Abstract
IntroductionUse of antiretroviral therapy (ART) during treatment of drug susceptible tuberculosis (TB) improves survival. However, data from HIV infected individuals with drug resistant TB are lacking. Second line TB drugs when combined with ART may increase drug interactions and lead to higher rates of toxicity and greater noncompliance. This systematic review sought to determine the benefit of ART in the setting of second line drug therapy for drug resistant TB.MethodsWe included individual patient data from studies that evaluated treatment of drug-resistant tuberculosis in HIV-1 infected individuals published between January 1980 and December of 2009. We evaluated the effect of ART on treatment outcomes, time to smear and culture conversion, and adverse events.ResultsTen observational studies, including data from 217 subjects, were analyzed. Patients using ART during TB treatment had increased likelihood of cure (hazard ratio (HR) 3.4, 95% CI 1.6–7.4) and decreased likelihood of death (HR 0.4, 95% CI 0.3–0.6) during treatment for drug resistant TB. These associations remained significant in patients with a CD4 less than 200 cells/mm3 and less than 50 cells/mm3, and when correcting for drug resistance pattern.LimitationsWe identified only observational studies from which individual patient data could be drawn. Limitations in study design, and heterogeneity in a number of the outcomes of interest had the potential to introduce bias.DiscussionWhile there are insufficient data to determine if ART use increases adverse drug interactions when used with second line TB drugs, ART use during treatment of drug resistant TB appears to improve cure rates and decrease risk of death. All individuals with HIV appear to benefit from ART use during treatment for TB.
Highlights
Use of antiretroviral therapy (ART) during treatment of drug susceptible tuberculosis (TB) improves survival
Patients using ART during TB treatment had increased likelihood of cure (hazard ratio (HR) 3.4, 95% confidence interval (CI) 1.6–7.4) and decreased likelihood of death (HR 0.4, 95% CI 0.3–0.6) during treatment for drug resistant TB
While there are insufficient data to determine if ART use increases adverse drug interactions when used with second line TB drugs, ART use during treatment of drug resistant TB appears to improve cure rates and decrease risk of death
Summary
Use of antiretroviral therapy (ART) during treatment of drug susceptible tuberculosis (TB) improves survival. International guidelines recommend that antiretroviral therapy (ART) be started as soon as possible after TB treatment is initiated in patients with HIV and TB [2,3,4,5,6]. It is not clear if the benefit of early ART extends to individuals on second-line TB treatment regimens for DR-TB. Individuals on second line TB drugs, those with HIV, may experience more side effects, more overlapping toxicities with ART, and have higher rates of non-adherence with TB therapy [7]. Given that secondline treatment may be associated with higher rates of adverse treatment outcomes and higher default rates, evidence based strategies are needed for the management of HIV infected individuals with DR-TB [2,8]
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