Poor Access to Treatment Quadruples Risk for TB in HIV-Positive Patients in Eastern Europe

Becky McCall

November 13, 2009

November 13, 2009 (Cologne, Germany) — HIV-positive patients in Eastern Europe have nearly 4 times the risk of developing tuberculosis (TB) as HIV-infected patients in Western Europe because of limited access to antiretroviral therapy (ART).

Presenting data at the 12th European AIDS Conference/European AIDS Clinical Society, Daria Podlekareva, MD, from the University of Copenhagen in Denmark, reported that the incidence of TB has dropped considerably in Western Europe since the introduction of combination ART in 1994. Now, the incidence of TB in HIV-infected patients in Eastern Europe is 4 times higher than it is in similar patients in Western Europe.

Dr. Podlekareva stressed that the difference is "dramatic" and can be linked to the suboptimal availability of antiretroviral treatment for HIV-positive patients in Eastern European countries.

"These patients in Eastern Europe need HIV therapies and should receive them to prevent tuberculosis. ART is the best tuberculosis-prevention method in HIV-positive patients, as it improves immune function and suppresses viral replication. In addition, HIV-infected patients should be regularly screened for TB, and TB patients with unknown HIV status should also be screened for this infection," she said.

The data are drawn from the EuroSIDA study, which is an international prospective observational cohort study of more than 16,000 HIV-1-infected patients from Europe, Israel, and Argentina. It has been underway since 1994. The Eastern European countries involved were Belarus, Bosnia, Bulgaria, Croatia, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Russia, Serbia, Slovakia, Slovenia, and the Ukraine.

"The strength and uniqueness of the EuroSIDA study is that it is the only HIV-cohort study with a broad representation in Eastern Europe, thus providing us an ideal opportunity to compare HIV epidemics in [Eastern and Western Europe]," said Dr. Podlekareva. This study looked particularly at temporal changes in TB incidence in Western Europe between the early 1990s and 2009. These results were compared with the incidence of TB in Eastern Europe after 2001.

In this study, approximately 80% of patients were white and male, and 46% of HIV-infected patients were men who acquired the virus through sex with men.

TB incidence in Western Europe fell from 2 cases per 100 person-years of follow-up in the early 1990s to 0.6 cases in 2008. In Eastern Europe, from 2001 to 2009, there was an adjusted incidence rate ratio of 3.77 between Eastern and Western Europe (95% confidence interval, 2.33 - 6.09).

The figures reflect differences in access to ART between the 2 sides of Europe, Dr. Podlekareva observed. "In Western Europe, antiretroviral therapy has been used since the early 1990s. . . . Patients in the West have wide access to ART. In contrast, in the East, there is restricted access to ART and patients do not receive the treatment they need."

According to a World Health Organization report published earlier this year, combination ART coverage in Russia is less than 25%. Multidrug-resistant TB is also widespread in Eastern Europe, which contributes to the problem. The issue is compounded by the high proportion of intravenous drug users in Eastern Europe where, in contrast to Western Europe, substitution therapy is unavailable.

"Another recent study my colleagues and I conducted showed that 27% of [HIV-positive] patients with tuberculosis in Eastern Europe died within the first year," added Dr. Podlekareva (AIDS. 2009, 23:2485-2495).

Anders Sönnerborg, MD, from the Karolinska Institute in Stockholm, Sweden, works closely with the Baltic States and Russia. "We have several projects in these countries, especially, on multidrug-resistant tuberculosis, developing algorithms on how to handle the problem. This extensive tuberculosis relates mainly to inefficient use of TB drugs. Therapy is often given for too short a period or with too few drugs. Russian prisons are also overcrowded and the transmission rate is very high, including multidrug-resistant TB. If people acquire HIV infection, reactivation of tuberculosis increases substantially due to immune deficiency," he said.

Dr. Podlekareva and Dr. Sönnerborg have disclosed no relevant financial relationships.

12th European AIDS Conference/European AIDS Clinical Society (EACS): Abstract PS8. Presented November 13, 2009.