Prevalent tuberculosis at HIV diagnosis in Rio de Janeiro, Brazil: The TB/HIV in Rio (THRio) cohort

Background: Although Brazil has model HIV care programs, many patients continue to present late to care. We studied the frequency of tuberculosis (TB) diagnosed at HIV diagnosis in Rio de Janeiro, Brazil, to quantify missed opportunities for TB prevention. Methods: People living with HIV (PLHIV) and enrolled in the TB/HIV in Rio study between September 1, 2005, and August 31, 2009, were included. Prevalent TB was defined as TB diagnosed within 60 days of HIV diagnosis or HIV diagnosis during TB therapy. Survival was measured from HIV diagnosis. We conducted Kaplan-Meier survival plots and Cox regression analyses. Results: Four thousand five hundred forty-eight newly diagnosed PLHIV were enrolled: 476 (10.5%) with prevalent TB. Individuals with prevalent TB were older, had lower CD4 counts, and higher viral loads than did those without TB. Median time to receiving highly active antiretroviral therapy (HAART) in those with prevalent TB was 99 days (interquartile range = 58-191) vs. 126 days (interquartile range = 63-301) in those without TB (P = 0.021). Among those with prevalent TB, 17% died during follow-up compared with 8% among those without TB (P < 0.001). After adjustment for sex, age, baseline CD4, and baseline viral load, the risk of occurrence of death remained significantly higher among those with prevalent TB [adjusted hazard ratio = 1.72 (confidence interval 95% 1.19 to 2.48)]. Conclusions: More than 10% of new PLHIV in our study presented to care with concurrent active TB disease and thus missed the opportunity for undergoing TB preventive therapy. Despite initiating HAART more quickly, these individuals were at a significantly greater risk of death. Earlier HIV diagnosis is necessary to provide earlier initiation of HAART and TB preventive therapy to reduce morbidity and mortality in PLHIV.