Several studies in HIV-negative cohorts have suggested that the risk of mortality is increased after tuberculosis (TB) cure, compared to individuals without TB. Data are limited on long-term survival after TB cure among people living with HIV (PLWH).
The study cohort included PLWH who were ≥18 years of age and who were ART-naïve at first clinic visit at a CCASAnet clinical site in Brazil, Chile, Haiti, Honduras, Mexico, or Peru from 2006 to 2015. Baseline TB was defined as TB diagnosed within 30 days before or after enrollment. Follow-up started at 9 months after enrollment or date of TB diagnosis, as a proxy for TB treatment completion in those with baseline TB. We compared time to death among patients with and without baseline TB, using Kaplan-Meier analysis and the log-rank test. We estimated predictors of mortality with univariable and multivariable Cox models, stratified by site and adjusting for baseline TB, sex, mode of transmission, education, age, year of enrollment, and CD4 count.
Of 19,197 patients, 1306 (6.8%) were diagnosed with TB at baseline. Of these, 15,999 patients remained in care 9 months after enrollment and were included in the analysis; 1051 (6.6%) had baseline TB. Patients with TB were more likely to be male, older, less educated, with lower CD4 counts, and residing in Haiti or Peru. Starting 9 months after enrollment (Figure 1), patients with a history of baseline TB had higher long-term mortality compared with those without baseline TB (p-value <0.001). The unadjusted 5-year mortality (measured from 9 months after enrollment) was 10.0% for patients with baseline TB vs. 5.6% in those without baseline TB; 10-year mortality was 19.1% vs. 10.5%, respectively. In multivariable Cox models, increased mortality was associated with baseline TB (hazard ratio [HR]=1.53, 95% confidence interval [CI]: 1.21-1.93), lower CD4 count (100 vs. 350 cells/mm3: HR=1.59, 95% CI: 1.45-1.76; 500 vs. 350 cells/mm3: HR=0.89, 95% CI: 0.81-0.99), older age (age 55 vs. 35: HR=1.52, 95% CI: 1.29-1.79), and lower education (none vs. at least secondary: HR=1.21, 95% CI: 0.90-1.64).
PLWH who present with baseline TB have an elevated risk of long-term mortality, even after TB treatment completion. Further study is necessary to understand the long-term clinical impact of TB disease in PLWH.