Prevalence and Clinical Profiling of Dysglycemia and HIV Infection in Persons With Pulmonary Tuberculosis in Brazil

Abstract

Background: There are scarce data on the prevalence and disease presentation of HIV in patients with tuberculosis (TB) and dysglycemia (diabetes [DM] and prediabetes [PDM]), especially in TB-endemic countries.

Methods: We assessed the baseline epidemiological and clinical characteristics of patients with culture-confirmed pulmonary TB, enrolled in a multicenter prospective cohort in Brazil (RePORT-Brazil) during 2015-2019. Dysglycemia was defined by elevated glycated hemoglobin and stratified as PDM or DM. Additionally, we used data from TB cases obtained through the Brazilian National Notifiable Diseases Information System (SINAN), during 2015-2019. In SINAN, diagnosis of diabetes was based on self-report. Logistic regression models were performed to test independent associations between HIV, dysglycemia status, and other baseline characteristics in both cohorts.

Results: In the RePORT-Brazil cohort, the prevalence of DM and of PDM was 23.7 and 37.8%, respectively. Furthermore, the prevalence of HIV was 21.4% in the group of persons with TB-dysglycemia and 20.5% in that of patients with TBDM. In the SINAN cohort, the prevalence of DM was 9.2%, and among the TBDM group the prevalence of HIV was 4.1%. Logistic regressions demonstrated that aging was independently associated with PDM or DM in both the RePORT-Brazil and SINAN cohorts. In RePORT-Brazil, illicit drug use was associated with PDM, whereas a higher body mass index (BMI) was associated with DM occurrence. Of note, HIV was not associated with an increased risk of PDM or DM in patients with pulmonary TB in both cohorts. Moreover, in both cohorts, the TBDM-HIV group presented with a lower proportion of positive sputum smear and a higher frequency of tobacco and alcohol users.

Conclusion: There is a high prevalence of dysglycemia in patients with pulmonary TB in Brazil, regardless of the HIV status. This reinforces the idea that DM should be systematically screened in persons with TB. Presence of HIV does not substantially impact clinical presentation in persons with TBDM, although it is associated with more frequent use of recreational drugs and smear negative sputum samples during TB screening.

Keywords: HIV infection; Mycobacterium tuberculosis; diabetes; dysglycemia; pulmonary tuberculosis.

Figure 1

HIV infection among dysglycemic patients with active tuberculosis in RePORT-Brazil and SINAN cohorts. (A) Left panel: Scatter plot comparing distribution of HbA1c levels between subgroups of pulmonary TB cases per HIV infection status. Data were compared using the Mann-Whitney U test. Left panel: Total frequency of HIV infection among diabetic TB patients was 20.5%, among prediabetics was 22·2% and among normoglycemic patients was 20.7% (chi-square test p > 0·05). (B) Frequency of individuals with diagnosis of diabetes, prediabetes and HIV infection in the indicated age category (in years) among pulmonary TB patients is shown. Data were compared using the Pearson's chi-square test. (C) Box plot comparing distribution of HbA1c levels between subgroups of pulmonary TB cases per ART-experience and ART-naive status. Data were compared using the Mann-Whitney U test. (D) Spearman correlation between HbA1c and viral load (log10) levels (Left panel) and CD4 (log10) levels (Right panel) at baseline in pulmonary TB patients grouped according to the dysglycemic status. Line and shaded area represent linear curve fit with 95% confidence interval. (E) Total frequency of HIV infection among diabetic TB patients was 4.1% and among normoglycemic patients was 12.3% (chi-square test p > 0·05). The statistical analyzes were carried out only with the available data, omitting the cases with missing information (14 patients were removed due to lack in HIV status). (F) Frequency of individuals with diagnosis of diabetes and HIV infection in the indicated age category (in years) among pulmonary TB patients is shown. Data were compared using the Pearson's chi-square test. ART, antiretroviral therapy.

Figure 2

Factors associated with dysglycemia in patients with active pulmonary tuberculosis in RePORT-Brazil and SINAN cohorts. (A) A multinomial logistic regression analyses were used to test association between indicated characteristics of pulmonary TB patients and presence of prediabetes (left panel) or diabetes (right panel). Variables included in the adjusted model exhibited univariate p-values ≤ 0·2 (See Supplementary Table 2 for details). (B) Binomial logistic regression to test association between indicated characteristics of TB patients and presence of diabetes. Only variables with significant p-value in the adjusted model are shown. Variables included in the adjusted model exhibited univariate p-values ≤ 0.2 (See Supplementary Table 3 for details). BMI, Body Mass Index.

Figure 3

Clinical Characteristics of people with TB according glycemic and HIV status in the RePORT-Brazil cohort. (A) Proportion of positive smears and abnormal X-rays in each study group. (B) Frequency of TB cases according glycemic and HIV status regarding smoking habit, alcohol consumption and illicit drug use (smoking, alcohol, and illicit drug: in the past or at the time of evaluation before anti-TB treatment). (C) Frequency of TB classical symptoms in each study group. The data were compared between the groups using the Pearson's chi-square test. Comparisons with significant p-values are displayed in bold. TB, tuberculosis; DM, diabetes; PDM, prediabetes.

Figure 4

Clinical Characteristics of people with TB according glycemic and HIV status of the SINAN cohort. (A) Proportion of positive smears and abnormal X-rays in each study group. (B) Frequency of positive cultures. (C) TB cases according glycemic and HIV status regarding smoking habit, alcohol consumption and illicit drug use (smoking, alcohol, and illicit drug: in the past or at the time of evaluation before anti-TB treatment). The data were compared between the groups using the Pearson's chi-square test. Comparisons with significant p-values are displayed in bold. TB, tuberculosis; DM, diabetes; PDM, prediabetes.