Tuberculosis mortality in HIV-infected individuals: a cross-national systematic assessment

Christopher Au-Yeung¹, Steve Kanters¹, Erin Ding¹, Philippe Glaziou², Aranka Anema^1,3, Curtis L Cooper⁴, Julio SG Montaner^1,3, Robert S Hogg^1,5, Edward J Mills^1,6
1BC Centre for Excellence in HIV/AIDS, Vancouver, Canada; ²Stop TB Department, World Health Organization, Geneva, Switzerland; ³Faculty of Medicine, University of British Columbia, Vancouver, Canada; ⁴The Ottawa Hospital Division of Infectious Diseases; ⁵Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada; ⁶Faculty of Health Sciences, University of Ottawa, Ottawa, Canada

Objective: Tuberculosis (TB) is a leading cause of death in human immunodeficiency virus (HIV)-positive individuals. We sought to compare mortality rates in TB/HIV co-infected individuals globally and by country/territory.
Design: We conducted a cross-national systematic assessment.
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 the years 2006–2008. Multivariate linear regression determined the impact of health care resource and economic variables on our outcome variable, and TB mortality rates.
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 American Region (LAMR) at 4 and 3 respectively per 100,000 population. African countries’ HIV-positive TB mortality rates were 29.9 times higher than non-African countries (95% confidence interval [CI]: 16.8–53.4). Every US$100 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 highly active antiretroviral therapy (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.

Keywords: tuberculosis, HIV, antiretroviral therapy, mortality