title: Active tuberculosis is associated with worse clinical outcomes in HIV-infected African patients on antiretroviral therapy.
abstract: OBJECTIVE
  This cohort study utilized data from a large HIV treatment program in western Kenya to describe the impact of active tuberculosis (TB) on clinical outcomes among African patients on antiretroviral therapy (ART).
  
  
  METHODS
  We included all patients initiating ART between March 2004 and November 2007. Clinical (signs and symptoms), radiological (chest radiographs) and laboratory (mycobacterial smears, culture and tissue histology) criteria were used to record the diagnosis of TB disease in the program's electronic medical record system.
  
  
  METHODS
  We assessed the impact of TB disease on mortality, loss to follow-up (LTFU) and incident AIDS-defining events (ADEs) through Cox models and CD4 cell and weight response to ART by non-linear mixed models.
  
  
  RESULTS
  We studied 21,242 patients initiating ART-5,186 (24%) with TB; 62% female; median age 37 years. There were proportionately more men in the active TB (46%) than in the non-TB (35%) group. Adjusting for baseline HIV-disease severity, TB patients were more likely to die (hazard ratio--HR = 1.32, 95% CI 1.18-1.47) or have incident ADEs (HR = 1.31, 95% CI: 1.19-1.45). They had lower median CD4 cell counts (77 versus 109), weight (52.5 versus 55.0 kg) and higher ADE risk at baseline (CD4-adjusted odds ratio = 1.55, 95% CI: 1.31-1.85). ART adherence was similarly good in both groups. Adjusting for gender and baseline CD4 cell count, TB patients experienced virtually identical rise in CD4 counts after ART initiation as those without. However, the overall CD4 count at one year was lower among patients with TB (251 versus 269 cells/µl).
  
  
  CONCLUSIONS
  Clinically detected TB disease is associated with greater mortality and morbidity despite salutary response to ART. Data suggest that identifying HIV patients co-infected with TB earlier in the HIV-disease trajectory may not fully address TB-related morbidity and mortality.
authors.affiliation: School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.
authors.forename: Abraham M
authors.initials: AM
authors.lastname: Siika
authors.forename: Constantin T
authors.initials: CT
authors.lastname: Yiannoutsos
authors.forename: Kara K
authors.initials: KK
authors.lastname: Wools-Kaloustian
authors.forename: Beverly S
authors.initials: BS
authors.lastname: Musick
authors.forename: Ann W
authors.initials: AW
authors.lastname: Mwangi
authors.forename: Lameck O
authors.initials: LO
authors.lastname: Diero
authors.forename: Sylvester N
authors.initials: SN
authors.lastname: Kimaiyo
authors.forename: William M
authors.initials: WM
authors.lastname: Tierney
authors.forename: Jane E
authors.initials: JE
authors.lastname: Carter
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D015496:CD4-Positive T-Lymphocytes / Q000166:cytology; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D007630:Kenya; D008297:Male; D016347:Medical Records Systems, Computerized; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy / Q000401:mortality*; D015430:Weight Gain
chemical_list: D044966:Anti-Retroviral Agents