The impact of antiretroviral therapy on mortality in HIV positive people during tuberculosis treatment: a systematic review and meta-analysis.
OBJECTIVE
To quantify the impact of antiretroviral therapy (ART) on mortality in HIV-positive people during tuberculosis (TB) treatment.


METHODS
We conducted a systematic literature review and meta-analysis. Studies published from 1996 through February 15, 2013, were identified by searching electronic resources (Pubmed and Embase) and conference books, manual searches of references, and expert consultation. Pooled estimates for the outcome of interest were acquired using random effects meta-analysis.


METHODS
The study population included individuals receiving ART before or during TB treatment.


METHODS
Main outcome measures were: (i) TB-case fatality ratio (CFR), defined as the proportion of individuals dying during TB treatment and, if mortality in HIV-positive people not on ART was also reported, (ii) the relative risk of death during TB treatment by ART status.


RESULTS
Twenty-one studies were included in the systematic review. Random effects pooled meta-analysis estimated the CFR between 8% and 14% (pooled estimate 11%). Among HIV-positive TB cases, those receiving ART had a reduction in mortality during TB treatment of between 44% and 71% (RR = 0.42, 95%CI: 0.29-0.56).


CONCLUSIONS
Starting ART before or during TB therapy reduces the risk of death during TB treatment by around three-fifths in clinical settings. National programmes should continue to expand coverage of ART for HIV positive in order to control the dual epidemic.
TB Modelling Group, Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America; University of Parma, School of Medicine, Parma, Italy.
Anna
A
Odone
University Division of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia, Italy.
Silvia
S
Amadasi
TB Modelling Group, Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Richard G
RG
White
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America; Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
Theodore
T
Cohen
TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Alison D
AD
Grant
TB Modelling Group, Centre for the Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Rein M G J
RM
Houben
D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015897:Comorbidity; D003627:Data Interpretation, Statistical; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000401:mortality*; D006679:HIV Seropositivity; D006801:Humans; D012307:Risk Factors; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy* / Q000401:mortality*
D044966:Anti-Retroviral Agents