title: Risk factors for mortality in smear-negative tuberculosis suspects: a cohort study in Harare, Zimbabwe.
abstract: OBJECTIVE
  To investigate mortality rates and risk factors for death among smear-negative tuberculosis (TB) suspects.
  
  
  METHODS
  Cohort study nested within a cluster-randomised trial of community-based active case finding. Smear-negative TB suspects were followed for 12 months, with home tracing where necessary. We calculated mortality rates and used regression analysis to investigate the relationship between clinical characteristics and death.
  
  
  RESULTS
  Between February 2006 and June 2007, 1195 smear-negative TB suspects were followed for 1136.8 person-years. Human immunodeficiency virus (HIV) prevalence was 63.3%. During follow-up, 139 participants died (11.6%) and mortality rates remained high throughout; 119 (16.5%) HIV-positive individuals and 13 (3.1%) HIV-negative individuals died (HR = 5.8, 95%CI 3.3-10.4, P < 0.001). Advanced immunosuppression was the main risk factor for death among HIV-positive participants, with CD4 count < 50 cells/μ l associated with a 13-fold increased risk of death. Antiretroviral treatment (ART) was initiated by only 106 (14.7%), with long delays in accessing care.
  
  
  CONCLUSIONS
  HIV-positive smear-negative TB suspects are at high and sustained risk of death. Current guidelines for the management of HIV-infected TB suspects are limited, and this study adds to evidence that specific policies are required to promote earlier HIV and TB diagnosis and reduce delays in ART initiation.
authors.affiliation: Wellcome Trust Tropical Centre, Liverpool School of Tropical Medicine, Liverpool, UK. p.macpherson@liv.ac.uk
authors.forename: P
authors.initials: P
authors.lastname: Macpherson
authors.forename: M
authors.initials: M
authors.lastname: Dimairo
authors.forename: T
authors.initials: T
authors.lastname: Bandason
authors.forename: A
authors.initials: A
authors.lastname: Zezai
authors.forename: S S
authors.initials: SS
authors.lastname: Munyati
authors.forename: A E
authors.initials: AE
authors.lastname: Butterworth
authors.forename: S
authors.initials: S
authors.lastname: Mungofa
authors.forename: S
authors.initials: S
authors.lastname: Rusakaniko
authors.forename: K
authors.initials: K
authors.lastname: Fielding
authors.forename: P R
authors.initials: PR
authors.lastname: Mason
authors.forename: E L
authors.initials: EL
authors.lastname: Corbett
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D016000:Cluster Analysis; D015331:Cohort Studies; D060085:Coinfection; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D015995:Prevalence; D011379:Prognosis; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013183:Sputum / Q000382:microbiology; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality*; D055815:Young Adult; D015030:Zimbabwe / Q000453:epidemiology