Declining Tuberculosis Incidence among People Receiving HIV Care and Treatment Services in East Africa, 2007–2012

Abstract

Background— Antiretroviral therapy (ART) reduces the risk of TB among people living with HIV (PLWH). With ART scale-up in sub-Saharan Africa over the past decade, incidence of TB among PLWH engaged in HIV care is predicted to decline. Methods— We conducted a retrospective analysis of routine clinical data from 168,330 PLWH receiving care at 35 facilities in Kenya, Tanzania, and Uganda during 2003–2012, participating in the East African region of the International Epidemiologic Databases to Evaluate AIDS (IeDEA). Temporal trends in facility-based annual TB incidence rates (per 100,000 person-years (PYs)) among PLWH and country-specific standardized TB incidence ratios (SIRs) using annual population-level TB incidence data from the World Health Organization (WHO) were computed between 2007 and 2012. We examined patient- and facility-level factors associated with incident TB using multivariable Cox models. Results— Overall, TB incidence rates among PLWH in care declined 5-fold between 2007 and 2012 from 5,960 to 985 per 100,000 PYs [p=0.0003] (Kenya: 7,552 to 1,115 [p=0.0007]; Tanzania: 7,153 to 635 [p=0.0025]; Uganda: 3,204 to 242 [p=0.018]). SIRs significantly decreased in the three countries, indicating a narrowing gap between incidence rates among PLWH and the general population. We observed lower hazards of incident TB among PLWH on ART and/or IPT and receiving care in facilities offering TB treatment on-site. Conclusions— Annual TB incidence rates among PLWH significantly declined during ART scale-up but remained higher than the general population. Increasing access to ART and IPT and co-location of HIV and TB treatment may further reduce TB incidence among PLWH.