1. Incidence of tuberculosis in the first year of antiretroviral treatment in West-African HIV-infected adults
B. Tchakounte Youngui1, P. Coffie2, E. Messou3, A. Poda4, L. Fortes Déguénonvo5, D. Hawerlander6, A. Minga7, E. Balestre8, F. Dabis9, O. Marcy9
(1) ISPED, University of Bordeaux, France, (2) Programme PACCI, Site ANRS, Abidjan, Côte D'Ivoire, (3) CePReF-Aconda-VS, Abidjan, Côte D'Ivoire, (4) CHU Souro Sanou, Bobo-Dioulasso, Burkina Faso, (5) CHNU Fann, Dakar, Senegal, (6) CIRBA, Abidjan, Côte D'Ivoire, (7) CNTS/PRIMO-CI, Abidjan, Côte D'Ivoire, (8) INSERM U897, ISPED, University of Bordeaux, France, (9) INSERM U1219, University of Bordeaux, France
Paris
July 24th 2017

2. “No conflicts of interest to declare”.
Conflict of Interest
“No conflicts of interest to declare”.

3. Background HIV prevalence |2015 TB burden in PLHIV |2015
36.7 million worlwide / 25.5 million (69.9%) in Sub-Saharan Africa
TB burden in PLHIV |2015
1.17 million cases worlwide /834,000 (71.3%) in Africa
390,000 deaths worlwide/ 300,000 (76.9%) in Africa
TB incidence in PLHIV
Improved access to antiretroviral therapy (ART) ⇒ reduction of TB incidence
remains higher in PLHIV on ART than in non-infected persons
TB prevention in PLHIV
Isoniazid preventive therapy (IPT) recommended, not implemented in West Africa
UNAIDS Data, WHO Global TB report 2016, Duda et al 2010 (IeDEA)

4. Background and Objective
Assess tuberculosis incidence during the first year of antiretroviral therapy and identify associated factors in HIV- infected adults in West Africa

5. Methods: Study design and population
IeDEA West African collaboration cohort
3 HIV outpatient centers in Côte d'Ivoire (Abidjan), Burkina Faso (Bobo Dioulasso), and Senegal (Dakar)
Inclusion criteria
HIV-infected adults (≥16 years)
initiating ART between 2010 and 2014
Without ongoing TB at ART initiation
≥1 follow-up visit
Patient follow-up
Usual site visit calendars
No IPT

6. Methods: Study design and population
TB diagnosis
Systematic symptom screening for active TB
According to national recommendations
Sputum microscopy and chest radiography
Xpert perfom if smear negative (since 2013)
Endpoint: incident TB defined as first TB event notified > 1 week and ≤ 1 year on ART
Statistics:
Crude incidence
Adjusted incidence and associated factors identified by multivariate Poisson regression models

7. 3,213 included in our analysis
Results
4,154 started ART since 2010 in the 3 sites
3,404 on ART with ≥ 1 follow-up visit
750 without follow-up visit after ART initiation
3,213 included in our analysis
191 patients with ongoing TB at initiation of ART.
170 incident TB cases

8. Results – Patients characteristicsN
n or median
% or IQR
Country
3213
Côte d’Ivoire (CI)
959
29.8
Burkina Faso (BF)
1863
58.0
Senegal (SN)
391
12.2
Age (years)
3192
38.5
32.0 – 45.4
Sex female
3210
2153
67.1
BMI (kg/m2)
3064
20.6
18.0 – 24.0
Past TB history
2559
176
6.9
CD4 cell count (cells/µl)
3067
211
95 – 343
Hemoglobin level (g/dl)
3063
11.0
9.4 – 12.2

9. Results - TB incidence density rate
Period at risk (years),
median (IQR)
No. at risk
PY at risk
TB cases
Crude incidence rate /100 PY (95%CI) CI
1.00 (0.51 – 1.00)
959
744.7
106
14.23 (11.52–16.94) BF
1.00 (0.37 – 1.00)
1863
1334.0 59
4.42 (3.29–5.55) SN
0.99 (0.46 – 1.00)
391
281.8 5
1.77 (0.22–3.33)
ALL
1.00 (0.44 – 1.00)
3213
2360.5
170
7.2 (6.12–8.28)

10. Results - TB incidence and associated factors
Now looking at associated factors with incidence of TB in adjusted model. The country, sex, BMI, past history of TB, CD4 count and hemoglobin was significally associated with occurrence of TB in PLHIV
As we can see in penultimate column, the risk of TB was more high in patient living in Côte d’Ivoire than patient living in Burkina Faso and Senegal. Male patients had almost 2 times more risk than female, patient with a past history of TB had 4 times more risk than patient without past TB history and patients with hemoglobin less than nine had almost 2 times more risk than patient with hemoglobin at least eleven
Finally, we highlight here adjusted incidence rate of tuberculosis in the first year of ART after controlling baseline characteristics, corresponding to the incidence of tuberculosis in a female patient from Burkina Faso, with a normal BMI, CD4 count greater than 500 and hemoglobin greater than eleven. It was one point forty two case per one hundred patients at risk which corresponds to one thousand forty hundred and twenty cases per one hundred thousand patients at risk if we convert according to the usual unit used by the World Health Organisation

11. Discussion
Overall TB incidence rate is 20 times higher than the incidence of TB in the general population of the 3 countries.
Associated factors: sex, CD4, Hb level, past history of TB strongly associated with the incidence of TB on ART: similar result found by Seyler et al. In 2005 in Abidjan.
Adjusted incidence 4 times higher in patients from CI in line with incidence rates in the general population:
BF: 54 [48 – 59] cases / 100,000 PY
CI: 165 [150 – 179] cases / 100,000 PY
SN: 138 [122 – 154] cases / 100,000 PY

12. Conclusion
Tuberculosis incidence remains high during the first year on ART in the West African context in the absence of IPT
Several studies demonstrate the efficacity of combining ART and IPT in reducing of tuberculosis incidence and mortality in PLHIV
Implementation of IPT is necessary in PLHIV in West African settings despite lower incidence rates in the general population compared to Eastern or Southern Africa
Temprano Anrs Study Group, 2015

13. IeDEA West Africa participating sites:
Acknowledgments
All the team of IeDEA West Africa Regional Office (PAC-CI, Abidjan, Côte d’Ivoire)
IeDEA West Africa participating sites:
Burkina Faso , Bobo Dioulasso: Jacques Zoungrana, Ibrahim Soré, Achille Tapsoba (CHU Souro Sanou)
Côte d’Ivoire, Abidjan: Henri Chenal, Magloire Moh (CIRBA), Joachim Charles Gnokoro, Koffi Ladji Issouf (ACONDA-CePReF), Yao Abo, Jean Michel Yoboue (CMSDS/CNTS)
Senegal, Dakar: Moussa Seydi, Judicael Malick Tine(SMIT, CHU Fann)

14. THANK YOU FOR YOUR ATTENTION