Combining Antiretroviral and Anti-Tuberculosis Treatment Reduces Risk of Death

October 2009–More than half of all tuberculosis cases worldwide in 2009 were in Asia.¹ The three countries with the highest disease burden were India with two million cases, China with 1.3 million, and Indonesia with more than half a million.

People who have both HIV and tuberculosis are at much higher risk of death than those with either infection alone, and up to half of all HIV patients may die during tuberculosis treatment. However, starting tuberculosis treatment too soon after beginning antiretroviral treatment (ART) can lead to even higher risk of death due to complex interactions between the body's immune system and the tuberculosis bacteria.

In order to better understand what factors reduced the risk of death, researchers in Thailand studied patients with both HIV and tuberculosis.² Their study included 667 patients with tuberculosis and HIV from 32 government supported hospitals. More than half (58 percent) of the patients had tuberculosis only in the lungs, about a third (31 percent) had tuberculosis in other places in their bodies, and the rest had disease in multiple places, including the lungs. The median CD4 cell count was 60 cells/mm³; 80 percent of patients were below the WHO-recommended treatment threshold (<200 cells/ mm³). However, only 41 percent of patients received ART during their tuberculosis treatment. Those who started ART for the first time generally delayed ART for two months (median 62 days).

A total of 112 patients (17 percent) died after their tuberculosis diagnosis. Being on ART during tuberculosis treatment was associated with an 84 percent reduction of the risk of death. The use of co-trimoxazole or fluconazole to prevent opportunistic infections was also found to be beneficial.

Researchers are still working to determine the best time to start ART during tuberculosis treatment, but this study shows that waiting too long or not starting ART at all can lead to much higher risk of death.

¹ WHO. Global Tuberculosis Control 2009: Epidemiology, Strategy, Financing. 2009; Geneva: WHO.

² Varma JK, et al. HIV care and treatment factors associated with improved survival during tuberculosis treatment in Thailand: An observational study. BMC Infectious Diseases 2009, volume 9: article 42 (available for free at www.biomedcentral.com/1471-2334/9/42).