HIV care and treatment factors associated with improved survival during TB treatment in Thailand: an observational stud

HIV care and treatment factors associated with improved survival during TB treatment in Thailand: an observational study.

In Southeast Asia, HIV-infected patients frequently die during tuberculosis treatment. Many physicians are reluctant to treat HIV-infected tuberculosis patients with antiretroviral therapy and have questions about the added value of opportunistic infection prophylaxis to antiretroviral therapy, the optimum antiretroviral therapy regimen, and the benefit of initiating antiretroviral therapy early during tuberculosis treatment. Varma and colleagues conducted a multi-center observational study of HIV-infected patients newly diagnosed with tuberculosis in Thailand. Clinical data was collected from the beginning to the end of tuberculosis treatment. They conducted multivariable proportional hazards analysis to identify factors associated with death. Of 667 HIV-infected tuberculosis patients enrolled, 450 (68%) were smear and/or culture positive. Death during tuberculosis treatment occurred in 112 (17%). In proportional hazards analysis, factors strongly associated with reduced risk of death were antiretroviral therapy use (Hazard Ratio [HR] 0.16; 95% confidence interval [CI] 0.07-0.36), fluconazole use (HR 0.34; CI 0.18-0.64), and co-trimoxazole use (HR 0.41; CI 0.20-0.83). Among 126 patients that initiated antiretroviral therapy after tuberculosis diagnosis, the risk of death increased the longer that antiretroviral therapy was delayed during tuberculosis treatment. Efavirenz- and nevirapine-containing antiretroviral therapy regimens were associated with similar rates of adverse events and death. Among HIV-infected patients living in Thailand, the single most important determinant of survival during TB treatment was the use of antiretroviral therapy. Controlled clinical trials are needed to confirm our findings that early antiretroviral therapy initiation improves survival and that the choice of non-nucleoside reverse transcriptase inhibitor does not.

The sequential arm (antiretroviral treatment given after 6 to 8 months of TB treatment) has already been shut down in one randomised controlled trial (SAPIT at CAPRISA, South Africa) due to a 55% lower mortality in the two integrated arms (immediate antiretroviral treatment and after 2 months of TB treatment). It is not surprising then that this prospective study in Thailand found that TB patients who took antiretroviral treatment had one-fifth the risk of dying as those who did not and those who started antiretroviral treatment earlier did better. Physicians need to overcome their concerns about overlapping toxicity, pill burden, and immune reconstitution inflammatory syndrome to place all their TB/HIV infected patients on cotrimoxasole and those with CD4+ counts under 350 cells on antiretroviral treatment.