Injecting drug use predicts active tuberculosis in a national cohort of people living with HIV

Joanne R. Winter*, Helen R. Stagg, Colette J. Smith, Alison Brown, Maeve K. Lalor, Marc Lipman, Anton Pozniak, Andrew Skingsley, Peter Kirwan, Zheng Yin, Helen Thomas, Valerie Delpech, Ibrahim Abubakar

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

7 Citations (Scopus)


Objectives: Tuberculosis (TB) is common in people living with HIV, leading to worse clinical outcomes including increased mortality. We investigated risk factors for developing TB following HIV diagnosis. Design: Adults aged at least 15 years first presenting to health services for HIV care in England, Wales or Northern Ireland from 2000 to 2014 were identified from national HIV surveillance data and linked to TB surveillance data. Methods: We calculated incidence rates for TB occurring more than 91 days after HIV diagnosis and investigated risk factors using multivariable Poisson regression. Results: A total of 95003 adults diagnosed with HIV were followed for 635591 person-years; overall incidence of TB was 344 per 100000 person-years (95% confidence interval 330-359). TB incidence was high for people who acquired HIV through injecting drugs [PWID; men 876 (696-1104), women 605 (365-945)] and black Africans born in high TB incidence countries [644 (612-677)]. The adjusted incidence rate ratio for TB amongst PWID was 4.79 (3.35-6.85) for men and 6.18 (3.49-10.93) for women, compared with MSM. The adjusted incidence rate ratio for TB in black Africans from high-TB countries was 4.27 (3.42-5.33), compared with white UK-born individuals. Lower time-updated CD4 + cell count was associated with increased rates of TB. Conclusion: PWID had the greatest risk of TB; incidence rates were comparable with those in black Africans from high TB incidence countries. Most TB cases in PWID were UK-born, and likely acquired TB through transmission within the United Kingdom. Earlier HIV diagnosis and quicker initiation of antiretroviral therapy should reduce TB incidence in these populations.

Original languageEnglish
Pages (from-to)2403-2413
Number of pages11
Issue number17
Publication statusPublished - 13 Nov 2017

Bibliographical note

Funding Information:
J.R.W., A.E.B., M.K.L., M.L., A.S., P.K., Z.Y., H.L.T., V.D. and I.A. have no conflicts of interests to declare. H.R.S. declares funding from the National Institute for Health Research, UK during the conduct of the study; and, outside of the submitted work, grants and personal fees from Otsuka Pharmaceutical, nonfinancial support from Sanofi, and other support from the WHO. Outside the submitted work, C.J.S. reports personal fees from Gilead Sciences and ViiV Healthcare. A.P. is chair of the BHIVA TB guidelines committee. J.R.W. had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Funding Information:
J.R.W. is funded by a UCL IMPACT studentship. This report is independent research supported by the National Institute for Health Research (Postdoctoral Fellowship, H.R.S., PDF-2014-07-008). I.A. acknowledges funding from NIHR (NF-SI-0616-10037 and SRF-2011-04-001), MRC and the Wellcome Trust. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

Funding Information:
aCentre for Molecular Epidemiology and Translational Research, bCentre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute of Global Health, University College London, cHIV surveillance, dTB section, National Infections Service, Public Health England, eRespiratory Medicine, Royal Free London National Health Service Foundation Trust, and fHIV & Sexual Health, Chelsea and Westminster Hospital, London, UK. Correspondence to Joanne R. Winter, MSc, Institute for Global Health, University College London, London, UK. Tel: +44 02079052123; e-mail: *Valerie Delpech and Ibrahim Abubakar are joint senior authors. Received: 23 June 2017; revised: 11 August 2017; accepted: 21 August 2017.

Publisher Copyright:
© 2017 Wolters Kluwer Health, Inc. All rights reserved.


  • HIV
  • cohort studies
  • coinfection
  • observational study
  • risk factors
  • tuberculosis


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