TB death rate four times higher in Eastern Europe due to lack of HIV treatment after TB diagnosis

People living with HIV in Eastern Europe who develop tuberculosis (TB) are four times more likely to die within a year when compared to similar patients in Western and Southern Europe or Latin America, a large international study presented on Thursday at the 15th European AIDS Conference in Barcelona has shown.

The study found that even after taking into account the prevalence of resistance to first-line TB drugs and receipt of appropriate TB treatment, people with TB in Western and Southern Europe or Latin America were around 70% less likely to die during the year following a TB diagnosis compared to those in Eastern Europe.

Lack of access to antiretroviral treatment may have been a factor, said Daria Podlekareva of the University of Copenhagen. Antiretroviral treatment coverage in Eastern Europe and Central Asia is the lowest in the world: in 2013, only 21% of people living with HIV across the region were receiving antiretroviral therapy.

The findings come from a prospective study of 1407 people living with HIV who were diagnosed with TB. The analysis was restricted to 367 people diagnosed with drug-susceptible TB, and evaluated survival one year after TB diagnosis.

There were no significant differences in the characteristics of the tuberculosis or its treatment between regions. A similar proportion of people had disseminated tuberculosis in each region (45% in Eastern Europe, 41% in Western and Southern Europe and 42% in Latin America). A similar proportion of people received the standard first-line regimen for TB treatment consisting of rifampicin, isoniazid, pyrazinamide and one other drug in each region (91%, 92% and 94% respectively).

However, far fewer people in Eastern Europe were receiving antiretroviral therapy at the time of TB diagnosis, and significantly fewer received antiretroviral therapy in the year following their diagnosis – despite a World Health Organization recommendation that all people living with HIV diagnosed with tuberculosis should receive antiretroviral therapy regardless of CD4 count, as soon as possible after beginning TB treatment.

Only 18% of people living with HIV were already receiving antiretroviral therapy at the time of TB diagnosis in the Eastern European cohort, compared to 39% in Western and Southern Europe, and 41% in Latin America. By twelve months after TB diagnosis, 64% of people living with HIV were receiving antiretroviral therapy in Eastern Europe, compared to 87% in Western and Southern Europe, and 81% in Latin America.

The probability of death one year after TB diagnosis was almost four times as high among people living with HIV in Eastern Europe compared to the other regions. A total of 38 people died during the follow-up period, 27 of these in Eastern Europe. The 1-year probability of death after TB diagnosis was 19.5% in Eastern Europe compared to 5% in the other regions combined. Tuberculosis was the underlying cause of death in 70% of people in Eastern Europe compared to 29% in Western Europe and 25% in Latin America.