Incidence and predictors of mortality and the effect of tuberculosis immune reconstitution inflammatory syndrome in a cohort of TB/HIV patients commencing antiretroviral therapy

BACKGROUND:: Tuberculosis-HIV (TB-HIV) co-infection remains an important cause of mortality in antiretroviral therapy (ART) programmes. In a cohort of TB-HIV co-infected patients starting ART we examined the incidence and predictors of early mortality. METHODS:: Consecutive TB-HIV co-infected patients eligible for ART were enrolled in a cohort study at the Mulago National Tuberculosis and Leprosy Programme clinic in Kampala, Uganda. Predictors of mortality were assessed using Cox proportional hazards analysis. RESULTS:: Three hundred and two patients (median CD4 count 53 cells/muL (interquartile range, 20-134)) were enrolled. Fifty three patients died, 36 (68%) of these died within the first 6 months of TB diagnosis. Male sex (HR, 2.19; 95% CI, 1.19-4.03; p=0.011), anergy to tuberculin skin test (HR 2.59 (1.10-6.12); p=0.030), a positive serum cryptococcal antigen (serum CrAG) result at enrollment (HR, 4.27; 95% CI, 1.50-12.13; p=0.006) and no ART use (HR, 4.63; 95% CI, 2. 37-9.03; p=<0.001) were independent predictors of mortality by multivariate analysis. Six (10%) patients with TB-immune reconstitution inflammatory syndrome died and in most an alternative contributing cause of death was identified. CONCLUSION:: Mortality among these TB-HIV co-infected patients was high particularly when presenting with advanced HIV disease and not starting ART, reinforcing the need for timely and joint treatment for both infections. Screening for a concomitant cryptococcal infection and antifungal treatment for patients with cryptococcal antigenemia may further improve clinical outcome.