Tuberculosis Late Diagnosis and Mortality Decrease among HIV Positive People in U.S.

The rate of death due to tuberculosis (TB) in the U.S. has decreased by half since the early 1990s, mostly attributable to a reduction among HIV positive people, according to a study described in the November 26, 2010 Morbidity and Mortality Weekly Report. What's more, among people with HIV, the proportion who were not diagnosed with TB until after they died also declined, reflecting better access to medical care.

Centers for Disease Control and Prevention (CDC) investigators looked at the effect of HIV infection on the risk of death during treatment for tuberculosis in the U.S.

Worldwide, TB incidence increased from 125 cases per 100,000 people in 1990 to 142 cases per 100,000 in 2004, primarily due to the HIV epidemic, the study authors noted as background. People with HIV are at increased risk for TB infection and development of TB disease, and also have a higher risk of TB-related death.

"This is documented most clearly in resource-limited settings, where limited access to antiretroviral therapy (ART) and other health care services contribute to the elevated mortality," they wrote.

The impact of HIV on TB outcomes is less clear in high-income countries such as the U.S., however. In this study, investigators analyzed data from all culture-positive patients with TB documented between 1993 and 2008, as reported to the CDC's National TB Surveillance System.


These findings show that the decrease in deaths among people with TB between 1993 and 2008 was mostly entirely attributable to a reduction in mortality among people with HIV.

"In 2008, however, 21% of patients with TB still had unknown HIV status, and this proportion was even higher in certain demographic groups," wrote the authors of an accompanying editorial note. "This is unacceptable given that knowledge of HIV status is essential for appropriate treatment and that current guidelines recommend HIV testing for all patients with TB in the United States."

Based on these results, the investigators recommended, "Further reductions in mortality can be achieved by enhanced TB/HIV program collaboration and service integration."

Investigator affiliations: Dept of Medicine, Albert Einstein College of Medicine, Bronx, NY; Div of TB Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; EIS Officer, CDC.



S Shah, K Cain, S Marks, and others. Mortality Among Patients with Tuberculosis and Associations with HIV Status -- United States, 1993 -- 2008. Morbidity and Mortality Weekly Report 59(46): 1509-1513 (Abstract). November 26, 2010.