title: Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.
abstract: OBJECTIVE
  Rates of TB/HIV coinfection and multi-drug resistant (MDR)-TB are increasing in Eastern Europe (EE). We aimed to study clinical characteristics, factors associated with MDR-TB and predicted activity of empiric anti-TB treatment at time of TB diagnosis among TB/HIV coinfected patients in EE, Western Europe (WE) and Latin America (LA).
  
  
  METHODS
  Between January 1, 2011, and December 31, 2013, 1413 TB/HIV patients (62 clinics in 19 countries in EE, WE, Southern Europe (SE), and LA) were enrolled.
  
  
  RESULTS
  Significant differences were observed between EE (N = 844), WE (N = 152), SE (N = 164), and LA (N = 253) in the proportion of patients with a definite TB diagnosis (47%, 71%, 72% and 40%, p<0.0001), MDR-TB (40%, 5%, 3% and 15%, p<0.0001), and use of combination antiretroviral therapy (cART) (17%, 40%, 44% and 35%, p<0.0001). Injecting drug use (adjusted OR (aOR) = 2.03 (95% CI 1.00-4.09), prior anti-TB treatment (3.42 (1.88-6.22)), and living in EE (7.19 (3.28-15.78)) were associated with MDR-TB. Among 585 patients with drug susceptibility test (DST) results, the empiric (i.e. without knowledge of the DST results) anti-TB treatment included ≥3 active drugs in 66% of participants in EE compared with 90-96% in other regions (p<0.0001).
  
  
  CONCLUSIONS
  In EE, TB/HIV patients were less likely to receive a definite TB diagnosis, more likely to house MDR-TB and commonly received empiric anti-TB treatment with reduced activity. Improved management of TB/HIV patients in EE requires better access to TB diagnostics including DSTs, empiric anti-TB therapy directed at both susceptible and MDR-TB, and more widespread use of cART.
authors.affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Anne Marie W
authors.initials: AM
authors.lastname: Efsen
authors.affiliation: Department of Infection and Population Health, University College London Medical School, London, United Kingdom.
authors.forename: Anna
authors.initials: A
authors.lastname: Schultze
authors.affiliation: Department of Sexual Health, Caldecot Centre, King's College Hospital, London, United Kingdom.
authors.forename: Frank A
authors.initials: FA
authors.lastname: Post
authors.affiliation: Department of HIV/TB, TB hospital 2, St. Petersburg, Russia.
authors.forename: Alexander
authors.initials: A
authors.lastname: Panteleev
authors.affiliation: Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland.
authors.forename: Hansjakob
authors.initials: H
authors.lastname: Furrer
authors.affiliation: Centre for Sexual Health and HIV Research, Mortimer Market Centre, University College London, London, United Kingdom.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Miller
authors.affiliation: Department of immunocompromised, Hospital J.M. Ramos Mejia, Buenos Aires, Argentina.
authors.forename: Marcelo H
authors.initials: MH
authors.lastname: Losso
authors.affiliation: Department of immunocompromised, Hospital J.M. Ramos Mejia, Buenos Aires, Argentina.
authors.forename: Javier
authors.initials: J
authors.lastname: Toibaro
authors.affiliation: Clinical Department, Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus.
authors.forename: Aliaksandr
authors.initials: A
authors.lastname: Skrahin
authors.affiliation: Infectious Diseases Service, Hospital Clinic-IDIBAPS. University of Barcelona, Barcelona, Spain.
authors.forename: Jose M
authors.initials: JM
authors.lastname: Miro
authors.affiliation: Agencia de Salud Pública de Barcelona, Barcelona, España; Programa Integrado de Investigación en Tuberculosis de SEPAR (PII-TB); Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
authors.forename: Joan A
authors.initials: JA
authors.lastname: Caylà
authors.affiliation: Department of Infectious Diseases INMI "L. Spallanzani", Ospedale L Spallanzani, Rome, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Girardi
authors.affiliation: INSERM, ISPED, Centre Inserm U897- Epidemiologie-Biostatistique, Bordeaux, France.
authors.forename: Mathias
authors.initials: M
authors.lastname: Bruyand
authors.affiliation: Department of Infectious Diseases and Rheumatology, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Niels
authors.initials: N
authors.lastname: Obel
authors.affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Daria N
authors.initials: DN
authors.lastname: Podlekareva
authors.affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Jens D
authors.initials: JD
authors.lastname: Lundgren
authors.affiliation: Department of Infection and Population Health, University College London Medical School, London, United Kingdom.
authors.forename: Amanda
authors.initials: A
authors.lastname: Mocroft
authors.affiliation: Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, CHIP, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Ole
authors.initials: O
authors.lastname: Kirk
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000627:therapeutic use*; D060085:Coinfection / Q000188:drug therapy*; D005060:Europe; D005061:Europe, Eastern; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007843:Latin America; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy*
chemical_list: D044966:Anti-Retroviral Agents; D000995:Antitubercular Agents