TB outcomes in HIV are improved with ART: meta-analysis
Antiretroviral therapy (ART) improves the outcome of tuberculosis (TB) treatment in the HIV/TB co-infected population, an updated systematic review and meta-analysis confirms.
"Since the publication of our original review, three randomized controlled trials have demonstrated that early ART initiation in patients with active TB reduces mortality," Dr. Faiz Ahmad Khan, of McGill University, Montreal, and colleagues say.
"A new finding from the update," they say, is the trend towards increased acquired drug resistance (ADR) with intermittent treatment."
"There is an urgent need to increase the number of co-infected patients receiving ART," the study team concludes in a report online July 19 in Clinical Infectious Diseases.
Dr. Carol Dukes Hamilton, co-chair of the Scientific Advisory Committee for the Infectious Disease Society of America (IDSA)/HIV Medicine Association (HIVMA) Center for Global Health Policy, agrees.
"This paper is important because it emphasizes the fact that for patients who have HIV/AIDS and TB it's really quite urgent to get them on medication for their HIV infection as soon as possible after starting them on their TB therapy," she said in a telephone interview with Reuters Health.
"There used to be a lot of question about whether you should just finish the TB treatment first, because it's already a complicated treatment, and then start somebody on their HIV treatment," she explained.
The message from this meta-analysis, "which looks at the really good studies that have been published, is: don't wait," said Dr. Hamilton, who was not involved in the meta-analysis. At Duke University in Durham, North Carolina, she is a professor of medicine and senior scientist, Global Health, Population & Nutrition.
The meta-analysis, she noted, found "that people who were started on antiretroviral therapy in addition to TB therapy had less chance of TB relapse and less likelihood of developing drug resistance."
"Unfortunately, she added, "several studies have shown that worldwide less than 50% of patients with proven TB on TB treatment are also on ART."
In May 2010 in Clinical Infectious Diseases, the research team published a systematic review and meta-analysis on the effects of rifamycin duration, schedule of dosing, and ART on the TB treatment outcomes of failure, relapse and death among patients with HIV infection.
That analysis showed that use of rifamycins for only two months and use of intermittent dosing in the intensive phase increased the risk of poor treatment outcomes. The use of rifamycins for at least eight months and ART were associated with nonsignificant trends toward improved treatment outcomes.
Based on these observations and those of systematic reviews in largely HIV-negative populations, the 4th edition of the World Health Organization's guidelines for treating TB call for use of rifamycins for six months, daily dosing in the intensive phase, and ART (regardless of CD4 cell count) in patients with HIV and active TB infection.
The updated meta-analysis from Dr. Khan and colleagues includes seven additional studies (two randomized controlled trials and five cohort studies) published between 2008 and November 2011 and supports their original conclusions, namely, that TB/HIV patients have improved treatment outcomes with ART.
"Point estimates for risk of relapse decreased with increasing duration of rifamycin and were lower with daily dosing compared to intermittent dosing in the intensive phase," Dr. Khan and colleagues report in the paper.
After covariate adjustment, the odds of relapse were significantly higher with two or six months of rifamycin treatment (adjusted odds ratios 5.0 and 2.4, respectively) as compared to at least eight months of treatment (the reference) and in the absence of ART (aOR 14.3).
There were also trends toward increased likelihood of acquired drug resistance with intermittent treatment in the initial intensive phase and in the absence of ART.
This finding, Dr. Hamilton said, "is most relevant to North America and Europe, where we typically use (a) twice a week or three times a week regimen to help us manage the direct observation of treatment. Intermittent therapy is not used in areas of the world where most of the TB/HIV co-infection exists."
A patient with HIV/AIDS and TB "should be on daily therapy not intermittent therapy," she said.
The authors did respond to request for comment by press time. The study had no commercial funding and the authors have declared no conflicts of interest.
SOURCE: http://bit.ly/M3NbzQ
Clin Infect Dis 2012.
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