CD4 deficit and tuberculosis risk persist with delayed antiretroviral therapy: 5-year data from CIPRA HT-001

Abstract

Delays in ART initiation for HIV-infected adults with CD4 counts of 200-350 cells/mm(3) can result in long-term immune dysfunction and persistent increased risk for TB.

Health system challenges affecting the implementation of isoniazid preventive therapy in people living with HIV in Lesotho

“…In addition, patients deemed too sick were also delayed. Apparently, patients considered too sick are at the greatest risk of developing TB [25]. Healthcare workers' education is therefore also needed to address this problem.…”

Scale-up of ART in Malawi has reduced case notification rates in HIV-positive and HIV-negative tuberculosis

“…Kanyerere, 1 B. Girma, 1,2 J. Mpunga, 1 K. Tayler-Smith, 3 A. D. Harries, 4,5 A. Jahn, 2,6 F. M. Chimbwandira 6 H uman immunodeficiency virus (HIV) infection is the most important risk factor for the development of tuberculosis (TB) in persons infected with Mycobacterium tuberculosis, and has been responsible for the huge upsurge in TB cases in affected southern African countries over the last 25 years. Antiretroviral therapy (ART) reverses the immune dysfunction associated with HIV, and with initiation of treatment there is rapid functional recovery of mycobacteria-specific immune responses, which results in enhanced capacity to restrict mycobacterial growth.…”

“…3 More recent studies have confirmed these findings and have also highlighted the TB preventive benefits of early initiation of ART. [4][5][6][7] At the programme level, although PLHIV are often initiated late on ART and with low CD4 counts, studies from Malawi and Swaziland have shown that when high ART coverage rates are reached among HIV-infected populations, the TB case notification rate (CNR) decreases. [8][9][10][11][12] In a study from Malawi reporting data up to 2012, there was some preliminary evidence to suggest that while the declines in TB were most apparent in those with HIV infection, there might also be a decline in patients who were HIV-negative.…”

“…First, in line with the WHO's rapid advice in 2015 and recently released 2016 guidelines to start all PLHIV on ART regardless of clinical stage or CD4 cell count, 23,24 Malawi has made a strategic decision to start what is called 'HIV test and treat'. Early start of ART has been shown to further reduce the risk of TB in PLHIV, [4][5][6][7] and this should enhance the gains already made in the past several years. TB is also a major cause of hospitalisation and in-hospital mortality in adults and children globally, and early ART is likely to substantially reduce this burden.…”

Understanding and intervening in HIV-associated tuberculosis

“…There is also evidence that person time accrued at lower CD4 strata is associated with an increased risk of tuberculosis after commencement of ART. 4,6 Implementation of integrated HIV and tuberculosis care programmes is essential to reduce the dual burden of disease.…”