TB-HIV: Can we initiate early ART in patients?

Dr Richa Sharma, CNS Correspondent, India
Photo credit: CNS: citizen-news.org
History is witness to the slow response that was meted out to the gradual rise of TB-HIV co-infection worldwide. It came to be knows as a ‘syndemic’ which refers to the convergence of two or more diseases that act synergistically to magnify the burden of disease. Globally, the figures stand at a whopping 36.9 million HIV affected patients at the end of 2014.

Also, in 2013 there were 9 million new cases of TB of which 1.1 million (13%) were among people living with HIV (PLHIV). TB is known to be the most common as well as a lethal opportunistic infection in PLHIV and needs to be diagnosed and treated at the earliest. The parallel screening for both the conditions and the required treatment to reduce the mortality and morbidity among patients has been on the agenda of nations for almost a decade. However globally only 48% of notified TB patients had a documented HIV test result in 2013.

In the wake of this call, India also developed and implemented a “Intensified HIV-TB package” in 2007-08 which was further strengthened in 2013 with the main purpose of increasing universal access to prevention, early diagnosis and timely treatment. It was also envisaged with the aim of streamlining and strengthening the coordination between the two National Programmes addressing both the conditions.

WHO envisages that the most important intervention to reduce mortality among HIV-positive TB patients is ART. In 2013, 70% of TB patients known to be HIV-positive were on anti retroviral therapy (ART). This level, however, falls short of the 100% target set for 2015.

START (Strategic Timing of Antiretroviral Treatment), a recent study conducted by INSIGHT (International Network for Strategies Initiatives in Global HIV Trials) concluded that early initiation of ART prevents a combination of adverse outcomes that include AIDS event and serious non-AIDS events and death not attributable to AIDS. Currently, WHO’s HIV treatment guidelines recommend initiation of ART when CD4+ cell counts fall below 500 cm/mm3 or less. The START study, however gives sufficient data to recommend that ART should be started in PLHIV, immediately after diagnosis of HIV, irrespective of the CD4+ cell count.

In the face of such results, it seems appropriate for countries to take up the early initiation of ART among patients. However, this needs careful consideration especially in the low resource settings, considering innumerable issues like drug side effects, adherence problems and infrastructural deficiencies. While answering a question on similar lines, Dr Kumaraswamy, Chief Medical Officer, YRGCARE centre, during a CNS hosted webinar, addressed the concerns of exposing the patients to ART in the early stages of the condition and explained that the patients with higher CD4+ count have a stronger immune system which facilitates the drugs to hasten recovery and also prevents side effects. Mechanisms of ensuring adherence, especially in healthy individuals, was another issue raised in the webinar.

Dr Nilesh Gawde, Assistant Professor at Tata Institute of Social Sciences and having experience in the field of TB research highlighted a very important point-- “About 7.68 lakh patients (including children) were on ART (and alive) by March 2014 against an estimated total of 20 lakh patients currently infected with HIV (threefold the number of patients currently on treatment) in India. Many who are in need of ART are not receiving it. Initiating ART in early phase will put a large demand on the existing resources. This year, NACO budget has been slashed and is likely to decline further over the next few years. How then, with less resource commitment, will the country make ART available early for all?” he said.

He also added that drug resistance has emerged and an early ART with irregular supply of drugs and weak mechanisms to ensure adherence to treatment may result in emergence of drug resistant epidemic, making it more difficult to treat and manage.

The first and foremost focus should be on prevention and its importance cannot be highlighted enough. Initiating early ART will definitely give good results and improve the quality of treatment and recovery for affected patients but considerations should be made about the feasibility of delivering the intervention without crunching the existing mechanisms.

As Dr Nilesh said “It is very important to maintain the focus on prevention. The proportion of budget spent on prevention must be maintained at higher level and should not get compromised due to increased expenditure of ART.”

Dr Richa Sharma, Citizen News Service - CNS
September 7, 2015

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