HIV-1 and recurrence, relapse, and reinfection of tuberculosis after cure: a cohort study in South African mineworkers

• Published in: The Lancet (British edition) 2001-11, Vol.358 (9294), p.1687-1693
• Main Authors: Sonnenberg, Pamela, Murray, Jill, Glynn, Judith R, Shearer, Stuart, Kambashi, Bupe, Godfrey-Faussett, Peter
• Format: Article
• Language: English
• Subjects: Adult; Antitubercular Agents - therapeutic use; Biological and medical sciences; Cavitation; Cohort analysis; Cure monitoring; Deoxyribonucleic acid; DNA; DNA Fingerprinting; Drug resistance; Employment; Epidemiology; Fingerprints; Health risk assessment; HIV; HIV Seronegativity; HIV Seropositivity; HIV-1 - immunology; Human immunodeficiency virus; Human viral diseases; Humans; Infections; Infectious diseases; Laboratories; Male; Medical sciences; Middle Aged; Mines; Mining; Mortality; Occupational Exposure; Patients; Prevalence; Recurrence; Recurrent infection; Risk analysis; Risk Factors; South Africa - epidemiology; Survival analysis; Tuberculosis; Tuberculosis, Pulmonary - drug therapy; Tuberculosis, Pulmonary - epidemiology; Tuberculosis, Pulmonary - etiology; Viral diseases; Viral diseases of the lymphoid tissue and the blood. Aids
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(01)06712-5

The proportion of recurrent tuberculosis cases attributable to relapse or reinfection and the risk factors associated with these different mechanisms are poorly understood. We followed up a cohort of 326 South African mineworkers, who had successfully completed treatment for pulmonary tuberculosis in 1995, to determine the rate and mechanisms of recurrence. Patients were examined 3 and 6 months after cure, and then were monitored by the routine tuberculosis surveillance system until December, 1998. IS6110 DNA fingerprints from initial and subsequent episodes of tuberculosis were compared to determine whether recurrence was due to relapse or reinfection All patients gave consent for HIV-1 testing. During follow-up (median 25·1 months, IQR 13·2–33·4), 65 patients (20%) had a recurrent episode of tuberculosis, a recurrence rate of 10·3 episodes per 100 person-years at risk (PYAR)—16·0 per 100 PYAR in HIV-1-positive patients and 6·4 per 100 PYAR in HIV-1-negative patients. Paired DNA fingerprints were available in 39 of 65 recurrences: 25 pairs were identical (relapse) and 14 were different (reinfection). 93% (13/14) of recurrences within the first 6 months were attributable to relapse compared with 48% (12/25) of later recurrences. HIV-1 infection was a risk factor for recurrence (hazard ratio 2·4, 95% CI 1·5–4·0), due to its strong association with disease caused by reinfection (18·7 2·4–143), but not relapse (0·58; 0·24–1·4). Residual cavitation and increasing years of employment at the mine were risk factors for relapse. In a setting with a high risk of tuberculous infection, HIV-1 increases the risk of recurrent tuberculosis because of an increased risk of reinfection. Interventions to prevent recurrent disease, such as lifelong chemoprophylaxis in HIV-1-positive tuberculosis patients, should be further assessed.