title: Initiation of antiretroviral therapy in HIV-infected tuberculosis patients in rural Kenya: an observational study.
abstract: OBJECTIVE
  To provide information on the effect of timing of antiretroviral therapy (ART) initiation on outcomes of TB infection in real-life, non-clinical trial, rural settings in sub-Saharan Africa.
  
  
  METHODS
  We conducted an observational cohort study of all HIV-infected TB patients presenting to a rural hospital in Kenya between 2005 and 2009. We analysed the association between timing of initiation of ART and mortality, using a Cox regression survival analysis, adjusted for measured confounders.
  
  
  RESULTS
  A total of 404 antiretroviral-naïve HIV/TB coinfected patients were included in the study. Initiation of ART during the first 8 weeks of TB treatment (early group) was not associated with changes in mortality at 1 year compared with initiation of ART after 8 weeks (late group) [Hazard Ratio (HR) = 0.74 (Confidence Interval (CI), 0.33-1.64, P = 0.46]. In patients with baseline CD4 counts ≤50 cells/μl, there was a significant reduction in mortality in the early group compared with the late group (HR = 0.20; 95% CI, 0.042-0.99; P = 0.049). In patients with a CD4 count >50 cells/μl, there was no significant difference between early and late groups (HR 1.79; 95% CI, 0.64-5.03; P = 0.27).
  
  
  CONCLUSIONS
  We found that in HIV/TB coinfected patients in rural Kenya, early ART initiation (within 8 weeks) was associated with reduced mortality in those with CD4 counts ≤50 cells/μl. In patients with CD4 counts >50 cells/μl, there was no association seen between timing of ART and mortality.
authors.affiliation: Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK. alexstockdale@doctors.org.uk
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Stockdale
authors.forename: Joseph
authors.initials: J
authors.lastname: Nkuranga
authors.forename: M Estée
authors.initials: ME
authors.lastname: Török
authors.forename: Brian
authors.initials: B
authors.lastname: Faragher
authors.forename: David G
authors.initials: DG
authors.lastname: Lalloo
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D016001:Confidence Intervals; D004334:Drug Administration Schedule; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D036301:Qualitative Research; D012424:Rural Population; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents