Human immunodeficiency virus and the outcome of treatment for new and recurrent pulmonary tuberculosis in African patients

The purpose of this study was to evaluate the impact of human immunodeficie ncy virus (HIV) infection on treatment for tuberculosis (TB). The study pop ulation comprised 28,522 black Southern African gold miners. Patients with sputum culture-positive new or recurrent pulmonary TB diagnosed in 1995 wer e prospectively enrolled in the cohort. Directly observed therapy (DOT) was practiced and outcomes were assessed at 6 mo after treatment was begun. Th ere were 376 cases of TB (incidence 1,318 per 100,000), of which 190 (50%) were HIV positive and 82 (22%) had recurrent TB. There was no association b etween HIV status and history of previous TB or drug resistance. Neither th e treatment interruption rate (2%) nor the rate at which patients transferr ed out of the treatment program (1.6%) were associated with HIV status. Exc luding deaths, cure rates were similar for HIV-positive and HIV-negative pa tients (89% versus 88%), but significantly lower in those with recurrent th an in those with new TB (77% versus 92%). Mortality was 0.5% in HIV-negativ e patients versus 13.7% in HIV-positive patients, and in the latter group w as associated with CD4(+) lymphocyte depletion. Autopsy examination showed that in HIV-positive patients, early mortality was due to TB whereas late d eaths were most commonly due to cryptococcal pneumonia. The study showed th at a well-run TB control program can result in acceptable cure rates even i n a population with a very high incidence of TB and HIV infection. Particul ar vigilance is needed for concurrent infections, which may contribute sign ificantly to mortality during treatment of TB in HIV-positive patients.