Antiretroviral therapy for prevention of tuberculosis in adults with HIV: a systematic review and meta-analysis.
BACKGROUND
Human immunodeficiency virus (HIV) infection is the strongest risk factor for developing tuberculosis and has fuelled its resurgence, especially in sub-Saharan Africa. In 2010, there were an estimated 1.1 million incident cases of tuberculosis among the 34 million people living with HIV worldwide. Antiretroviral therapy has substantial potential to prevent HIV-associated tuberculosis. We conducted a systematic review of studies that analysed the impact of antiretroviral therapy on the incidence of tuberculosis in adults with HIV infection.


RESULTS
PubMed, Embase, African Index Medicus, LILACS, and clinical trial registries were systematically searched. Randomised controlled trials, prospective cohort studies, and retrospective cohort studies were included if they compared tuberculosis incidence by antiretroviral therapy status in HIV-infected adults for a median of over 6 mo in developing countries. For the meta-analyses there were four categories based on CD4 counts at antiretroviral therapy initiation: (1) less than 200 cells/µl, (2) 200 to 350 cells/µl, (3) greater than 350 cells/µl, and (4) any CD4 count. Eleven studies met the inclusion criteria. Antiretroviral therapy is strongly associated with a reduction in the incidence of tuberculosis in all baseline CD4 count categories: (1) less than 200 cells/µl (hazard ratio [HR] 0.16, 95% confidence interval [CI] 0.07 to 0.36), (2) 200 to 350 cells/µl (HR 0.34, 95% CI 0.19 to 0.60), (3) greater than 350 cells/µl (HR 0.43, 95% CI 0.30 to 0.63), and (4) any CD4 count (HR 0.35, 95% CI 0.28 to 0.44). There was no evidence of hazard ratio modification with respect to baseline CD4 count category (p = 0.20).


CONCLUSIONS
Antiretroviral therapy is strongly associated with a reduction in the incidence of tuberculosis across all CD4 count strata. Earlier initiation of antiretroviral therapy may be a key component of global and national strategies to control the HIV-associated tuberculosis syndemic.


BACKGROUND
International Prospective Register of Systematic Reviews CRD42011001209 Please see later in the article for the Editors' Summary.
Department of HIV/AIDS, World Health Organization, Geneva, Switzerland. amitabh.suthar@gmail.com
Amitabh B
AB
Suthar
Stephen D
SD
Lawn
Julia
J
del Amo
Haileyesus
H
Getahun
Christopher
C
Dye
Delphine
D
Sculier
Timothy R
TR
Sterling
Richard E
RE
Chaisson
Brian G
BG
Williams
Anthony D
AD
Harries
Reuben M
RM
Granich
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D011785:Quality Assurance, Health Care / Q000592:standards; D016032:Randomized Controlled Trials as Topic; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy* / Q000517:prevention & control*
D019380:Anti-HIV Agents