High conversion of tuberculin skin tests during the first year of antiretroviral treatment among South African adults in primary care

Objectives: Anergy reduces the sensitivity of the tuberculin skin test (TST) to detect Mycobacterium tuberculosis infection in people living with HIV. Antiretroviral treatment (ART) can reverse TST anergy, but data is scarce. Methods: To estimate TST conversion rates and factors associated with TST conversion, TST was placed at ART initiation, and 6 and 12 months thereafter (if TST negative at prior assessment). Results: Of 328 ART-eligible participants, 70% (231/328) had a valid TST result of whom 78% (180/231) were TST negative. At 6-month follow-up, 22% (24/109, 95% confidence interval [CI] 15%, 31%) of participants on ART, without incident tuberculosis (TB), and with a valid TST result converted to a positive TST. Of these 109 individuals, those with baseline CD4(+) cell count >250 cells/mu l were more likely to TST convert compared to those with baseline CD4(+) cell count <= 250 cells/mu l (odds ratio [OR] 3.54, 95% CI 1.29, 11.47). At 12 months post-ART initiation, an additional 12% (9/78, 95% CI 6, 20) of participants on ART, without incident TB and with a valid TST result experienced TST conversion. After 1 year on ART, TST conversion rate was 38 per 100 person-years (95% CI 26, 52), and lower in individuals with baseline CD4(+) cell count <= 250 cells/mu l (23/100 person-years, 95% CI 11, 41) compared to those with baseline CD4(+) cell count >250 cells/mu l (50/100 person-years, 95% CI 32, 73). Conclusions: TST conversion rate in the first year of ART is high, especially among people with CD4(+) cell count >250 cells/mu l. A TST-based eligibility strategy at ART initiation may underestimate eligibility for preventive therapy for tuberculosis.

Automated summary

TST conversion rate is high in the first year of ART, especially among individuals with baseline CD4(+) cell count >250 cells/µl.