What is the optimum time to start antiretroviral therapy in people with HIV and tuberculosis coinfection? A systematic review and meta-analysis.
HIV
antiretroviral therapy
public health
rapid ART
systematic review
tuberculosis
Journal
Journal of the International AIDS Society
ISSN: 1758-2652
Titre abrégé: J Int AIDS Soc
Pays: Switzerland
ID NLM: 101478566
Informations de publication
Date de publication:
07 2021
07 2021
Historique:
revised:
07
06
2021
received:
11
01
2021
accepted:
24
06
2021
entrez:
21
7
2021
pubmed:
22
7
2021
medline:
26
10
2021
Statut:
ppublish
Résumé
HIV and tuberculosis are frequently diagnosed concurrently. In March 2021, World Health Organization recommended that antiretroviral therapy (ART) should be started within two weeks of tuberculosis treatment start, at any CD4 count. We assessed whether earlier ART improved outcomes in people with newly diagnosed HIV and tuberculosis. We did a systematic review by searching nine databases for trials that compared earlier ART to later ART initiation in people with HIV and tuberculosis. We included studies published from database inception to 12 March 2021. We compared ART within four weeks versus ART more than four weeks after TB treatment, and ART within two weeks versus ART between two and eight weeks, and stratified analysis by CD4 count. The main outcome was death; secondary outcomes included IRIS and AIDS-defining events. We pooled effect estimates using random effects meta-analysis. We screened 2468 abstracts, and identified nine trials. Among people with all CD4 counts, there was no difference in mortality by earlier ART (≤4 week) versus later ART (>4 week) (risk difference [RD] 0%, 95% confidence interval [CI] -2% to +1%). Among people with CD4 count ≤50 cells/mm Earlier ART did not alter risk of death overall among people living with HIV who had TB disease. For logistical and patient preference reasons, earlier ART initiation for everyone with TB and HIV may be preferred to later ART.
Sections du résumé
BACKGROUND
HIV and tuberculosis are frequently diagnosed concurrently. In March 2021, World Health Organization recommended that antiretroviral therapy (ART) should be started within two weeks of tuberculosis treatment start, at any CD4 count. We assessed whether earlier ART improved outcomes in people with newly diagnosed HIV and tuberculosis.
METHODS
We did a systematic review by searching nine databases for trials that compared earlier ART to later ART initiation in people with HIV and tuberculosis. We included studies published from database inception to 12 March 2021. We compared ART within four weeks versus ART more than four weeks after TB treatment, and ART within two weeks versus ART between two and eight weeks, and stratified analysis by CD4 count. The main outcome was death; secondary outcomes included IRIS and AIDS-defining events. We pooled effect estimates using random effects meta-analysis.
RESULTS AND DISCUSSION
We screened 2468 abstracts, and identified nine trials. Among people with all CD4 counts, there was no difference in mortality by earlier ART (≤4 week) versus later ART (>4 week) (risk difference [RD] 0%, 95% confidence interval [CI] -2% to +1%). Among people with CD4 count ≤50 cells/mm
DISCUSSION
Earlier ART did not alter risk of death overall among people living with HIV who had TB disease. For logistical and patient preference reasons, earlier ART initiation for everyone with TB and HIV may be preferred to later ART.
Identifiants
pubmed: 34289243
doi: 10.1002/jia2.25772
pmc: PMC8294654
doi:
Substances chimiques
Anti-HIV Agents
0
Types de publication
Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
e25772Subventions
Organisme : Wellcome Trust
ID : 200901/Z/16/Z
Pays : United Kingdom
Organisme : Wellcome Trust
ID : FC0010218
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 203133
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 203905/Z/16/Z
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 206575/Z/17/Z
Pays : United Kingdom
Organisme : Wellcome Trust
Pays : United Kingdom
Organisme : Cancer Research UK
ID : FC0010218
Pays : United Kingdom
Organisme : World Health Organization
ID : 001
Pays : International
Informations de copyright
© 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.
Références
N Engl J Med. 2014 Jun 26;370(26):2487-98
pubmed: 24963568
Clin Spine Surg. 2017 Nov;30(9):404-406
pubmed: 29049130
Ann Intern Med. 2015 Jul 7;163(1):32-9
pubmed: 26148280
Clin Infect Dis. 2011 Jun;52(11):1374-83
pubmed: 21596680
N Engl J Med. 2011 Oct 20;365(16):1482-91
pubmed: 22010914
BMC Infect Dis. 2012 Jul 31;12:168
pubmed: 22846195
Clin Infect Dis. 2020 Feb 3;70(4):549-556
pubmed: 30918967
J Acquir Immune Defic Syndr. 2012 Aug 1;60(4):377-83
pubmed: 22592586
Syst Rev. 2016 Dec 5;5(1):210
pubmed: 27919275
N Engl J Med. 2011 Oct 20;365(16):1492-501
pubmed: 22010915
AIDS Res Hum Retroviruses. 2009 Dec;25(12):1277-85
pubmed: 20001518
Patient Prefer Adherence. 2012;6:887-91
pubmed: 23271897
HIV AIDS (Auckl). 2015 Feb 12;7:49-64
pubmed: 25709503
N Engl J Med. 2011 Oct 20;365(16):1471-81
pubmed: 22010913
PLoS One. 2015 May 12;10(5):e0122587
pubmed: 25966339
PLoS One. 2015 May 22;10(5):e0127645
pubmed: 26000446
AIDS. 2015 Sep 24;29(15):1987-2002
pubmed: 26266773
N Engl J Med. 2016 Sep 1;375(9):830-9
pubmed: 27424812
Curr Opin HIV AIDS. 2018 Nov;13(6):512-521
pubmed: 30124473
PLoS Med. 2016 May 10;13(5):e1002015
pubmed: 27163694
Expert Opin Drug Saf. 2020 Jan;19(1):23-41
pubmed: 31809218
BMC Public Health. 2014 Feb 20;14:183
pubmed: 24555530
J Int AIDS Soc. 2016 Jan 12;19(1):20714
pubmed: 26765347
PLoS Med. 2017 Jul 25;14(7):e1002357
pubmed: 28742880
N Engl J Med. 2018 Nov 15;379(20):1915-1925
pubmed: 30428290
Lancet Infect Dis. 2010 Apr;10(4):251-61
pubmed: 20334848
BMJ. 2014 Nov 13;349:g6694
pubmed: 25395503
BMJ. 2019 Aug 28;366:l4898
pubmed: 31462531
Lancet Infect Dis. 2008 Aug;8(8):516-23
pubmed: 18652998
Lancet Infect Dis. 2014 Jun;14(6):459-67
pubmed: 24726095
Lancet Infect Dis. 2014 Jul;14(7):563-71
pubmed: 24810491