title: Empirical treatment for TB in HIV: lessons from a cohort study of people living with HIV treated in Recife, Brazil.
abstract: BACKGROUND
  Tuberculosis (TB) is the leading cause of death related to HIV worldwide. This study analyzes the survival of People Living with HIV (PLHIV) reporting cough without bacteriological confirmation of TB and identify factors associated with death.
  
  
  METHODS
  Prospective cohort with a consecutive sample of PLHIV, aged ≥ 18 years. Patient inclusion criteria were complaint of current cough of any duration at the time of the first study interview or during their subsequent routine visits to health services and for whom AFB sputum smear was either negative or not performed during the whole follow-up period. Kaplan-Meier method was used to calculate the probability of survival. We estimated the Hazard Ratio (HR) in bivariate and multivariate Cox regression analyses.
  
  
  RESULTS
  Mortality was 4.6 per 100 py; 73% were receiving HAART at recruitment. Average time from the first recorded date of cough until empirical treatment for tuberculosis was six months. Mortality was higher when the CD4 count was low (HR = 5.3; CI 95%: 3.2-9.0; p = 0.000), in those with anemia (HR = 3.0; CI 95%: 1.6-5.6; p = 0.001) and with abnormal chest X-rays (HR = 2.4; CI 95%: 1.4-4.0; p = 0.001). Mortality was higher in those receiving empirical TB treatment (HR = 2.4; CI 95%: 1.4-4.0; p = 0.002), but only in those with normal X-rays, no history of tuberculosis and no bacteriology requests. Empirical treatment for TB was more frequent in PLHIV with low CD4 counts, anemia, history of opportunistic infections, weight loss, previous tuberculosis, negative bacteriology test (as opposed to not having a test) and abnormal chest X-ray.
  
  
  CONCLUSIONS
  Higher mortality in PLHIV reporting a current cough without bacteriological confirmation of tuberculosis was identified for those with a CD4 cell count <200, abnormal chest X-ray, anemia and empirical treatment for tuberculosis. Mortality was not significantly higher in those empirically treated for TB, who had three characteristics suggestive of the disease (abnormal chest X-ray, history of TB treatment, AFB sputum smear or M.tb culture testing). Routine cohorts are not an adequate setting to evaluate the impact of empirical treatment for TB on the mortality of PLHIV.
authors.affiliation: NESC Department, Centro de Pesquisas Aggeu Magalhães/FIOCRUZ, Recife, Brazil. militaofatima@gmail.com.
authors.forename: Maria de Fátima Pessoa Militão
authors.initials: Mde F
authors.lastname: Albuquerque
authors.forename: Isabella
authors.initials: I
authors.lastname: Coimbra
authors.forename: Joanna d'Arc
authors.initials: Jd
authors.lastname: Batista
authors.forename: Magda
authors.initials: M
authors.lastname: Maruza
authors.forename: Ricardo A A
authors.initials: RA
authors.lastname: Ximenes
authors.forename: Heloísa R
authors.initials: HR
authors.lastname: Lacerda
authors.forename: Demócrito B
authors.initials: DB
authors.lastname: Miranda-Filho
authors.forename: Marcela L
authors.initials: ML
authors.lastname: Santos
authors.forename: Laura C
authors.initials: LC
authors.lastname: Rodrigues
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy* / Q000401:mortality; D000328:Adult; D000740:Anemia / Q000209:etiology; D023241:Antiretroviral Therapy, Highly Active; D001938:Brazil / Q000453:epidemiology; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003371:Cough / Q000209:etiology; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D015994:Incidence; D008297:Male; D016016:Proportional Hazards Models; D013183:Sputum / Q000382:microbiology; D016019:Survival Analysis; D014376:Tuberculosis / Q000188:drug therapy* / Q000401:mortality