HIV care and treatment factors associated with improved survival during TB treatment in Thailand: an observational study.
BACKGROUND
In Southeast Asia, HIV-infected patients frequently die during TB treatment. Many physicians are reluctant to treat HIV-infected TB patients with anti-retroviral therapy (ART) and have questions about the added value of opportunistic infection prophylaxis to ART, the optimum ART regimen, and the benefit of initiating ART early during TB treatment.


METHODS
We conducted a multi-center observational study of HIV-infected patients newly diagnosed with TB in Thailand. Clinical data was collected from the beginning to the end of TB treatment. We conducted multivariable proportional hazards analysis to identify factors associated with death.


RESULTS
Of 667 HIV-infected TB patients enrolled, 450 (68%) were smear and/or culture positive. Death during TB treatment occurred in 112 (17%). In proportional hazards analysis, factors strongly associated with reduced risk of death were ART use (Hazard Ratio [HR] 0.16; 95% confidence interval [CI] 0.07-0.36), fluconazole use (HR 0.34; CI 0.18-0.64), and co-trimoxazole use (HR 0.41; CI 0.20-0.83). Among 126 patients that initiated ART after TB diagnosis, the risk of death increased the longer that ART was delayed during TB treatment. Efavirenz- and nevirapine-containing ART regimens were associated with similar rates of adverse events and death.


CONCLUSIONS
Among HIV-infected patients living in Thailand, the single most important determinant of survival during TB treatment was use of ART. Controlled clinical trials are needed to confirm our findings that early ART initiation improves survival and that the choice of non-nucleoside reverse transcriptase inhibitor does not.
Varma
Jay K
JK
U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA. jvarma@cdc.gov
Nateniyom
Sriprapa
S
Akksilp
Somsak
S
Mankatittham
Wiroj
W
Sirinak
Chawin
C
Sattayawuthipong
Wanchai
W
Burapat
Channawong
C
Kittikraisak
Wanitchaya
W
Monkongdee
Patama
P
Cain
Kevin P
KP
Wells
Charles D
CD
Tappero
Jordan W
JW
D017088:AIDS-Related Opportunistic Infections / Q000150:complications / Q000188:drug therapy*; D000293:Adolescent; D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012307:Risk Factors; D013785:Thailand / Q000453:epidemiology; D013997:Time Factors; D016896:Treatment Outcome; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D055815:Young Adult
D019380:Anti-HIV Agents; D000995:Antitubercular Agents