Initiation of antiretroviral therapy in advanced AIDS with active tuberculosis: clinical experiences from Thailand

To study treatment outcomes of antiretroviral therapy (ART) initiated in advanced HIV-infected patients with active tuberculosis (TB).

A retrospective cohort study was conducted in ART-naïve HIV-infected patients who presented with active TB, CD4<200 cells/microl, and had been initiated ART. ART, TB treatment and treatment outcomes of both HIV and TB were studied.

There were 29 patients (19 males) with a median age of 37 (range 26-65) years. Site of TB were: lung (70%), lymph node (27.6%), and gastrointestinal tract (3.4%). At the time of TB diagnosis, median (range) CD4 cell count and HIV RNA were 74 (23-178) cells/microl and 229,000 (26,100-750,000) copies/ml, respectively. All patients received isoniazid, rifampin, ethambutol, and pyrazinamide in the first 2 months of TB therapy but the continuation phase was different depending on whether efavirenz (EFV) or nevirapine (NVP) was used. ART was initiated at a median of 8 weeks of TB treatment. All patients received NNRTI-based regimens (EFV 62.1%, NVP 37.9%). Percentage of patients with HIV RNA<50 copies/ml at 24 and 48 weeks of ART was 65.5 and 75.9%. Median CD4 cell count at 24, 48, and 72 weeks were 156, 186, and 227 cells/microl, respectively. Eighteen patients were cure; eight were treatment completed; two were treatment interrupted; and one died from CMV encephalitis. There was neither occurrence of new OI or relapse of TB in 26 patients who completed 72-week follow-up.

Initiation of ART with NNRTI-based regimens at 4-12 weeks of TB treatment in advanced AIDS may be safe and effective, and may not be delayed. Further, prospective clinical studies for the optimal timing of ART initiation and ART regimen are needed.