Timing of antiretroviral therapy initiation in adults with HIV-associated tuberculosis: Outcomes of therapy in an urban hospital in KwaZulu-Natal

Abstract

Background. HIV-associated tuberculosis (TB) is common in South Africa. The optimal time for initiating antiretroviral therapy (ART) in co-infected patients is a clinical challenge.
Aim. We aimed to compare clinical outcomes of patients with HIV-associated TB who commenced ART at different stages of TB therapy.

Methods. A retrospective chart review was conducted of 458 patients who initiated ART at 28 days (immediate), 29 - 56 days (early) and 57 days (delayed) after commencing TB therapy, and clinical outcomes after 6 months of ART were compared.

Results. There was a higher mortality in the immediate group, although this was not significant. Renal impairment (hazard ratio (HR) 2.5; 95% confidence interval (CI) 1.3 - 4.9; p=0.004) and inpatient ART initiation (HR 3.7; 95% CI 1.6 - 8.2; p=0.001) were risk factors for HIV-associated TB mortality. A baseline haemoglobin concentration 10 g/dl (HR 0.2; 95% CI 0.1 - 0.6; p=0.003), extrapulmonary as opposed to pulmonary TB (PTB) (HR 0.3; 95% CI 0.1 - 0.7; p=0.005) and extrapulmonary plus PTB as opposed to PTB (HR 0.3, 95% CI 0.1 - 0.6; p=0.002) were significantly associated with decreased mortality.

Conclusion. The timing of initiation of ART after commencing TB therapy was not significantly associated with increased mortality or survival. Patients with more advanced disease were more likely to die. Early HIV testing and ART initiation is recommended to decrease mortality.