Tuberculosis mortality in HIV-infected individuals: a global assessment
C.G. Au-Yeung1, S. Kanters1, E. Ding1, P. Glaziou2, A. Anema1,3, C.L. Cooper4, H. Timimi2, J.S.G. Montaner1,3, R.S. Hogg1,5, E.J. Mills1,6
1BC Centre for Excellence in HIV/AIDS, Vancouver, Canada, 2World Health Organization, Stop TB Department, Geneva, Switzerland, 3University of British Columbia, Faculty of Medicine, Vancouver, Canada, 4University of Ottawa, The Ottawa Hospital Division of Infectious Diseases, Ottawa, Canada, 5Simon Fraser University, Faculty of Health Sciences, Burnaby, Canada, 6University of Ottawa, Faculty of Health Sciences, Ottawa, Canada
Background: Tuberculosis (TB) is a leading cause of death in HIV-positive individuals. We sought to compare mortality rates in TB/HIV co-infected individuals globally and by country/territory, using data gathered from our prospectively maintained Globally Accumulated health Indicator Archive (GAIA) of publicly accessible health statistics.
Methods: TB mortality rates in HIV-positive and HIV-negative individuals were obtained from the World Health Organization (WHO) Stop TB department for 212 recognized countries/ territories in years 2006-2008. Multivariate linear regression determined the impact of healthcare resource and economic variables on our outcome variable; TB mortality rate in HIV-positive individuals per 100,000 general population.
Results: In 2008, an estimated 13 TB/HIV deaths occurred per 100,000 population globally with the African Region having the highest death rate [(AFRH) ≥4% adult HIV-infection rate] at 86 per 100,000 individuals. The next highest rates were for the Eastern European Region (EEUR) and the Latin America Region (LAMR) at 4 and 3 respectively per 100,000 population. Bivariate analysis (year 2006-2008) revealed TB/HIV mortality rates that were 3.6 times higher in countries with < 15% highly active antiretroviral therapy (HAART) coverage compared to those with ≥15% coverage (95% confidence interval [CI] 1.8-7.4). In the multivariate model, African countries' HIV-positive TB mortality rates were 29.9 times higher than non-African countries (95% [CI] 16.8-53.4). Every $100 US of government per capita health expenditure was associated with a 33% (95% [CI] 24-42%) decrease in TB/HIV mortality rates. The multivariate model also accounted for calendar year and did not include HAART coverage.
Conclusions: Our results indicate that while the AFRH has the highest TB/HIV death rates, countries in EEUR and LAMR also have elevated mortality rates. Increasing health expenditure directed towards universal HAART access may reduce mortality from both diseases.
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