title: Evaluation of a pro-active strategy for managing tuberculosis-HIV co-infection in a UK tertiary care setting.
abstract: Management of tuberculosis (TB)-HIV co-infection is complicated by interactions between the diseases and their therapies. We developed and evaluated a strategy to (i) treat co-infected patients in a single co-infection clinic, (ii) maximize use of first-line drugs, (iii) delay antiretroviral therapy (ART) until two months post-TB treatment except in severe immunosuppression, (iv) commence efavirenz at 600 mg daily with therapeutic drug monitoring (TDM) and (v) target treatment completion. We conducted a prospective cohort review over 5.5 years in a UK tertiary referral center where 56 HIV-positive patients treated for TB were followed-up for a median 30 months. Main outcome measures were treatment completion, adverse events, immune reconstitution inflammatory syndrome, immunological and virological parameters, and TDM for efavirenz. Treatment completion rates were 88% (49/56); four patients were lost to local follow-up and three (5.4%) died during treatment; no deaths were TB-related. Adverse events were common (55%), but caused no treatment interruptions. Standard doses (600 mg daily) of efavirenz with rifampicin achieved or exceeded therapeutic levels in 25/28 (89%). This study supports combined management for TB-HIV co-infected patients. Delaying ART to two months post-TB treatment did not seem to result in poor clinical outcomes in this well-resourced context. Although efavirenz 600 mg daily usually achieved satisfactory levels, TDM is recommended.
authors: Infection & Immunity Research Centre, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK.
authors: R M
authors: RM
authors: Wake
authors: P
authors: P
authors: Poulikakos
authors: J
authors: J
authors: Groth
authors: T S
authors: TS
authors: Harrison
authors: D C
authors: DC
authors: Macallan
mesh_terms: D000328:Adult; D000480:Alkynes; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000904:Antibiotics, Antitubercular / Q000009:adverse effects / Q000627:therapeutic use*; D048588:Benzoxazines / Q000627:therapeutic use; D060085:Coinfection / Q000150:complications / Q000188:drug therapy; D003521:Cyclopropanes; D016903:Drug Monitoring / Q000379:methods*; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D008875:Middle Aged; D009161:Mycobacterium / Q000302:isolation & purification; D011446:Prospective Studies; D012293:Rifampin / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy*; D006113:United Kingdom; D019562:Viral Load
chemical_list: D000480:Alkynes; D019380:Anti-HIV Agents; D000904:Antibiotics, Antitubercular; D048588:Benzoxazines; D003521:Cyclopropanes; C098320:efavirenz; D012293:Rifampin
keywords: AIDS; HIV; Mycobacterium tuberculosis; TB; antiretroviral therapy; co-infection; efavirenz; immune reconstitution inflammatory syndrome; rifampicin; therapeutic drug monitoring; treatment outcomes; tuberculosis