Abstract
ObjectiveWe aimed to perform a systematic review and meta-analysis examining the impact of TB treatment at the time of combination antiretroviral therapy (cART) initiation on subsequent mortality.MethodsWe searched PubMed, EMBASE, and selected conference proceedings for studies that report adult mortality on cART, stratified by TB treatment status at cART initiation. Stratified random-effects and meta-regression analyses were used to examine the influence of study and population characteristics.Results22 eligible cohort studies reported data on 98,350 (range 74-15,225) adults, of whom 14,779 (15%) were receiving TB treatment at cART initiation. Studies of those receiving vs. not receiving TB treatment had an average mortality relative risk of 1.10 (95% confidence interval 0.87-1.40) at 1-3 months (based upon 8 estimates), 1.15 (0.94-1.41) at 6-12 months (11 estimates), and 1.33 (1.02-1.75) at 18-98 months (10 estimates) following cART initiation. However, there was a wide range of estimates and those at later time points were markedly heterogeneous. Meta-regression identified factors associated with elevated average risk estimates: lower median baseline CD4 counts and adjustment for baseline hemoglobin at 1-3 months; longer length of follow-up and women-only studies at 6-12 months; and not adjusting for BMI/weight at 18-98 months.ConclusionsPatients receiving TB treatment at cART initiation did not have a statistically significant estimated increase in short-term risk of all-cause mortality as compared to those not receiving TB treatment. TB treatment was significantly associated with increased mortality after about a year of cART, suggesting that patients with concurrent TB treatment at cART initiation may benefit from continued support after TB treatment completion.
Highlights
Tuberculosis (TB) continues to threaten the health of people living with human immunodeficiency virus (HIV) (PLWH)
In 2011, 13% of incident TB cases were co-infected with HIV and an estimated 0.4 million TB deaths occurred among people living with HIV (PLWH) [1]
Due to the paucity of studies reporting on patients on combination antiretroviral therapy (cART), the authors concluded that the effect of TB on mortality in PLWH exposed to cART must be further evaluated once more cohort study results become available
Summary
Tuberculosis (TB) continues to threaten the health of people living with HIV (PLWH). In 2011, 13% of incident TB cases were co-infected with HIV and an estimated 0.4 million TB deaths occurred among PLWH [1]. Autopsy studies have consistently shown TB to be an important cause of death in PLWH, both in the pre-cART [6,7,8] and cART eras [9]. In 2010, a meta-analysis of the effect of TB on mortality found PLWH suffering from TB had a greater risk of mortality than TB-free individuals (hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.4-2.3) [10]. Due to the paucity of studies reporting on patients on cART, the authors concluded that the effect of TB on mortality in PLWH exposed to cART must be further evaluated once more cohort study results become available
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