Tuberculosis in human immunodeficiency virus-exposed or -infected United States children

This study was designed to provide a preliminary assessment of the occurrence of tuberculosis exposure, infection and disease within a national sample of infants and children with human immunodeficiency virus (HIV) exposure or infection, and to determine the prevalence of Mycobacterium tuberculosis isolates resistant both to isoniazid and rifampin in these patients or their adult source contacts. A retrospective questionnaire survey was conducted of infants and children with HN exposure or infection evaluated by pediatric HIV referral centers in the United States comprising the pediatric units or subunits of the Pediatric Acquired Immunodeficiency Syndrome Clinical Trials Group (PACTG). Seventy of 72 sites during a mean period of 5 (range, 1 to 12) years participated in this study and had provided care for 14038 patients. There were 75 cumulative total cases of tuberculosis disease seen since each site was established. Therapy for asymptomatic infection was given to another 40 children and for tuberculosis exposure to 71 children. Annualized case rates mere 478/100000 for sites established in 1990 to 1992, 117/100000 for 1988 to 1989, 63/100000 for 1986 to 1987 and 58/100000 for 1981 to 1985 (P = 0.05, Spearman's p test for trend). By comparison, the 1992 age specific tuberculosis case rate for all U.S. children <5 years was 5.5/100000. Twenty percent of isolates from PACTG patients and 15% of isolates from adult source contacts were resistant to isoniazid and rifampin. In children with HIV exposure or infection, incident case rates of tuberculosis appear to exceed greatly those of comparably aged children in the general population. Annualized case rates increased progressively across PACTG sites of increasingly recent establishment, possibly indicating that rates of infection increased over time. Infection with and exposure to multiply drug-resistant strains was common in PACTG patients. This study has identified the need to monitor tuberculosis trends in HIV-exposed or -infected pediatric patients, to determine the circumstances in which these children are exposed to tuberculosis, to identify opportunities to intervene and to integrate the needs of these children into national plans for tuberculosis control.