, among TB patients with unknown HIV status, 6%
(624 out of 10,468) were diagnosed with TB after death
in 1993, but this proportion did not decline over time.
findings show that the decrease in deaths among people with
TB between 1993 and 2008 was mostly entirely attributable
to a reduction in mortality among people with HIV.
"In 2008, however, 21% of patients with TB still had
unknown HIV status, and this proportion was even higher in
certain demographic groups," wrote the authors of an
accompanying editorial note. "This is unacceptable given
that knowledge of HIV status is essential for appropriate
treatment and that current guidelines recommend HIV testing
for all patients with TB in the United States."
Based on these results, the investigators recommended, "Further
reductions in mortality can be achieved by enhanced TB/HIV
program collaboration and service integration."
Investigator affiliations: Dept of Medicine, Albert Einstein
College of Medicine, Bronx, NY; Div of TB Elimination, National
Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention;
EIS Officer, CDC.
Shah, K Cain, S Marks, and others. Mortality Among Patients
with Tuberculosis and Associations with HIV Status -- United
States, 1993 -- 2008. Morbidity and Mortality Weekly Report
59(46): 1509-1513 (Abstract).
November 26, 2010.