Treatment outcomes after early initiation of antiretroviral therapy for human immunodeficiency virus-associated tuberculosis

Abstract

Objective To evaluate the optimal timing for initiating antiretroviral therapy in patients with human immunodeficiency virus (HIV)- associated tuberculosis in Hong Kong. Design Historical cohort. Setting Tuberculosis and Chest Service and Special Preventive Programme, Public Health Service Branch, Centre for Health Protection, Department of Health, Hong Kong. Patients Consecutive patients with HIV-associated tuberculosis in a territory-wide TB-HIV registry encountered from 1996 to 2009. Results Of the 260 antiretroviral therapy-naïve patients with HIVassociated tuberculosis, 32 (12%) had antiretroviral therapy initiated within 2 months after starting anti-tuberculosis treatment (early antiretroviral therapy). Early antiretroviral therapy was associated with a more favourable outcome (cure or treatment completion without relapse) at 24 months (91% vs 67%; P=0.007) than those with antiretroviral therapy started later or not initiated, and remained an independent predictor of a favourable outcome after adjustment for potential confounders. Adverse effects from anti-tuberculosis drugs tended to occur more frequently in patients with early antiretroviral therapy (13/32 or 41%) compared with the remainder (59/228 or 26%; P=0.08). A significantly higher proportion of patients in the former group experienced immune reconstitution inflammatory syndrome than in the latter group (7/32 or 22% vs 9/228 or 4%; P<0.001). There was no death attributable to immune reconstitution inflammatory syndrome. Conclusions Early initiation of antiretroviral therapy is associated with more favourable tuberculosis treatment outcomes in patients with HIVassociated tuberculosis with a low CD4 count (<200/μL). Drug co-toxicity and immune reconstitution inflammatory syndrome that may be increased by earlier initiation of antiretroviral therapy does not undermine tuberculosis treatment outcomes to a significant extent.