Abstract
BackgroundGiven the high death rate the first two months of tuberculosis (TB) therapy in HIV patients, it is critical defining the optimal time to initiate combination antiretroviral therapy (cART).MethodsA randomized, open-label, clinical trial comparing efficacy and safety of efavirenz-based cART initiated one week, four weeks, and eight weeks after TB therapy in patients with baseline CD4 count < 200 cells/μL was conducted. The primary endpoint was all-cause mortality rate at 48 weeks. The secondary endpoints were hepatotoxicity-requiring interruption of TB therapy, TB-associated immune reconstitution inflammatory syndrome, new AIDS defining illnesses, CD4 counts, HIV RNA levels, and AFB smear conversion rates. All analyses were intention-to-treat.ResultsWe studied 478 patients with median CD4 count of 73 cells/μL and 5.2 logs HIV RNA randomized to week one (n = 163), week four (n = 160), and week eight (n = 155). Sixty-four deaths (13.4%) occurred in 339.2 person-years. All-cause mortality rates at 48 weeks were 25 per 100 person-years in week one, 18 per 100 person-years in week four and 15 per 100 person-years in week eight (P = 0.2 by the log-rank test). All-cause mortality incidence rate ratios in subgroups with CD4 count below 50 cells/μL versus above were 2.8 in week one (95% CI 1.2–6.7), 3.1 in week four (95% CI 1.2–8.6) and 5.1 in week eight (95% CI 1.8–16). Serum albumin < 3gms/dL (adjusted HR, aHR = 2.3) and CD4 < 50 cells/μL (aHR = 2.7) were independent predictors of mortality. Compared with similar subgroups from weeks four and eight, first-line TB treatment interruption was high in week one deaths (P = 0.03) and in the CD4 subgroup <50 cells/μL (P = 0.02).ConclusionsAntiretroviral therapy one week after TB therapy doesn’t improve overall survival. Despite increased mortality with CD4 < 50 cells/μL, we recommend cART later than the first week of TB therapy to avoid serious hepatotoxicity and treatment interruption.Trial RegistrationClinicalTrials.gov NCT 01315301
Highlights
Tuberculosis (TB) is the most frequent cause of death in HIV infected patients
We studied 478 patients with median CD4 count of 73 cells/μL and 5.2 logs HIV RNA randomized to week one (n = 163), week four (n = 160), and week eight (n = 155)
All-cause mortality incidence rate ratios in subgroups with CD4 count below 50 cells/μL versus above were 2.8 in week one PLOS ONE | DOI:10.1371/journal.pone
Summary
Tuberculosis (TB) is the most frequent cause of death in HIV infected patients. People living with HIV are 27–32 times more likely to develop TB than HIV-negatives. TB case fatality ratios (CFR) in African and Asian patients not receiving combination antiretroviral therapy (cART) or in whom it was deferred for 8 weeks varied from 16–35% [8,9,10]. Various studies showed no differences in incidence rates of AIDS- defining illnesses or death when cART initiated between two to eight weeks of TB therapy as compared with later except for sub-groups with CD4 count < 50 cells/μL[12,15,16,17]. Our study hypothesis is that initiating cART earlier than second week of TB therapy in patients with CD4 counts < 200 cells/ μL, will improve overall survival at 48 weeks. Given the high death rate the first two months of tuberculosis (TB) therapy in HIV patients, it is critical defining the optimal time to initiate combination antiretroviral therapy (cART)
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