Another Study Supports Treating TB and HIV Simultaneously

The ideal time to initiate antiretroviral therapy (ART) in patients with HIV infection and tuberculosis (TB) has been widely debated. On the one hand, starting the two therapies simultaneously could increase the risk for TB-associated immune reconstitution inflammatory syndrome (IRIS) and potentially harmful drug interactions. On the other hand, delaying ART could accelerate the progression of AIDS and increase the likelihood of additional opportunistic infections and AIDS-defining malignancies. In late 2008, preliminary results from a large randomized trial in South Africa showed that concurrent initiation of ART and TB therapy reduced mortality risk among coinfected patients by 55% (JW AIDS Clin Care Sep 29 2008). As we await the final results of this and other trials, additional information continues to emerge from observational studies.

In the latest such study, investigators reviewed data from 313 HIV-infected patients in Spain who received TB diagnoses between 1996 and 2004. A total of 140 patients started ART during the first 2 months of TB treatment (simultaneous treatment), and 173 delayed ART until at least 3 months after TB diagnosis. The two groups were similar with respect to age, sex, median CD4 count at TB diagnosis (approximately 157 cells/mm³), presence of other AIDS-defining conditions, and diagnosis of extrapulmonary TB (67% overall). Patients in the simultaneous-treatment group had significantly lower viral loads at TB diagnosis than did those who delayed ART (median, 4.8 vs. 5.1 log copies/mL).

During 80 months of follow-up, 47 patients died: 13 in the simultaneous-treatment group and 34 in the delayed-ART group. In both univariate and multivariate analyses, simultaneous treatment was an independent predictor of improved survival (hazard ratio, 0.37). This survival advantage was most pronounced at 6 months (HR, 0.15); it became attenuated at 12 months but remained significant throughout follow-up (HR, 0.33). At the end of follow-up, the two groups had similar median viral loads and CD4-cell counts.