Manosuthi W, Chottanapand S, Thongyen S, Chaovavanich A, Sungkanuparph S. Survival Rate and Risk Factors of Mortality Among HIV/Tuberculosis-Coinfected Patients with and without Antiretroviral Therapy. J Acquir Immune Defic Syndr. 2006 Sep;43(1):42-6.
To compare the survival rate among HIV/tuberculosis co-infected patients who received or did not receive ART, to determine possible risk factors relating to death among these patients, and to determine the appropriate timing for initiating ART after tuberculosis (TB) diagnosis.
Retrospective cohort study.
Data were extracted from patients diagnosed at Bamrasnaradura Infectious Diseases Institute in Nonthaburi, Thailand.
A total of 1003 adult HIV-infected patients diagnosed with active TB between January 2000 and December 2004 were identified, 411 in the ART-plus group (receiving ART) and 592 in the ART-minus group (not receiving ART). Patients were eligible for inclusion if they were HIV/TB co-infected, older than 15 years, and receiving anti-tuberculosis therapy.
For all patients, isoniazid, rifampicin, pyrazinamide, and ethambutol were initiated for the first two months, followed by isoniazid and rifampicin for the subsequent four months. If evidence of a slow response was noted, therapy was continued to seven months. There was no directly observed therapy during the study period. Patients were divided into two groups; those receiving ART (defined as receiving ART on at least two visits) and those not receiving ART.
The primary outcome of interest was time from TB diagnosis to death. Survival rates were calculated at one, two, and three years after diagnosis. To determine possible risk factors related to death, patients' demographics, previous opportunistic infections, site of TB, baseline CD4 cell counts, baseline plasma HIV RNA, and susceptibility of M. tuberculosis to anti-TB drugs were also investigated.
Among HIV/TB co-infected patients receiving ART, survival rates at one, two and three years after TB diagnosis were 96.1%, 94.0%, and 87.7% respectively, compared to 44.4%, 19.2%, and 9.3% respectively among patients not receiving ART. Patients in the ART group had a higher proportion of isolated pulmonary TB, cervical tuberculosis lymphadenitis, isoniazid resistance, and multi-drug resistant tuberculosis (MDR-TB). Cox proportion hazard model showed that ART was associated with lower mortality, and that gastrointestinal TB and multi-drug resistant TB were associated with higher mortality (P< 0.05). Among patients in the ART-plus group, patients who delayed ART more than six months after TB diagnosis had a higher mortality rate than those who initiated ART <6 months after TB diagnosis (P<0.05).
This study found that antiretroviral therapy substantially reduces mortality among HIV/TB-coinfected patients and that initiation of ART within six months of TB diagnosis is associated with greater survival.
The quality of this retrospective cohort analysis was not graded. This study was limited in that baseline socioeconomic status was not included in the model on mortality analysis, although the cost of ART could be a reason why some patients received ART and some did not.
This study demonstrated the difference in survival rates between HIV/TB co-infected patients who received and did not receive ART. Although many studies have demonstrated that ART improves survival among HIV-infected patients, with successful immune restoration and reductions in morbidity and mortality,(1,2,3) one study could not demonstrate the survival benefit of ART among HIV/TB co-infected patients.(4)
The results of this study demonstrate that increased survival rates of HIV/TB co-infected patients could be achieved by initiating ART in patients with advanced HIV disease within the first six months of TB diagnosis. Collaboration between HIV and TB treatment programs may lead to the scale up of ART and/or the effective treatment and control of TB among HIV/TB co-infected patients.
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Palella FJ Jr, Delaney KM, Moorman AC, et al. HIV Outpatient Study Investigators.
Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med 1998; 338:853-60.
Whalen C, Horsburgh CR Jr, Hom D, Lahart C, Simberkoff M, Ellner J. Site of disease and opportunistic infection predict survival in HIV-associated tuberculosis. AIDS 1997; 11:455-60.