An. Ackah et al., RESPONSE TO TREATMENT, MORTALITY, AND CD4 LYMPHOCYTE COUNTS IN HIV-INFECTED PERSONS WITH TUBERCULOSIS IN ABIDJAN, COTE-DIVOIRE, Lancet, 345(8950), 1995, pp. 607-610
We examined the severity of immune deficiency in patients with HIV-ass
ociated tuberculosis in Cote d'Ivoire and assessed its effect on morta
lity and response to treatment. Consecutive patients attending a tuber
culosis treatment in Abidjan with smear-positive pulmonary or diagnose
d extrapulmonary tuberculosis were tested for HIV-1 and HIV-2 infectio
ns and had CD4 lymphocyte counts measured. Patients received standard
short-course chemotherapy. Analysis of outcome (restricted to smear-po
sitive tuberculosis patients) was done at 6 months. The 247 HIV-positi
ve patients were significantly more likely than the 312 HIV-negative p
atients to have CD4 lymphocyte counts of less than 200/mu L (43% vs 1%
; odds ratio 56.9; [95% CI 19.7-185.3]) and 200-499/mu L (39% vs 14%,
odds ratio 3.8; [2.5-5.9]). HIV-positive patients, median CD4 lymphocy
te in those with extrapulmonary tuberculosis (198/mu L; n=67) was lowe
r, but not significantly so, than among those with pulmonary tuberculo
sis (257/mu L; n=180). Among 460 patients with pulmonary tuberculosis,
the overall mortality rate was significantly higher in HIV-positive t
han HIV-negative persons (6% vs 0.4%; relative risk 17.1 [2.2-131.4]),
and increased with the severity of immune deficiency; mortality rates
in HIV-positive patients with CD4 counts of <200/mu L and 200-499/mu
L were 10% and 4%, relative risk 27.6 (3.5-220.8); and 11.5 (1.2-109),
respectively, compared to HIV-negatives. Among patients completing tr
eatment, cure rates were similar in HIV-positive patients (93%) and HI
V-negative patients (92%), and were not related to CD4 counts. Severit
y of immune deficiency was the major determinant of mortality in HIV-a
ssociated tuberculosis. Among people completing treatment, microbiolog
ical response was satisfactory irrespective of serological or immune s
tatus.