Clinical and laboratory predictors of treatment failure in patients with HIV/extrapulmonary tuberculosis co-infection
Importance of problem. Since the time of discovery, HIV-infection became a pandemic disease and is an issue of the global public health. Russia and Ukraine are the leaders by this aspect in the European region. Tuberculosis is the main opportunistic infection and the basic cause of death in HIV-infected patients. Sustained increase of morbidity with HIV/TB co-infection is observed in Ukraine. Secondary to the advanced immunodeficiency, TB course often has atypical features with the increased rate of the extrapulmonary forms.Objective of work. To analyze the efficacy of combination of antiretroviral and antimycobacterial therapy in the patients with HIV/extrapulmonary tuberculosis (EPTB) co-infection and to identify the predictors of treatment failures.Materials and methods. The studies have been conducted at the chair of infectious diseases of Bogomolets National Medical University at the site of Kyiv City Center of AIDS Prevention and Control in 2013-2017.We have followed up 104 patients with HIV/extrapulmonary tuberculosis co-infection. Patients with HIV/tuberculosis co-infection were treated and their laboratory values were monitored according to the acting protocols of the Ministry of Health of Ukraine for management and treatment of patients with HIV/TB. Phthisiologists prescribed anti-TB therapy course and adjusted it.Treatment efficacy was evaluated by the outcome of the combination therapy. Treatment failure included the death of the patient during the treatment of EPTB or relapse at time of follow up. Treatment of EPTB was considered effective if it was completed without recurrent EPTB during 2-year follow up.The statistical analysis of the obtained results has been performed using the parametritic and non- parametritic methods of variation statistics.Results and their discussion. HIV-infection was diagnosed first or simultaneously with EPTB in 89 (85.6%) of 104 patients. The patients were assigned into 4 groups by the localization of tuberculosis process - TB of lymphatic system, respiratory system without lung involvement, bones and joints and with the multiple localization. Fifty eight (55.8%) patients completed the anti-TB therapy course and had no relapse during the follow up (successful treatment), recurrent EPTB was observed in 17 (16.3%) patients and 29 (27.9%) patients died at time of anti-TB therapy.The successful treatment was observed more frequently in the patients who received ART - in 55 (67.9%) patients versus those who did not receive ART - in 3 (13.0%) patients (р<0.001).The lowest level of the successful therapy was observed in EPTB group with the multiple localization - in 5 (21.7%) patients. Died patients had lower baseline value of СD-4-T-lymphocytes, and in the relapse group after 9-month therapy versus patients with the successful treatment (р<0.05). Cachexia, anemia, kidney damage, active herpes virus infection, toxic hepatitis, treatment discontinuations had an effect on the treatment efficacy.Conclusions. Treatment failure in the patients with HIV/EPTB co-infection is mainly associated with the significant immunodeficiency resulting in the development of the advanced severe tuberculosis forms, secondary co-morbidity of both somatic and opportunistic conditions, treatment without ART, interrupted specific anti-TB therapy and ART, immunologic, virologic and/or clinical failures of ART. The paradoxical reaction to the successful ART - immune reconstitution syndrome may impair the treatment prognosis in the patients with HIV/EPTB who have marked immunodeficiency.