Improved survival and cure rates with concurrent treatment for MDR-TB/HIV co-infection in South Africa

Abstract

Background

The global epidemic of multidrug-resistant tuberculosis (MDR-TB) threatens gains in TB and HIV outcomes over the past two decades. Mortality in MDR-TB/HIV co-infection has historically been high, but most studies predated the availability of antiretroviral therapy (ART). We prospectively compared survival and treatment outcomes in MDR-TB/HIV co-infected patients on ART to those in patients with MDR-TB alone.

Methods

This prospective, observational study enrolled culture-confirmed MDR-TB patients, with and without HIV co-infection, in South Africa between 2011–2013. Participants received standardized MDR-TB and HIV regimens and were followed monthly for treatment response, adverse events, and adherence. The primary outcome was survival.

Results

Among 206 participants, 150 were HIV-infected, 131 (64%) were female, and the median age was 33 years (IQR 26-41). Of the 191 participants with a final MDR-TB outcome, 130 (73%) were cured or successfully completed treatment, which did not differ by HIV status (p=0.50). After two years, the median CD4 count was 386 cells/mm³ (IQR 219-510), an increase of 140 cells/mm³ from baseline (p=0.005), and 64% had an undetectable HIV viral load. HIV-infected and HIV-uninfected participants had high rates of survival (86% and 94%, respectively; p=0.34). The strongest risk factor for mortality was having a CD4 count ≤100 cells/mm³ (aHR 15.6, 95%CI 4.4-55.6).

Conclusions

Survival and treatment outcomes among MDR-TB/HIV individuals receiving concurrent ART were improved, approaching those of HIV-uninfected MDR-TB patients. The greatest risk of death was among HIV-infected individuals with CD4 counts ≤100 cells/mm³. These findings provide critical evidence to support concurrent treatment of MDR-TB and HIV.