title: The clinical burden of tuberculosis among human immunodeficiency virus-infected children in Western Kenya and the impact of combination antiretroviral treatment.
abstract: BACKGROUND
  The burden of tuberculosis (TB) disease in children, particularly in HIV-infected children, is poorly described because of a lack of effective diagnostic tests and the emphasis of public health programs on transmissible TB.
  
  
  OBJECTIVE
  The objectives of this study were to describe the observed incidence of and risk factors for TB diagnosis among HIV-infected children enrolled in a large network of HIV clinics in western Kenya.
  
  
  METHODS
  Retrospective observational study.
  
  
  METHODS
  The USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership is Kenya's largest HIV/AIDS care system. Since 2001, the program has enrolled over 70,000 HIV-infected patients in 18 clinics throughout Western Kenya.
  
  
  METHODS
  This analysis included all HIV-infected children aged 0 to 13 years attending an AMPATH clinic.
  
  
  METHODS
  The primary outcome was a diagnosis of any TB, defined either by a recorded diagnosis or by the initiation of anti-TB treatment. Diagnosis of TB is based on a modified Kenneth Jones scoring system and is consistent with WHO case definitions.
  
  
  RESULTS
  There were 6535 HIV-infected children aged 0 to 13 years, eligible for analysis, 50.1% were female. Of these, 234 (3.6%) were diagnosed with TB at enrollment. There were subsequently 765 new TB diagnoses in 4368.0 child-years of follow-up for an incidence rate of 17.5 diagnoses (16.3-18.8) per 100 child-years. The majority of these occurred in the first 6 months after enrollment (IR: 106.8 per 100 CY, 98.4-115.8). In multivariable analysis, being severely immune-suppressed at enrollment (Adjusted Hazard Ratio [AHR]: 4.44, 95% CI: 3.62-5.44), having ever attended school AHR: 2.65, 95% CI: 2.15-3.25), being an orphan (AHR: 1.57, 95% CI: 1.28-1.92), being severely low weight-for-height at enrollment (AHR: 1.46, 95% CI: 1.32-1.62), and attending an urban clinic (AHR: 1.39, 95% CI: 1.16-1.67) were all independent risk factors for having an incident TB diagnosis. Children receiving combination antiretroviral treatment were dramatically less likely to be diagnosed with incident TB (AHR: 0.15, 95% CI: 0.12-0.20).
  
  
  CONCLUSIONS
  These data suggest a high rate of TB diagnosis among HIV-infected children, with severe immune suppression, school attendance, orphan status, very low weight-for-height, and attending an urban clinic being key risk factors. The use of combination antiretroviral treatment reduced the probability of an HIV-infected child being diagnosed with incident TB by 85%.
authors.affiliation: School of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA. pbraitstein@yahoo.com
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: Winstone
authors.initials: W
authors.lastname: Nyandiko
authors.forename: Rachel
authors.initials: R
authors.lastname: Vreeman
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
authors.forename: Edwin
authors.initials: E
authors.lastname: Sang
authors.forename: Beverly
authors.initials: B
authors.lastname: Musick
authors.forename: John
authors.initials: J
authors.lastname: Sidle
authors.forename: Constantin
authors.initials: C
authors.lastname: Yiannoutsos
authors.forename: Samwel
authors.initials: S
authors.lastname: Ayaya
authors.forename: E Jane
authors.initials: EJ
authors.lastname: Carter
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000453:epidemiology*; D000293:Adolescent; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy*; D006801:Humans; D015994:Incidence; D007223:Infant; D007630:Kenya / Q000453:epidemiology; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D014376:Tuberculosis / Q000453:epidemiology*
chemical_list: D019380:Anti-HIV Agents