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

Abstract

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: HIV; antiretroviral therapy; mortality; tuberculosis.

Figure 1

HIV-positive TB mortality rates by WHO-defined region, excluding African countries with high HIV-infection rate (AFRH), 2008. Africa-countries with low HIV-infection rate (AFR) (N = 20), Central European region (CEUR) (N = 10), Eastern European region (EEUR) (N = 16), Eastern Mediterranean region (EMR) (N = 17), established market economies (EME) (N = 56), Latin American region (LAMR) (N = 31), South-East Asia region (SEAR) (N = 11), and Western Pacific region (WPR) (N = 25). Total N = 212. Abbreviations: HIV, human immunodeficiency virus; TB, tuberculosis; WHO, World Health Organization.