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Impact of the Antiretroviral Treatment Program on the Burden of Hospitalization for Culture-confirmed Tuberculosis in South African Children: A Time-series Analysis

Dangor, Ziyaad MBBCh, MMed, FCPaed*; Izu, Alane PhD; Hillier, Kelty MSc; Solomon, Fatima MBBCh; Beylis, Natalie MBBCh, FCPath§; Moore, David P. MBBCh, FCPaed, MPhil; Nunes, Marta C. PhD; Madhi, Shabir A. MBBCh, FCPaed, PhD†¶

Pediatric Infectious Disease Journal:
doi: 10.1097/INF.0b013e31828d9aa4
HIV Reports

Background: The HIV epidemic increased the burden of tuberculosis (TB) in sub-Saharan Africa. We evaluated the impact that scaling-up of the public-funded antiretroviral treatment (ART) program had on incidence of hospitalization for culture-confirmed and overall-TB in HIV-infected and HIV-uninfected children from 2005 to 2009.

Methods: The study was undertaken in Soweto, South Africa, where ART coverage of HIV-infected children increased from 43% in 2005 to 84% by 2009. Trends in incidence of hospitalization for clinically diagnosed and culture-confirmed TB in children 3 months to <15 years of age, identified through laboratory and electronic databases, were analyzed by comparing crude incidence and regression analysis.

Results: The incidence (per 100,000) of culture-confirmed TB declined by 63.1% from 2005 (69.8) compared with 2009 (25.8; P < 0.0001). This included a 70.6% reduction between 2005 and 2009 among HIV-infected children (incidence: 1566.3 versus 460.7, respectively; P < 0.0001) and 41.3% decrease in HIV-uninfected children (18.7 versus 11.0, respectively; P = 0.0003). The month-by-month rate of decline of culture-confirmed TB was 2.3% in HIV-infected and 1.1% in HIV-uninfected children over the study period. The residual burden of TB remained 42-fold greater in HIV-infected children, 78% of whom were severely immune compromised, compared with HIV-uninfected children by 2009.

Conclusion: Increase in ART coverage was associated with significant decline in TB hospitalizations in HIV-infected children. This reduction may also in part have been due to reduced Mycobacterium tuberculosis transmission resulting from increased ART access among HIV-infected adults, which may have contributed to the reduction of culture-confirmed TB in HIV-uninfected children.

Author Information

From the *Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases & Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; City of Hamilton Public Health Services, Hamilton, Ontario, Canada; §Mycobacteriology Referral Laboratory, National Health Laboratory Service, Johannesburg, South Africa; and National Institute for Communicable Diseases: a division of National Health Laboratory Service, Centre for Tuberculosis, Sandringham, South Africa.

Accepted for publication February 15, 2013.

K.H. was supported by a grant from McGill University Health Centre Research Institute Studentship. M.C.N. received a postdoctoral scholarship from the University of the Witwatersrand. S.A.M. is funded in part by National Research Foundation/Department of Science and Technology: South African Research Chair Initiative Program. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the article. The authors have no other funding or conflicts of interest to disclose.

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Address for correspondence: Shabir A. Madhi, MBBCh, FCPaed, PhD, National Institute of Communicable Diseases: a division of National Health Laboratory Service, 1 Modderfontein Road, Sandringham, Gauteng, 2131, South Africa. E-mail:

© 2013 by Lippincott Williams & Wilkins, Inc.