title: Timing of antiretroviral therapy initiation in adults with HIV-associated tuberculosis: outcomes of therapy in an urban hospital in KwaZulu-Natal.
abstract: BACKGROUND
  HIV-associated tuberculosis (TB) is common in South Africa. The optimal time for initiating antiretroviral therapy (ART) in co-infected patients is a clinical challenge. AIM. We aimed to compare clinical outcomes of patients with HIV-associated TB who commenced ART at different stages of TB therapy.
  
  
  METHODS
  A retrospective chart review was conducted of 458 patients who initiated ART at ≤ 28 days (immediate), 29 - 56 days (early) and ≥57 days (delayed) after commencing TB therapy, and clinical outcomes after 6 months of ART were compared.
  
  
  RESULTS
  There was a higher mortality in the immediate group, although this was not significant. Renal impairment (hazard ratio (HR) 2.5; 95% confidence interval (CI) 1.3 - 4.9; p=0.004) and inpatient ART initiation (HR 3.7; 95% CI 1.6 - 8.2; p=0.001) were risk factors for HIV-associated TB mortality. A baseline haemoglobin concentration ≥10 g/dl (HR 0.2; 95% CI 0.1 - 0.6; p=0.003), extrapulmonary as opposed to pulmonary TB (PTB) (HR 0.3; 95% CI 0.1 - 0.7; p=0.005) and extrapulmonary plus PTB as opposed to PTB (HR 0.3, 95% CI 0.1 - 0.6; p=0.002) were significantly associated with decreased mortality.
  
  
  CONCLUSIONS
  The timing of initiation of ART after commencing TB therapy was not significantly associated with increased mortality or survival. Patients with more advanced disease were more likely to die. Early HIV testing and ART initiation is recommended to decrease mortality.
authors.affiliation: Department of Family Medicine, University of KwaZulu-Natal, Durban, South Africa. maryanne_kendon@yahoo.com
authors.forename: Mary-Anne
authors.initials: MA
authors.lastname: Kendon
authors.forename: Stephen
authors.initials: S
authors.lastname: Knight
authors.forename: Andrew
authors.initials: A
authors.lastname: Ross
authors.forename: Janet
authors.initials: J
authors.lastname: Giddy
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000150:complications / Q000188:drug therapy*; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000627:therapeutic use; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy*; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D013019:South Africa; D013997:Time Factors; D016896:Treatment Outcome; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000188:drug therapy*
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents