Early initiation of antiretroviral therapy results in decreased morbidity and mortality among patients with TB and HIV

Abstract

IntroductionThe overlapping drug toxicity profiles, drug-drug interactions and complications of management of both HIV and tuberculosis (TB) in patients with advanced HIV have not been fully delineated.MethodsWe conducted a retrospective chart review of the outcomes of tuberculosis treatment among 69 HIV-infected patients with TB, who were hospitalized in Masih Daneshvari Hospital in Tehran, Iran between 2002 and 2006, and who received standard category 1 (CAT-1) regimens. Group I (N = 47) included those treated from 2002 to 2005 with highly active antiretroviral therapy (HAART) initiated after eight weeks of TB treatment for those whose CD4 count was <200 cells/mm3. Group II (N = 22) included TB patients treated from 2005 to 2006, with HAART initiated after two weeks of TB treatment if their CD4 count was <100 cells/mm3 and eight weeks after initiation of TB treatment for those whose CD4 count was between 101 and 200 cells/mm3.ResultsThere were no differences between Groups I and II with regard to: adverse drug reactions [four (8.5%) versus two (9%), p = ns]; IRIS [six (12.7%) versus three (10.7%), p = ns]; and new opportunistic infections [eight (17.0%) versus two (9.1%), p = ns]. Death, however, occurred more frequently in Group I than in Group II [13 (27.7%) versus (4.5%), p = 0.03], where HAART was initiated earlier. Injection of drugs was the most common route of HIV transmission in both groups (72.3% in Group I and 77.3% in Group II).ConclusionThis manuscript shows that in a retrospective review of HIV/TB patients hospitalized in Tehran, improved survival was associated with earlier initiation of antiretroviral therapy in HIV/TB patients with CD4 counts of below 100 cells/mm3.

Polyfunctional CD4+ and CD8+ T Cell Responses to Tuberculosis Antigens in HIV-1–Infected Patients before and after Anti-Retroviral Treatment

“…ART has been available in The Gambia since 2004, so it is hard to know if there has been a reduction in TB incidence, but a recent study in Iran showed a significant reduction in TB incidence when ART was initiated for patients with CD4 counts ,100/ml (29). The World Health Organization guidelines recommend ART initiation when CD4 counts drop below 300/ml and our data suggest this is crucial in the context of retaining an adequate response to TB Ags (polyfunctional responses were lost in patients with counts below 500/ ml).…”

HIV and Tuberculosis: a Deadly Human Syndemic

“…By the end of the 50-week follow-up period, there was a 33% difference in mortality, with 59 deaths in 332 patients in the early arm and 87 deaths in 329 patients in the late arm. A retrospective review of 69 patients with HIV and TB coinfection found that an earlier initiation of ART after 2 weeks of TB treatment in patients with CD4 counts below 100 cells/l had a significant mortality reduction compared with patients with CD4 counts below 200 cells/l who started ART after 8 weeks of TB treatment (4.5% versus 27.7%, respectively; P ϭ 0.03) (243). Some experts on the U.S. guideline panel recommend an initiation of ART after 2 weeks of TB treatment for those with CD4 counts below 100 cells/l (75).…”

The HIV-associated tuberculosis epidemic—when will we act?

“…Mortality risk is reduced by 64-95%, and excellent immunological and virological responses can be achieved, tuberculosis recurrence is reduced, and frequency of bacteriological clearance can be increased. 22,32,[105][106][107][108][109][110] Yet by the end of 2007, only 100 000 (7·3%) of an estimated 1·37 million HIV-infected tuberculosis patients worldwide were reported to have started ART. 26 Increase of uptake is a high priority and is likely to be 36 By contrast with previous guidelines, 35 WHO now recommends that all patients with tuberculosis, irrespective of CD4 cell count, should receive ART as soon as possible after start of tuberculosis treatment.…”