Tuberculosis and HIV Co-infection, California, USA, 1993–2008

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Release date: February 19, 2013; Expiration date: February 19, 2014

Learning Objectives

Upon completion of this activity, participants will be able to:
• Describe rates of HIV co-infection among persons with tuberculosis (TB) in California, and changes in TB incidence among persons with HIV from 1993 to 2008 in California, based on an epidemiological study using registry and surveillance system data
• Compare characteristics of patients with TB/HIV co-infection in the modern era with those in the pre-HAART era, based on an epidemiological study using registry and surveillance system data
• Describe mortality and other characteristics of TB/HIV in California, based on an epidemiological study using registry and surveillance system data.

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Karen L. Foster, Technical Writer/Editor, Emerging Infectious Diseases. Disclosure: Karen L. Foster has disclosed no relevant financial relationships.

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Authors

Disclosures: John Z. Metcalfe, MD, MPH; Travis Porco, PhD, MPH; Janice Westenhouse, MPH; Mark Damesyn, PhD; Matt Facer, PhD; Julia Hill, BS; Qiang Xia, MD, MPH; James P. Watt, MD, MPH; Philip Hopewell, MD; and Jennifer Flood, MD, MPH, have disclosed no relevant financial relationships.

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Volume 19, Number 3– March 2013

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Tuberculosis and HIV Co-infection, California, USA, 1993–2008 - Vol. 19 No. 3 - March 2013 - Emerging Infectious Disease journal - CDC

Tuberculosis and HIV Co-infection, California, USA, 1993–2008

John Z. Metcalfe

, Travis C. Porco, Janice Westenhouse, Mark Damesyn, Matt Facer, Julia Hill, Qiang Xia, James P. Watt, Philip C. Hopewell, and Jennifer Flood

Author affiliations: Author affiliations: University of California, San Francisco, California, USA (J.Z. Metcalfe, T.C. Porco, P.C. Hopewell); California Department of Public Health, Richmond, California, USA (J. Westenhouse, J. Hill, J.P. Watt, J. Flood); California Department of Public Health, Sacramento, California, USA (M. Damesyn, M. Facer); RTI International, Research Triangle Park, North Carolina, USA (Q. Xia)

Abstract

To understand the epidemiology of tuberculosis (TB) and HIV co-infection in California, we cross-matched incident TB cases reported to state surveillance systems during 1993–2008 with cases in the state HIV/AIDS registry. Of 57,527 TB case-patients, 3,904 (7%) had known HIV infection. TB rates for persons with HIV declined from 437 to 126 cases/100,000 persons during 1993–2008; rates were highest for Hispanics (225/100,000) and Blacks (148/100,000). Patients co-infected with TB–HIV during 2001–2008 were significantly more likely than those infected before highly active antiretroviral therapy became available to be foreign born, Hispanic, or Asian/Pacific Islander and to have pyrazinamide-monoresistant TB. Death rates decreased after highly active antiretroviral therapy became available but remained twice that for TB patients without HIV infection and higher for women. In California, HIV-associated TB has concentrated among persons from low and middle income countries who often acquire HIV infection in the peri-immigration period.

The modern resurgence of tuberculosis (TB) in conjunction with the HIV pandemic remains a major public health dilemma. In 2011, nine percent of all newly reported TB cases in the United Sates for which HIV status was known (1) and 13% (1.1 million cases) of cases reported worldwide (2) were associated with HIV co-infection. Despite compelling declines in TB incidence and associated deaths with use of highly active antiretroviral therapy (HAART), TB remains the leading cause of death among persons with HIV/AIDS (3,4).
California, the most populous state in the United States (38 million persons [12% of the US population]), reports the highest annual number of persons with TB (22.1% of total) and the second highest number of HIV-infected persons (103,073 [12.4%] cases) (5). Yet, because of prior restrictions on HIV reporting and limited systematic linking of state TB and HIV surveillance systems, California has not been included in key national surveillance reports of HIV incidence (6) or death in persons with TB–HIV (7).
Effective control of TB–HIV requires an understanding of the changing epidemiology of these diseases. To provide information for disease-reduction efforts and to improve survival among persons with TB–HIV, we retrospectively reviewed all incident TB–HIV cases in a 16-year period in California during which dynamic changes occurred in the HIV epidemic as a consequence of the introduction of HAART.

Methods

Study Population

We analyzed all TB cases reported to the California TB registry during January 1, 1993–December 31, 2008. California state law requires reporting of all verified cases of TB and HIV/AIDS (California Health and Safety Code Title 17§2505, and Section 121022 [2006]) to their respective programs. TB–HIV patients were identified through a statewide registry match with the California Office of AIDS by using Registry Plus Link Plus software (Technical Appendix

[PDF - 72 KB - 8 pages]). Annual state HIV prevalence was estimated through nonparametric back-calculation based on racial/ethnic group–specific counts of reported AIDS cases and reported AIDS-related deaths during 1981–2008 (Technical Appendix

[PDF - 72 KB - 8 pages]Table 1) (8). Demographic, behavioral, and clinical information, including deaths, was abstracted from state surveillance forms (Report of a Verified Case of Tuberculosis and Adult HIV/AIDS Confidential Case Report). Surveillance data for both diseases have demonstrated high validity (9,10).