Tamar Kahn
18 September 2008
Cape Town — Deaths among people infected with both tuberculosis (TB) and HIV could be halved if patients started taking antiretrovirals before they finished their six months of TB treatment, a new study shows.
Up to 10000 deaths a year could be avoided in SA if patients co-infected with the two diseases started taking anti-retrovirals sooner, said Prof Salim Abdool Karim, the study's principal investigator.
TB is the most common opportunistic disease affecting people with HIV in SA: 353 000 people were diagnosed with TB last year, about 70% of whom were also infected with HIV, said Karim.
Both diseases require treatment with several drugs that may have serious side-effects and place strain on the liver.
Since there is a major public health concern about growing resistance to TB treatment, patients are started on TB drugs straight away. Treatment with AIDS drugs usually starts a few months later, sometimes only when the TB course of treatment has been completed.
The World Health Organisation's (WHO's) guidelines say only HIV patients with a CD4 count below 200 should start taking antiretrovirals during TB treatment, leaving doctors to decide how to manage patients with a higher CD4 count. A CD4 count measures the strength of the immune system, and is used to gauge the progress of HIV.
The WHO guidelines are based on expert opinion, rather than clinical evidence, so researchers from the University of KwaZulu-Natal's Caprisa centre have been investigating the optimal point for starting treatment with antiretrovirals for patients infected with both diseases.
The trial -- known as the starting antiretroviral therapy at three points in tuberculosis study -- compared mortality among three groups of co- infected patients with a CD4 count below 500: starting treatment with antiretrovirals after two months of TB treatment, starting between two and six months after TB treatment begins, or waiting until the six months of TB treatment has been completed.
Interim results last week showed deaths were 55% lower in patients who started taking AIDS drugs within six months.
The researchers have halted the study arm where patients were to finish their TB treatment, and put these patients on AIDS drugs. Research was still going on to compare the remaining two groups of patients, said Karim.
The study has important implications for SA's AIDS treatment programme, as it suggests co-infected patients with a CD4 count as high as 500 would benefit from earlier treatment. Karim estimated there were 150000 patients co-infected with TB and HIV with a CD4 count between 200 and 500 last year who could have benefited from earlier treatment with AIDS drugs.
Dr Francois Venter, president of the Southern African HIV Clinicians Society, said the study presented compelling evidence to put co-infected patients on AIDS drugs sooner.
"The bottom line is that a laissez fair attitude to (co-infected) patients with a good CD4 count is not justified," he said.
The study underscored the need to integrate HIV and TB services in clinics and hospitals, he said. "People need to start seeing TB as an emergency."
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