title: When to start antiretroviral therapy during tuberculosis treatment?
abstract: OBJECTIVE
  Effective treatment exists for tuberculosis (TB) and for HIV, but treating both diseases simultaneously presents several challenges. This review assesses the evidence for the timing of antiretroviral therapy (ART) initiation in patients coinfected with TB.
  
  
  RESULTS
  Published evidence clearly demonstrates that TB-HIV integration is essential for improved survival, but the question of when to start ART during TB treatment is more complex. Five randomized controlled trials assessed this question: four trials showed no difference in the incidence rates of AIDS or death between TB patients initiating ART within 2 months compared to later during TB therapy, while one trial showed a significant survival gain with ART initiation within 2 weeks of TB therapy start. All five studies found improved AIDS-free survival with earlier ART initiation in TB patients with low CD4 T-cell counts, except among patients with TB meningitis. The survival benefit was, however, accompanied by increased immune reconstitution inflammatory syndrome events.
  
  
  CONCLUSIONS
  The trial data support the World Health Organization recommendations on when to start ART in TB-HIV coinfected patients including earlier ART initiation in severely immune-compromised patients. However, several challenges remain in integrating TB and HIV treatment in public healthcare services. Additional research on timing of ART is needed for patients with drug-resistant and extrapulmonary TB, notably TB meningitis.
authors.affiliation: Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Kogieleum
authors.initials: K
authors.lastname: Naidoo
authors.forename: Cheryl
authors.initials: C
authors.lastname: Baxter
authors.forename: Salim S
authors.initials: SS
authors.lastname: Abdool Karim
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy*; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015496:CD4-Positive T-Lymphocytes; D060085:Coinfection / Q000188:drug therapy*; D018572:Disease-Free Survival; D004334:Drug Administration Schedule; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D014376:Tuberculosis / Q000188:drug therapy* / Q000276:immunology
chemical_list: D044966:Anti-Retroviral Agents