1. Home>
2. Specialties>
3. HIV/AIDS Clinical Care>
4. Meeting Report

Concomitant HIV/TB Treatment Improves Survival

Delaying antiretroviral therapy until after TB treatment has been completed is associated with increased mortality risk.

Tuberculosis remains the most common HIV-related opportunistic infection (OI) worldwide. As with other OIs, the optimal time to start antiretroviral therapy (ART) in patients with TB is unknown. At this year’s Retrovirus Conference, Salim Abdool Karim presented important partial results from the SAPiT trial in South Africa [Abstract 36a; previously reported in JW AIDS Clin Care Sep 29 2008].

A total of 642 patients with TB and HIV infection were enrolled between June 2005 and July 2008 and were randomized to one of three strategies:

• Early integrated treatment: ART was initiated during the intensive four-drug phase of TB treatment.
  
• Late integrated treatment: ART was initiated after the intensive phase of TB treatment.
  
• Sequential treatment: ART was initiated after completion of a scheduled 6-month course of TB treatment.
  

For all study patients, ART consisted of once-daily ddI, 3TC, and efavirenz.

In September 2008, the Data and Safety Monitoring Board recommended that all patients in the sequential-treatment arm begin ART immediately because of excess mortality in that arm (12.1 deaths per 100 person-years, vs. 5.4 per 100 person-years in the integrated-treatment arms combined). The hazard ratio for death among those in the integrated-treatment arms combined was 0.44 (95% confidence interval, 0.25–0.79). Of note, TB treatment outcomes were similar between the groups; hence, most of the excess mortality in the sequential-treatment arm occurred after completion of TB treatment. Immune reconstitution inflammatory syndrome occurred in 12% of the integrated- versus 4% of the sequential-treatment group.

These results provide critically important information for the management of HIV-related TB worldwide. Clearly, deferral of ART until after completion of TB treatment allows HIV disease to progress, and such progression is sufficient to cause excess mortality. That TB treatment outcomes were similar likely has led some clinicians to believe that delaying ART would be a safe option, but this is clearly not the case. Comparison of the two integrated-treatment arms in the trial is ongoing.

— Paul E. Sax, MD

Published in Journal Watch HIV/AIDS Clinical Care March 9, 2009

2011 Year in Review