Earlier versus later start of antiretroviral therapy in HIV-infected adults with tuberculosis.
BACKGROUND
Tuberculosis remains an important cause of death among patients infected with the human immunodeficiency virus (HIV). Robust data are lacking with regard to the timing for the initiation of antiretroviral therapy (ART) in relation to the start of antituberculosis therapy.


METHODS
We tested the hypothesis that the timing of ART initiation would significantly affect mortality among adults not previously exposed to antiretroviral drugs who had newly diagnosed tuberculosis and CD4+ T-cell counts of 200 per cubic millimeter or lower. After beginning the standard, 6-month treatment for tuberculosis, patients were randomly assigned to either earlier treatment (2 weeks after beginning tuberculosis treatment) or later treatment (8 weeks after) with stavudine, lamivudine, and efavirenz. The primary end point was survival.


RESULTS
A total of 661 patients were enrolled and were followed for a median of 25 months. The median CD4+ T-cell count was 25 per cubic millimeter, and the median viral load was 5.64 log(10) copies per milliliter. The risk of death was significantly reduced in the group that received ART earlier, with 59 deaths among 332 patients (18%), as compared with 90 deaths among 329 patients (27%) in the later-ART group (hazard ratio, 0.62; 95% confidence interval [CI]; 0.44 to 0.86; P=0.006). The risk of tuberculosis-associated immune reconstitution inflammatory syndrome was significantly increased in the earlier-ART group (hazard ratio, 2.51; 95% CI, 1.78 to 3.59; P<0.001). Irrespective of the study group, the median gain in the CD4+ T-cell count was 114 per cubic millimeter, and the viral load was undetectable at week 50 in 96.5% of the patients.


CONCLUSIONS
Initiating ART 2 weeks after the start of tuberculosis treatment significantly improved survival among HIV-infected adults with CD4+ T-cell counts of 200 per cubic millimeter or lower. (Funded by the French National Agency for Research on AIDS and Viral Hepatitis and the National Institutes of Health; CAMELIA ClinicalTrials.gov number, NCT01300481.).
Pneumology Unit, Internal Medicine Department, Bicêtre Hospital, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France. xavier.blanc@bct.aphp.fr
François-Xavier
FX
Blanc
Thim
T
Sok
Didier
D
Laureillard
Laurence
L
Borand
Claire
C
Rekacewicz
Eric
E
Nerrienet
Yoann
Y
Madec
Olivier
O
Marcy
Sarin
S
Chan
Narom
N
Prak
Chindamony
C
Kim
Khemarin Kim
KK
Lak
Chanroeurn
C
Hak
Bunnet
B
Dim
Chhun Im
CI
Sin
Sath
S
Sun
Bertrand
B
Guillard
Borann
B
Sar
Sirenda
S
Vong
Marcelo
M
Fernandez
Lawrence
L
Fox
Jean-François
JF
Delfraissy
Anne E
AE
Goldfeld
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy*; D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage* / Q000009:adverse effects; D000995:Antitubercular Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy*; D019562:Viral Load
D044966:Anti-Retroviral Agents; D000995:Antitubercular Agents