Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low‐ and middle‐income countries: a multicohort study

• Published in: Journal of the International AIDS Society Vol. 22; no. 9; pp. e25392 - n/a
• Main Authors: Zürcher, Kathrin, Ballif, Marie, Kiertiburanakul, Sasisopin, Chenal, Henri, Yotebieng, Marcel, Grinsztejn, Beatriz, Michael, Denna, Sterling, Timothy R, Ngonyani, Kapella M, Fenner, Lukas, Veloso, Valdilea, Boni, Raquel, Wagner, Sandra Cardoso, Friedman, Ruth, Moreira, Ronaldo, Madero, Juan Sierra, Belaunzaran, Paco, Vega, Yanink Caro, Gotuzzo, Eduardo, Mejia, Fernando, Carriquiry, Gabriela, Shepherd, Bryan E, Sterling, Timothy, Jayathilake, Karu, Person, Anna K, Rebeiro, Peter F, Castilho, Jessica, Duda, Stephany N, Maruri, Fernanda, Vansell, Hilary, Gatechompol, S, Phanuphak, P, Phadungphon, C, Kiertiburanakul, S, Chumla, L, Sanmeema, N, Nguyen, KV, Bui, HV, Nguyen, DT, An, NV, Luan, NT, Sohn, AH, Ross, JL, Petersen, B, Law, MG, Jiamsakul, A, Ssali, John, Ngonyani, Kapella, Urassa, Mark, Machemba, Richard, Yiannoutsos, Constantin, Vreeman, Rachel, Musick, Beverly, Elul, Batya, Kantor, Rami, Martin, Jeffrey, Cohen, Craig, Azon‐Kouanou, Angèle, Traore, Hamar Alassane, Minta, Daouda, Toure, Amadou Abathina, Seydi, Moussa, Arrivé, Elise, Coffie, Patrick, Jaquet, Antoine, Lewden, Charlotte, Amani, Dieudonné, Azani, Jean‐Claude, Balestre, Eric, Bessekon, Serge, Bohossou, Franck, Gilbert, Camille, Gonsan, Jules Mahan, Le Carrou, Jérôme, Nchot, Célestin, Yao, Amon Roseamonde, Clouet, Gwenaelle, Dosso, Madikona, Doring, Alexandra, Rabourdin, Elodie, Rivenc, Jean, Ba, Boubacar, Ciaranello, Andrea, Datté, Sébastien, Desmonde, Sophie, Elvis Diby, Jean‐Serge, Gottlieb, Geoffrey S, Kangah, Serge N'zoré, Malvy, Denis, Meless, David, Ndondoki, Camille, Wandeler, Gilles, Dusingize, Jean Claude, Mutimura, Eugene, Tatwangire, Judy, Izabelle, Izimukwiye, Baramperanye, Evelyne, Edmonds, Andrew, Azinyue, Innocent, Ayangma, Liliane
• Format: Journal Article
• Language: English
• Published: Switzerland International AIDS Society 01-09-2019; John Wiley & Sons, Inc; BioMed Central (2008-2012) ; International Aids Society (2008-) ; Wiley (2017-); John Wiley and Sons Inc
• Subjects: Acquired immune deficiency syndrome; Adult; AIDS; AIDS-Related Opportunistic Infections - diagnosis; AIDS-Related Opportunistic Infections - etiology; AIDS-Related Opportunistic Infections - mortality; Anti-HIV Agents - administration & dosage; Antiretroviral agents; Antiretroviral drugs; Antiviral agents; Asia; Body mass index; Caribbean Region; Clinical outcomes; Cohort Studies; Comparative analysis; Consortia; Côte d'Ivoire; Data collection; Developing Countries; Diagnosis; Diagnostic tests; diagnostics; Drug therapy; Epidemiology; extrapulmonary tuberculosis; Female; France; Health aspects; Health care access; Highly active antiretroviral therapy; HIV; HIV Infections - complications; HIV Infections - drug therapy; HIV Infections - economics; HIV patients; HIV‐positive patients; Hospitals; Human immunodeficiency virus; Humans; Life Sciences; Logistic Models; lost to follow‐up; low‐ and middle‐income countries; Male; Microscopy; Mortality; Nucleic acids; Patient outcomes; Patients; Poverty; pulmonary tuberculosis; Short Report; Short Reports; South Africa; South America; Statistics; Sub-Saharan Africa; Tanzania; Thailand; Tuberculosis; Tuberculosis - diagnosis; Tuberculosis - epidemiology; Tuberculosis - etiology; Tuberculosis - mortality; South America; Asia; Caribbean Region; Tanzania; South Africa; Côte d'Ivoire; Thailand; France; Sub-Saharan Africa; Central America; Caribbean Islands; Pacific Rim; Burundi; United States > US; Senegal; Mali; Southern Africa; Rwanda; Central Africa; pulmonary tuberculosis; HIV-positive patients; diagnostics; extrapulmonary tuberculosis; tuberculosis; lost to follow-up; mortality; low- and middle-income countries
• ISSN: 1758-2652; 1758-2652
• DOI: 10.1002/jia2.25392

Introduction
Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under‐resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV‐positive adults in antiretroviral therapy (ART) programmes in low‐ and middle‐income countries (LMIC).
Methods
We collected data from HIV‐positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub‐Saharan Africa, Asia‐Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes.
Results and Discussion
We analysed 2695 HIV‐positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/μL (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result.
Conclusions
Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.