Tuberculosis in human immunodeficiency virus-infected children starting antiretroviral therapy in Côte d'Ivoire

SETTING: In Côte d'Ivoire, more than 2000 human immunodeficiency virus (HIV) infected children aged <15 years were started on antiretroviral therapy (ART) during 2004–2008.

OBJECTIVES: To estimate tuberculosis (TB) incidence and determinants among ART enrollees.

DESIGN: A nationally representative retrospective cohort study among 2110 children starting ART during 2004–2008 at 29 facilities.

RESULTS: At ART initiation, the median age was 5.1 years; 82% had World Health Organization Stage III/IV, median CD4% was 11%, 42% were severely undernourished (weight-for-age Z-score [WAZ] <-3), and 150 (7%) were taking anti-tuberculosis treatment. Documentation of TB screening before ART declined from 63% to 46% during 2004–2008. Children taking anti-tuberculosis treatment at ART enrollment had a lower median CD4% (9.0% vs. 11.0%, P = 0.037) and a higher prevalence of WAZ <-3 (59% vs. 40%, P < 0.001). Among children considered TB-free at ART enrollment, TB incidence was 6.28/100 child-years during days 0–90 of ART, declining to 0.56/100 child-years after 180 days. Children with one unit higher WAZ at ART enrollment had 13% lower TB incidence (adjusted HR 0.87, 95%CI 0.77–1.00, P= 0.047).

CONCLUSIONS: Ensuring clinician compliance with TB screening before ART and ensuring earlier ART initiation before children suffer from advanced HIV disease and nutritional compromise might reduce TB morbidity during ART.