TB treatment outcomes good for multidrug-resistant TB/HIV co-infected patients who start ART

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Treatment of multidrug-resistant tuberculosis (TB) has comparable efficacy and survival rates in patients infected with HIV and not uninfected with HIV when patients with HIV are given antiretroviral therapy, Infectious Disease Advisor reports according to the results of recent research.

Researchers recruited 206 adults in South Africa with culture-confirmed multidrug-resistant TB with HIV infection (n=150) or without HIV infection (n=56). During TB treatment, symptoms, adverse events, medication adherence, and sputum sample cultures were evaluated monthly. Following successful treatment, participants were evaluated quarterly for 1 year. Survival and treatment outcomes were compared in both groups.

In 191 participants with final outcomes for multidrug-resistant TB, 68% were cured and 5% completed treatment, which was considered a successful TB treatment outcome. The rate of successful treatment was not significantly different in either HIV-infected or HIV-uninfected participants (P =.50).

In HIV-infected participants receiving concurrent antiretroviral therapy and multidrug-resistant TB treatment, mean CD4 counts at 12 and 24 months (321 and 386 cells/mm3, respectively) were significantly higher compared with baseline (215 cells/mm3). Furthermore, 64% of participants with HIV had an undetectable viral load. Survival rates were not significantly different in HIV-infected and HIV-uninfected participants (86% vs 94%, respectively; P =.34). A CD4 count ≤100 cells/mm3 was associated with increased mortality risk (adjusted hazard ratio 15.6).

The report says in an interview, Dr James CM Brust, associate professor of medicine in the divisions of general internal medicine and infectious diseases at Albert Einstein College of Medicine in New York explained that “until recently, it was unknown how best to manage multidrug-resistant TB in patients with HIV.” Based on the results of this prospective study, Brust concluded that “all patients with multidrug-resistant TB/HIV co-infection should be initiated on antiretroviral therapy if they are not already receiving it. Furthermore, such patients must be monitored closely and provided with patient-centred care to ensure high levels of treatment adherence, consistent virologic suppression, and immunological recovery.”

Abstract
Background: Mortality in multidrug-resistant (MDR) tuberculosis–human immunodeficiency virus (HIV) coinfection has historically been high, but most studies predated the availability of antiretroviral therapy (ART). We prospectively compared survival and treatment outcomes in MDR tuberculosis–HIV-coinfected patients on ART to those in patients with MDR tuberculosis alone.
Methods: This observational study enrolled culture-confirmed MDR tuberculosis patients with and without HIV in South Africa between 2011 and 2013. Participants received standardized MDR tuberculosis and HIV regimens and were followed monthly for treatment response, adverse events, and adherence. The primary outcome was survival.
Results: Among 206 participants, 150 were HIV infected, 131 (64%) were female, and the median age was 33 years (interquartile range [IQR], 26–41). Of the 191 participants with a final MDR tuberculosis outcome, 130 (73%) were cured or completed treatment, which did not differ by HIV status (P = .50). After 2 years, CD4 count increased a median of 140 cells/mm3 (P = .005), and 64% had an undetectable HIV viral load. HIV-infected and HIV-uninfected participants had high rates of survival (86% and 94%, respectively; P = .34). The strongest risk factor for mortality was having a CD4 count ≤100 cells/mm3 (adjusted hazards ratio, 15.6; 95% confidence interval, 4.4–55.6).
Conclusions: Survival and treatment outcomes among MDR tuberculosis–HIV individuals receiving concurrent ART approached those of HIV-uninfected patients. The greatest risk of death was among HIV-infected individuals with CD4 counts ≤100 cells/mm3. These findings provide critical evidence to support concurrent treatment of MDR tuberculosis and HIV.

Authors
James C M Brust, N Sarita Shah, Koleka Mlisana, Pravi Moodley, Salim Allana, Angela Campbell, Brent A Johnson, Iqbal Master, Thuli Mthiyane, Simlatha Lachman, Lee-Megan Larkan, Yuming Ning, Amyn Malik, Jonathan P Smith, Neel R Gandhi

Infectious Disease Advisor material
Clinical Infectious Diseases abstract


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