Early antiretroviral treatment for people with HIV/TB coinfection could reduce mortality by half

People with HIV/tuberculosis coinfection who began antiretroviral treatment within six months of starting TB treatment had a 55% lower mortality rate than people with HIV/TB coinfection who did not begin antiretroviral therapy until after they had finished a six-month TB treatment course, according to a study conducted by researchers at the University of KwaZulu-Natal, Business Day reports (Kahn, Business Day, 9/18).

For the study, Salim Abdool Karim -- pro vice-chancellor of the university and director of the Center for the AIDS Program of Research in South Africa, or Caprisa -- and colleagues assigned 645 people with HIV/TB coinfection whose CD4+ T cell counts were less than 500 into one of three groups. One group received both TB and HIV treatment immediately; another group received TB drugs for two months before beginning antiretroviral therapy; and a third group began antiretroviral treatment after completing a six- to eight-month TB treatment course. All study participants were able to begin antiretroviral therapy "at any time if judged clinically necessary" by physicians, Karim said.

The study found that 26 of the 214 people in the group who did not receive antiretrovirals until completing TB treatment died and that the mortality rate in the group was 55% higher than the two groups receiving integrated HIV/TB treatment. Among the 431 participants in the two integrated HIV/TB treatment groups, 24 people died, the study found (Cullinan, The Star, 9/18). The study's findings prompted the trial's safety committee to halt research on the delayed antiretroviral treatment group and provide antiretrovirals to those participants. Research will continue among the other two groups, Karim said.

According to Karim, 70% of the 353,000 people diagnosed with TB in South Africa last year also were HIV-positive. In addition, 150,000 people with HIV/TB coinfection had CD4+ counts between 200 and 500 and would have benefited from taking antiretrovirals before finishing TB treatment (Business Day, 9/18). Karim added that the study's findings could prevent up to 10,000 deaths annually.

World Health Organization guidelines indicate that HIV-positive people whose CD4+ counts are below 50 should begin taking HIV and TB drugs immediately; those with CD4+ counts between 50 and 200 should start antiretroviral therapy after two months of TB treatment; and those with CD4+ counts greater than 200 should complete TB treatment before beginning antiretroviral therapy.

Reaction

Kogie Naidoo, a study researcher, said people with HIV/TB coinfection "do worse than those without TB, regardless of their CD4+ count" (The Star, 9/18). Karim added that the study's findings "provide compelling evidence to support the World Health Organization's call for greater collaboration between TB and HIV treatment services." Mark Dybul, the U.S. global AIDS coordinator who administers the President's Emergency Plan for AIDS Relief, said PEPFAR is "committed to increasing screening for both HIV and TB, which will allow greater numbers of patients to benefit from these study results" (SAPA/Independent Online, 9/18).

Francois Venter, president of South Africa's HIV Clinicians Society, said the study has "begun to answer one of the most important questions for the HIV field -- when we can start antiretrovirals safely in people with TB" (The Star, 9/18).Venter added that the "bottom line is that a laissez-faire attitude" toward HIV/TB coinfection "is not justified" and that health workers "need to start seeing TB as an emergency" (Business Day, 9/18).