Large Cape Town study challenges ART assumptions

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A large-scale SA study on patients infected with both HIV and tuberculosis (TB,) has implications for treatment policy in low-income nations. The study, by researchers from the [b]Desmond Tutu HIV Centre, the University of Cape Town medical school, and the City of Cape Town’s health directorate[/b], involved almost 40,000 patients over three years. It assessed the effect of antiretroviral treatment (ART) on survival during TB treatment for HIV infected TB patients at different levels of immune suppression as indicated by the CD4 cell count.

While ART slashed by half the mortality rates of HIV positive TB patients with low CD4 counts, the study found it had no effect on those with relatively higher CD4 counts. The researchers recommended that ART initiation should be prioritised for the patients with low CD4 counts. In 2012 SA adopted new [b]World Health Organisation (WHO)[/b] and US guidelines that strongly recommend ART for every HIV-positive TB patient. The study notes: ‘It is still unclear whether these strategies will have a beneficial effect on individual patient outcomes and although they may be easily implemented in well-resourced countries, they may be particularly challenging for low-income countries with a high burden of disease.’ The study further identified an ‘urgent problem’ that more than a third (35.4%) of patients with CD4 counts at the threshold that should have triggered ART that could potentially reduce TB deaths by 50% or more, did not receive any treatment.

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