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Early ART beneficial for newly diagnosed TB patients with low CD4
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Early initiation of ART after beginning treatment for tuberculosis may reduce mortality among immunosuppressed HIV patients, according to a recent literature review.
“Current [WHO] guidelines recommend starting TB treatment first, followed by HIV treatment as soon as possible within 2 to 8 weeks for patients who have moderately to severely compromised immune systems, but there was not conclusive evidence to guide treatment in other levels of immune suppression,” Jean B. Nachega, MD, PhD, MPH, of the Graduate School of Public Health at the University of Pittsburgh, said in a press release. “We aimed to investigate the optimal timing of HIV initiation in light of recent published randomized clinical trials on this topic.”
Nachega and colleagues reviewed previous studies examining the optimal timing of ART initiation among patients coinfected with TB. Randomized, controlled trials included in the evaluation compared early ART initiation (2 to 4 weeks after the start of TB treatment) with either delayed initiation (8 to 12 weeks after the start of TB treatment) or deferred initiation (after 6 months of TB treatment), and were assessed for potential biases. Relevant and acceptable data were combined using a fixed-effect meta-analysis. The primary outcomes were all-cause mortality and TB-associated immune reconstitution inflammatory syndrome (TB-IRIS).
After the data screening process, eight trials examining 4,568 participants with HIV and TB from Asia, Africa and the United States were included in the analysis. Patients assigned to early ART had lower all-cause mortality compared with those receiving delayed ART (RR = 0.81; 95% CI, 0.66-0.99). Subgroup analysis revealed this outcome to be greatest among patients with baseline CD4+ T-cell counts below the 0.05x109 cells/L threshold (RR = 0.71; 95% CI, 0.54-0.93), while no evidence of reduced mortality was seen among those above (RR = 1.05; 95% CI, 0.68-1.61). Despite this, early initiation of ART was associated with a higher risk for TB-IRIS development compared with delayed initiation (RR = 2.31; 95% CI, 1.87-2.86). No difference in all-cause mortality was observed in trials comparing early initiation with deferred initiation, but a greater risk for TB-IRIS development was again seen in the early initiation group (RR = 5.35; 95% CI, 2.58-11.11).
“Clinicians will need to weigh these benefits against the burden of co-administration of TB and HIV treatment on a case-by-case basis,” Nachega said, “but the overarching goal is likely to be a move toward treating all HIV-positive people as early as possible.” — by Dave Muoio
Disclosure: The researchers report no relevant financial disclosures.
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