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Maranchick NF, Kwara A, Peloquin CA. Clinical considerations and pharmacokinetic interactions between HIV and tuberculosis therapeutics. Expert Rev Clin Pharmacol 2024; 17:537-547. [PMID: 38339997 DOI: 10.1080/17512433.2024.2317954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious disease cause of mortality worldwide, especially for people living with human immunodeficiency virus (PLWH). Treating TB in PLWH can be challenging due to numerous drug interactions. AREAS COVERED This review discusses drug interactions between antitubercular and antiretroviral drugs. Due to its clinical importance, initiation of antiretroviral therapy in patients requiring TB treatment is discussed. Special focus is placed on the rifamycin class, as it accounts for the majority of interactions. Clinically relevant guidance is provided on how to manage these interactions. An additional section on utilizing therapeutic drug monitoring (TDM) to optimize drug exposure and minimize toxicities is included. EXPERT OPINION Antitubercular and antiretroviral coadministration can be successfully managed. TDM can be used to optimize drug exposure and minimize toxicity risk. As new TB and HIV drugs are discovered, additional research will be needed to assess for clinically relevant drug interactions.
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Affiliation(s)
- Nicole F Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Awewura Kwara
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
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Cao W, Fu X, Li H, Bei J, Li L, Wang L. Tuberculosis in pregnancy and assisted reproductive technology. Drug Discov Ther 2024; 18:80-88. [PMID: 38631867 DOI: 10.5582/ddt.2024.01007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Tuberculosis is a chronic infectious disease caused by mycobacterium tuberculosis infection. In the world, tuberculosis is an important factor affecting women's reproductive health, which can cause reproductive tract anatomy abnormalities, embryo implantation obstacles, ovarian reserve and ovulation dysfunction, leading to female infertility. This group of women usually need to seek assisted reproductive technology to conceive. Latent tuberculosis infection during pregnancy has no clinical manifestation, but may develop into active tuberculosis, leading to adverse pregnancy outcomes. Most pregnant women do not need to be treated for latent tuberculosis infection, unless they are combined with high-risk factors for tuberculosis progress, but they need close follow-up. Early diagnosis and treatment of active tuberculosis in pregnancy can reduce the incidence rate and mortality of pregnant women and newborns, and treatment needs multidisciplinary cooperation.
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Affiliation(s)
- Wenli Cao
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Xiayan Fu
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Haiyang Li
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Jialu Bei
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Lisha Li
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Ling Wang
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
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Castellanos Reynosa ME, Caal ME, Mercado D, Medina N, Pérez JC, Emeto TI, Arathoon E. Clinical characteristics, diagnosis, treatment and outcomes of patients living with HIV and co-infected with tuberculosis and histoplasmosis: a 5-y retrospective case series. Trans R Soc Trop Med Hyg 2024; 118:391-398. [PMID: 38279781 PMCID: PMC11149374 DOI: 10.1093/trstmh/trad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/18/2023] [Accepted: 01/01/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND In Latin America, tuberculosis (TB) and histoplasmosis are two of the most frequent opportunistic infections affecting people living with human immunodeficiency virus (HIV). However, there are limited data on the clinical characteristics and outcomes of patients with concurrent TB and histoplasmosis infections. METHODS This was a retrospective observational study to describe the clinical, epidemiological and laboratory characteristics and outcomes of 21 patients living with HIV (PLHIV) who were diagnosed with concurrent histoplasmosis and TB between 2017 and 2021 in Guatemala City, Guatemala. RESULTS Most patients were male and were newly diagnosed with HIV. All patients had advanced HIV disease (AHD). They presented with a median CD4 count of 20 cells/µl. The most common symptoms reported by the patients were fever, weight loss, cough and diarrhoea. Twelve patients died within 6 months of baseline evaluation, for a mortality rate of 57.1%. CONCLUSIONS PLHIV with concurrent TB and histoplasmosis infections are characterised by AHD, predominantly presenting with disseminated forms of these infections and with unspecific symptoms and signs. This evidence calls for early HIV and opportunistic infection screening and insights into the challenges and opportunities for the efficient diagnostic and therapeutic management of patients with AHD with concurrent histoplasmosis and TB infections.
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Affiliation(s)
- María Eugenia Castellanos Reynosa
- Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | | | - Danicela Mercado
- Clínica Familiar Luis Ángel García, Hospital General San Juan de Dios, Guatemala City, Guatemala
| | - Narda Medina
- Asociación de Salud Integral, Guatemala City, Guatemala
| | | | - Theophilus I Emeto
- Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Eduardo Arathoon
- Asociación de Salud Integral, Guatemala City, Guatemala
- Clínica Familiar Luis Ángel García, Hospital General San Juan de Dios, Guatemala City, Guatemala
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Le X, Shen Y. Advances in Antiretroviral Therapy for Patients with Human Immunodeficiency Virus-Associated Tuberculosis. Viruses 2024; 16:494. [PMID: 38675837 PMCID: PMC11054420 DOI: 10.3390/v16040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/09/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculosis is one of the most common opportunistic infections and a prominent cause of death in patients with human immunodeficiency virus (HIV) infection, in spite of near-universal access to antiretroviral therapy (ART) and tuberculosis preventive therapy. For patients with active tuberculosis but not yet receiving ART, starting ART after anti-tuberculosis treatment can complicate clinical management due to drug toxicities, drug-drug interactions and immune reconstitution inflammatory syndrome (IRIS) events. The timing of ART initiation has a crucial impact on treatment outcomes, especially for patients with tuberculous meningitis. The principles of ART in patients with HIV-associated tuberculosis are specific and relatively complex in comparison to patients with other opportunistic infections or cancers. In this review, we summarize the current progress in the timing of ART initiation, ART regimens, drug-drug interactions between anti-tuberculosis and antiretroviral agents, and IRIS.
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Affiliation(s)
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China;
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Díaz-Brochero C, Nocua-Báez LC, Valderrama-Rios MC, Cortés JA. Efficacy and safety of preemptive therapy for cytomegalovirus end-organ disease in people living with HIV: a systematic review and meta-analysis. Braz J Infect Dis 2023; 27:102805. [PMID: 37777185 PMCID: PMC10551618 DOI: 10.1016/j.bjid.2023.102805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/31/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023] Open
Abstract
INTRODUCTION Cytomegalovirus end-organ-disease (CMV EOD) is still a major cause of debilitating illness in people living with HIV, especially in developing countries. OBJECTIVE To evaluate the efficacy and safety of preemptive therapy against CMV EOD in HIV-positive adults with CMV viremia. METHODS Systematic review of clinical trials by searching electronic databases and clinical trial registries, screening and selection of references, data extraction and assessment of risk of bias. The results were presented in a narrative synthesis. Aggregated analyzes for dichotomous outcomes were reported as odds ratios with 95 % Confidence Intervals. RESULTS Four RTC were included. A reduction in the risk of CMV EOD with preemptive therapy was found OR=0.49 (95 % CI 0.31‒0.76). We did not identify significant differences for all-cause mortality, adverse events, and withdrawal of the therapy secondary to adverse events. CONCLUSIONS Preemptive therapy could be a potential option for preventing CMV EOD in people living with HIV.
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Affiliation(s)
- Cándida Díaz-Brochero
- Universidad Nacional de Colombia, School of Medicine, Department of Internal Medicine, Bogotá, Colombia.
| | - Laura Cristina Nocua-Báez
- Universidad Nacional de Colombia, School of Medicine, Department of Internal Medicine, Bogotá, Colombia; Hospital Universitario Nacional de Colombia, Infectious Diseases Unit, Bogotá, Colombia
| | | | - Jorge Alberto Cortés
- Universidad Nacional de Colombia, School of Medicine, Department of Internal Medicine, Bogotá, Colombia; Hospital Universitario Nacional de Colombia, Infectious Diseases Unit, Bogotá, Colombia
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Kay A, Mendez-Reyes J, Devezin T, Bakaya M, Steffy T, Dlamini S, Msekandiana A, Ness T, Bacha J, Amuge P, Matshaba M, Chodota M, Nyasulu P, Thahane L, Mwita L, Kekitiinwa A, DiNardo A, Lukhele B, Kirchner HL, Mandalakas A. Optimal Timing of Antiretroviral Therapy Initiation in Children and Adolescents With Human Immunodeficiency Virus-Associated Pulmonary Tuberculosis. Clin Infect Dis 2022; 76:10-17. [PMID: 36097966 PMCID: PMC9825818 DOI: 10.1093/cid/ciac765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/29/2022] [Accepted: 09/09/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There is insufficient evidence in children and adolescents with human immunodeficiency virus (CAHIV) to guide the timing of antiretroviral treatment (ART) initiation after starting treatment for pulmonary tuberculosis (pTB). To address this knowledge gap, we evaluated the risk of mortality associated with timing of ART initiation in ART-naive CAHIV treated for pTB. METHODS Data were extracted from electronic medical records of ART-naive patients, aged 0-19 years, who were treated for HIV-associated pTB at Baylor Centers of Excellence in Botswana, Eswatini, Malawi, Lesotho, Tanzania, or Uganda between 2013 and 2020. Data were analyzed against a primary outcome of all-cause mortality with unadjusted Kaplan-Meier curves and Cox proportional hazard models. RESULTS The study population included 774 CAHIV with variable intervals to ART initiation after starting TB treatment: <2 weeks (n = 266), 2 weeks to 2 months (n = 398), >2 months (n = 66), and no ART initiated (n = 44). Adjusted Cox proportional hazards models demonstrated increased mortality 1 year from TB treatment initiation in children never starting ART (adjusted HR [aHR]: 2.67; 95% CI: 1.03, 6.94) versus children initiating ART between 2 weeks and 2 months from TB treatment initiation. Mortality risk did not differ for the <2-weeks group (aHR: 1.02; 95% CI: .55, 1.89) versus the group initiating ART between 2 weeks and 2 months. CONCLUSIONS This retrospective study demonstrated no increase in mortality among CAHIV initiating ART <2 weeks from TB treatment initiation. Given the broad health benefits of ART, this evidence supports the recent WHO recommendation for CAHIV to initiate ART within 2 weeks of initiating TB treatment.
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Affiliation(s)
- Alexander Kay
- Correspondence: A. Kay, Baylor College of Medicine, Associate Director of the Baylor College of Medicine Global TB Program, Baylor College of Medicine Children's Foundation Eswatini, PO Box 110, Mbabane H-100, Eswatini or Baylor College of Medicine, 1102 Bates St, FC-630, Houston, TX 77030, USA ()
| | - Jose Mendez-Reyes
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Tara Devezin
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Meenakshi Bakaya
- Baylor College of Medicine Children's Foundation–Lesotho, Maseru, Lesotho
| | - Teresa Steffy
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Baylor College of Medicine Children's Foundation–Lesotho, Maseru, Lesotho
| | - Sandile Dlamini
- Baylor College of Medicine Children's Foundation–Swaziland, Mbabane, Eswatini
| | - Amos Msekandiana
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Tara Ness
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Jason Bacha
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Baylor College of Medicine Children’s Foundation–Tanzania, Mbeya, Tanzania
| | - Pauline Amuge
- Baylor College of Medicine Children's Foundation–Uganda, Kampala, Uganda
| | - Mogomotsi Matshaba
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana
| | - Moses Chodota
- Baylor College of Medicine Children’s Foundation–Tanzania, Mbeya, Tanzania
| | - Phoebe Nyasulu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Lineo Thahane
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Baylor College of Medicine Children's Foundation–Lesotho, Maseru, Lesotho
| | - Lumumbwa Mwita
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Baylor College of Medicine Children's Foundation–Tanzania, Mwanza, Tanzania
| | - Adeodata Kekitiinwa
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Baylor College of Medicine Children's Foundation–Uganda, Kampala, Uganda
| | - Andrew DiNardo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Bhekumusa Lukhele
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Baylor College of Medicine Children's Foundation–Swaziland, Mbabane, Eswatini
| | - H Lester Kirchner
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Population Health Sciences, Geisinger, Danville, Pennsylvania, USA
| | - Anna Mandalakas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA,Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA,Research Center Borstel, Clinical Infectious Diseases, Borstel, Germany
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Wu Y, Zhang Y, Wang Y, Wei J, Wang W, Duan W, Tian Y, Ren M, Li Z, Wang W, Zhang T, Wu H, Huang X. Bedaquiline and Linezolid improve anti-TB treatment outcome in drug-resistant TB patients with HIV: A systematic review and meta-analysis. Pharmacol Res 2022; 182:106336. [PMID: 35779814 DOI: 10.1016/j.phrs.2022.106336] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES We aimed to assess the effect of second-line anti-TB treatment and determine which drugs can achieve the greatest clinical benefit for DR-TB-HIV patients by comparing multiple chemotherapy regimens, to provide a basis for evidence-based practice. METHODS We searched three electronic databases (PubMed, Web of Science and Cochrane) for related English studies published since 2010. A random-effect model was used to estimate the pooled result for the treatment outcomes. Subgroup analysis based on possible factors, such as ART, baseline CD4 T-cell count, treatment regimens, and profiles of drug resistance, was also conducted to assess factors for favorable outcome. Outcomes were treatment success and mortality. RESULTS 38 studies, 40 cohorts with 9279 patients were included. The pooled treatment success, mortality, treatment failure, and default rates were 57.5 % (95 % CI 53.1-61.9), 21 % (95 % CI 17.8-24.6), 4.8 % (95 % CI 3.5-6.5), and 10.7 % (95 % CI 8.7-13.1), respectively, in patients with DR-TB and HIV co-infection. Subgroup analysis showed that BDQ and LZD based regimen, and ≥ 2 Group A drugs were associated with a higher treatment success rate. Besides, higher CD4 T-cell count at baseline was also correlated with higher treatment success rate, too. CONCLUSIONS Suboptimal anti-TB outcomes underlining the need to expand the application of effective drugs and better regimen in high HIV setting. BDQ and LZD based all-oral regimen and early ART could contribute to higher treatment success, particularly among XDR-TB-HIV patients. Given that all included studies were observational, our findings emphasize the need for high-quality studies to further investigate the optimal treatment regimen for DR-TB-HIV.
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Affiliation(s)
- Yaxin Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Yingying Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Jiaqi Wei
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wenjing Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Wenshan Duan
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yakun Tian
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Meixin Ren
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Zhen Li
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wen Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Tong Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Hao Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Xiaojie Huang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China.
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Pooranagangadevi N, Padmapriyadarsini C. Treatment of Tuberculosis and the Drug Interactions Associated With HIV-TB Co-Infection Treatment. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.834013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Tuberculosis (TB) is a communicable disease that is a major source of illness, one of the ten causes of mortality worldwide, and the largest cause of death from a single infectious agent Mycobacterium tuberculosis. HIV infection and TB are a fatal combination, with each speeding up the progression of the other. Barriers to integrated treatment as well as safety concerns on the co-management of HIV- TB co-infection do exist. Many HIV TB co-infected people require concomitant anti-retroviral therapy (ART) and anti-TB medication, which increases survival but also introduces certain management issues, such as drug interactions, combined drug toxicities, and TB immune reconstitution inflammatory syndrome which has been reviewed here. In spite of considerable pharmacokinetic interactions between antiretrovirals and antitubercular drugs, when the pharmacological characteristics of drugs are known and appropriate combination regimens, dosing, and timing of initiation are used, adequate clinical response of both infections can be achieved with an acceptable safety profile. To avoid undesirable drug interactions and side effects in patients, anti TB treatment and ART must be closely monitored. To reduce TB-related mortality among HIV-TB co-infected patients, ART and ATT (Anti Tuberculosis Treatment) outcomes must improve. Clinical practise should prioritise strategies to promote adherence, such as reducing treatment duration, monitoring and treating adverse events, and improving treatment success rates, to reduce the mortality risk of HIV-TB co-infection.
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Sullivan A, Nathavitharana RR. Addressing TB-related mortality in adults living with HIV: a review of the challenges and potential solutions. Ther Adv Infect Dis 2022; 9:20499361221084163. [PMID: 35321342 PMCID: PMC8935406 DOI: 10.1177/20499361221084163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/12/2022] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) is the leading cause of death in people living with HIV (PLHIV) globally, causing 208,000 deaths in PLHIV in 2019. PLHIV have an 18-fold higher risk of TB, and HIV/TB mortality is highest in inpatient facilities, compared with primary care and community settings. Here we discuss challenges and potential mitigating solutions to address TB-related mortality in adults with HIV. Key factors that affect healthcare engagement are stigma, knowledge, and socioeconomic constraints, which are compounded in people with HIV/TB co-infection. Innovative approaches to improve healthcare engagement include optimizing HIV/TB care integration and interventions to reduce stigma. While early diagnosis of both HIV and TB can reduce mortality, barriers to early diagnosis of TB in PLHIV include difficulty producing sputum specimens, lower sensitivity of TB diagnostic tests in PLHIV, and higher rates of extra pulmonary TB. There is an urgent need to develop higher sensitivity biomarker-based tests that can be used for point-of-care diagnosis. Nonetheless, the implementation and scale-up of existing tests including molecular World Health Organization (WHO)-recommended diagnostic tests and urine lipoarabinomannan (LAM) should be optimized along with expanded TB screening with tools such as C-reactive protein and digital chest radiography. Decreased survival of PLHIV with TB disease is more likely with late HIV diagnosis and delayed start of antiretroviral (ART) treatment. The WHO now recommends starting ART within 2 weeks of initiating TB treatment in the majority of PLHIV, aside from those with TB meningitis. Dedicated TB treatment trials focused on PLHIV are needed, including interventions to improve TB meningitis outcomes given its high mortality, such as the use of intensified regimens using high-dose rifampin, new and repurposed drugs such as linezolid, and immunomodulatory therapy. Ultimately holistic, high-quality, person-centered care is needed for PLHIV with TB throughout the cascade of care, which should address biomedical, socioeconomic, and psychological barriers.
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Affiliation(s)
- Amanda Sullivan
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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