Mortality risk in CAMELIA TB patients starting antiretrovirals
Tuberculosis and other HIV diseases accounted for three quarters of the deaths in the first 26 weeks of the CAMELIA trial of early versus delayed antiretroviral therapy (ART) for people being treated for TB. An array of factors explained a higher risk of death.
CAMELIA randomized HIV-positive Cambodian adults being
treated for TB to begin ART 2 weeks or 8 weeks after TB
therapy began. All study participants had a CD4 count at or
below 200 cells/µL. Early ART resulted in a 34% overall
lower death rate in the trial. The new study determined causes
of death and used Cox proportional hazard models to identify
factors associated with death.
The analysis involved 661 people, 149 of whom (22.5%) died.
Mortality was significantly lower in the early-ART group than
in the later ART group (8.3 versus 13.8 deaths per 100
person-years, P = 0.002).
Causes of death in the first 26 weeks of the trial in the
early and late ART groups were TB (27% and 46%), other HIV
conditions (27% and 20%), either TB or HIV conditions (19% and
14%), drug toxicity (3% and 6%), other non-TB/HIV conditions
(19% and 10%), and unknown causes (5% and 4%). Factors
independently associated with death in the first 26 weeks were
older age, lower body mass index, lower hemoglobin,
disseminated tuberculosis, and nontuberculous mycobacterial
disease.
Causes of death from week 26 to week 50 in the early and late
ART groups were TB (0% and 15%), HIV conditions (33% and 15%),
either TB or HIV conditions (33% and 15%), drug toxicity (11%
and 23%), other non-TB/HIV conditions (1% and 15%), and
unknown caues (1% and 15%). Factors independently associated
with death in trial weeks 26 to 50 were late ART, loss to
follow-up, and no cotrimoxazole prophylaxis.
Although early ART lowered mortality in CAMELIA, the authors
observe that “mortality remained high during the first 6
months following tuberculosis diagnosis, and tuberculosis was
the leading cause of these deaths.” Among people alive
at trial week 50, subsequent mortality was twice higher in the
late ART group than in the early ART group.
To improve long-term survival, the CAMELIA team proposes
reconsidering the appropriate time to stop cotrimoxazole
prophylaxis. “Optimized case management,” they
advise, “should include early ART initiation and
opportunistic infection prophylaxis, appropriate management of
TB-IRIS and toxicities, and support of adherence to avoid
treatment interruption, but also possibly intensification of
tuberculosis initial treatment.”
Source:
Olivier Marcy, Didier Laureillard, Yoann Madec, Sarin Chan,
Charles Mayaud, Laurence Borand, Narom Prak, Chindamony Kim,
Kim Khemarin Lak, Chanroeurn Hak, Bunnet Dim, Thim Sok,
Jean-François Delfraissy, Anne E. Goldfeld,
François-Xavier Blanc, for the CAMELIA (ANRS 1295-CIPRA
KH001) Study Team. Causes and determinants of mortality in
HIV-infected adults with tuberculosis: an analysis from the
CAMELIA ANRS 1295-CIPRA KH001 randomized trial.
Clinical Infectious Diseases. 2014; 59:
435-445.
Source:
IAS
