Tackling the burden of HIV and TB: When to initiate ART?

Dr Balu Mote, CNS Correspondent, India
Photo credit: CNS: citizen-news.org
TB is one of the world’s ancient and deadliest diseases with a current estimated burden of 9.0 million people infected with it globally. According to the World Health Organization (WHO), in 2014, 1.5 million people died of TB, of which 360000 were people living with HIV (PLHIV). Though the burden of TB is decreasing slowly, the deaths attributed to this curable disease are not acceptable. The burden of HIV among TB patients and burden of TB among HIV patients is not uncommon, even as efforts for preventing mortality due to TB and/or HIV go on.

When, about a decade ago, the antiretroviral therapy (ART) finally arrived on the scene giving a new lease of life to PLHIV, the next question was when to initiate it. The enigma of ‘early versus late’ start of ART remained one of the biggest challenges for clinicians, researchers and community health people. But beginning from ‘When to start’ the approach shifted to ‘Do not treat unless you have to and certainly not before CD4+ counts are below 350 cells /mm3’ and finally now to ‘Hit hard, hit early & treat everyone’.

At a recent webinar on “What do recent studies mean for people co-infected with TB-HIV” one of the speakers Dr. Avinash Kanchar, from the WHO, presented the guidelines for the treatment plan for people living with TB-HIV. He explained that there is need of early screening of TB among PLHIV, especially those with symptoms like more than 2 weeks old cough, fever, weight loss. He also suggested starting of early ART, irrespective of CD4+ cell count, in PLHIV.

Results of the START (Strategic Timing of Antiretroviral Treatment) study show the  importance of ‘early initiation of ART’ in preventing common AIDS-related illnesses such as pulmonary TB, Kaposi’s sarcoma and non-Hodgkins lymphoma.

Another study, done in collaboration with US National Institute of Allergy and Infection Diseases and the US National Institute of Health in 35 different geographical countries assessed a group of 4685 asymptomatic HIV-positive patients  and showed a reduction of 53% in the risk of HIV-related illness or death among those who started ART early.

Speaking on the ‘Impact of Antiretroviral Therapy on TB disease in Resource Limited Settings’ Dr. N. Kumararasamy of YRGCARE, India said that the risk of progression of pulmonary TB is nearly 3.5 times more in PLHIV, warranting the need of early screening and treatment of TB among them.

The TEMPRANO ANRS Trial—‘Study of Early Antiretroviral and Isoniazid Prevention Therapy  (IPT) in Africa’ focussed specifically on Sub-Saharan African countries with highest burden of HIV-associated TB. According to the lead study author early initiation of ART and 6 months of IPT independently resulted in a risk of severe HIV-related illness that was 44% lower and a risk of death from any cause that was 35% lower than the risks with deferred initiation of ART and no IPT.

There are various studies suggesting early initiation of ART among HIV-TB patients. One such study reviewed data of more than 4500 people participating in eight randomized clinical trials conducted in Asia, Africa, and United States. It revealed better survival rates among those who started on ART earlier than those in the delayed ART arm. Lead author of the study, Dr. Nachega, said, “Our findings support guidelines recommending early initiation of ART in patients with a high degree of immune system compromise, but delaying ART might be possible until the end of TB treatment with patients with CD4 counts greater than 220 cells/mm3, which could reduce the burden of taking two complex drug regimens at the same time.”

All these studies show a strong relation between early initiation and good outcome. The main points that emerge from these discussions are that there is positive relation between early initiation of ART and survival chances; early initiation also decreases the chances of AIDS and AIDS related diseases; and it also reduces the risk of sexually transmitted diseases and Hepatitis B as well. So now we eventually arrive at the new suggestion of ‘test and treat’ (irrespective of CD+4 cell count) for decreasing mortality and morbidity related to TB and HIV co-infections.

Balu Mote, Citizen News Service - CNS
September 16, 2015