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Chang MH, Guo Y, Acbo A, Bao H, McSweeney T, Vo CA, Nori P. Antiretroviral Stewardship: Top 10 Questions Encountered by Stewardship Teams and Solutions to Optimize Therapy. Clin Ther 2024; 46:455-462. [PMID: 38704295 DOI: 10.1016/j.clinthera.2024.04.002] [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: 11/16/2023] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Infectious disease pharmacists and physicians overseeing antimicrobial stewardship programs possess expertise and often advanced certification in management of antiretrovirals to treat HIV. Stewardship programs are responsible for managing facility formularies and must stay up to date with the latest antiretrovirals, including once daily formulations and depot injectables. Furthermore, stewardship program members need to understand drug-interactions, short-, and long-term toxicities of these regimens, including dyslipidemia and cardiovascular effects. Patients receiving chronic antiretroviral therapy may present to the acute care, ambulatory care, and long-term care settings. Like other antimicrobials, audit-and-feedback, drug monitoring, and dose-optimization are often required to prevent antiretroviral associated medication errors and minimize resistance. METHODS A narrative review was conducted on antiretroviral stewardship, addressing common clinical questions encountered by stewardship teams and best practices to optimize antiretroviral therapy and reduce the risk for treatment interruptions, resistance, drug interactions, long term toxicities, and other adverse effects. FINDINGS People living with HIV are often hospitalized and treated by medical teams without formal HIV training. For this reason, these patients are at greater risk for medication errors during hospitalization and between transitions of care. Many opportunities are present for antiretroviral stewardship to mitigate these errors. Frequent updates to simplify HIV regimen, maintain select patients on fixed-dose combination tablets, and strategies to minimize drug interactions make it difficult for even the seasoned clinician to keep up regularly. IMPLICATIONS Despite the availability of free online HIV resources and progress made in HIV management, significant opportunities for antiretroviral stewardship remain. Implementing electronic order entry updates, formulary upgrades, and formal pharmacy renal dose adjustments to optimize antiretroviral therapy will help clinicians harness these opportunities. Dedicated time and expertise for antiretroviral stewardship as part of local antimicrobial stewardship programs are needed.
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Affiliation(s)
- Mei H Chang
- Department of Pharmacy, Montefiore Health System, Bronx, New York.
| | - Yi Guo
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | - Antoinette Acbo
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | - Hongkai Bao
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | | | - Christopher A Vo
- Division of Infectious Diseases, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York
| | - Priya Nori
- Division of Infectious Diseases, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York
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Azoulay LD, Houist AL, Feredj E, Vindrios W, Gallien S. [Paradoxical tuberculosis reaction]. Rev Med Interne 2024; 45:279-288. [PMID: 38267320 DOI: 10.1016/j.revmed.2024.01.008] [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: 07/23/2023] [Revised: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
Paradoxical tuberculosis reaction is defined as the aggravation of lesions present at diagnosis or the development of new lesions under anti-tuberculosis treatment, after exclusion of other alternate causes. It affects 5 to 30% of tuberculosis patients, with a variable prevalence depending on the site of infection and the clinical background. The diagnosis of paradoxical reaction is one of elimination, and requires having ruled out therapeutic failure, notably linked to poor compliance and/or to the presence of mycobacterial antibiotic resistance. The severity of paradoxical tuberculosis reaction lies in its neurological impairment. Despite its clinical importance, the mechanisms involved remain poorly understood and its management is not consensual. Corticosteroids are the cornerstone in the medical management. The role of anti-TNF agents, currently proposed in cases of corticodependence or corticoresistance, remains to be properly defined.
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Affiliation(s)
- L-D Azoulay
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France.
| | - A-L Houist
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - E Feredj
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - W Vindrios
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - S Gallien
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
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Choi Y, Choi BY, Kim SI, Choi J, Kim J, Park BY, Kim SM, Kim SW, Choi JY, Song JY, Kim YJ, Kim HY, Lee JS, Kim JH, Jun YH, Lee M, Seong J. Effect of characteristics on the clinical course at the initiation of treatment for human immunodeficiency virus infection using dimensionality reduction. Sci Rep 2023; 13:5547. [PMID: 37016006 PMCID: PMC10073208 DOI: 10.1038/s41598-023-31916-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/20/2023] [Indexed: 04/06/2023] Open
Abstract
The beginning of human immunodeficiency virus (HIV) infection treatment depends on various factors, which are significantly correlated with the initial CD4 cell number. However, a covariate correlation between these factors may not reflect the correct outcome variable. Thus, we evaluated the effects of a combination of fixed factors (reduced dimensions), which determine when to start treatment for the first time, on short-term outcome, long-term outcome, and survival, considering correlations between factors. Multiple correspondence analysis was performed on variables obtained from 925 patients who participated in a Korean HIV/acquired immunodeficiency syndrome cohort study (2006-2017). Five reduced dimension groups were derived according to clinical data, viral load, CD4 cell count at diagnosis, initial antiretroviral therapy, and others. The dimension group with high initial viral loads (55,000 copies/mL) and low CD4 cell counts (< 200 cells/mm3) should start treatment promptly after diagnosis. Groups with high initial CD4 cell counts (> 350 cells/mm3) that did not require immediate treatment according to previous guidelines had a higher failure rate for long-term relative CD4 recovery. Our results highlight the importance of early diagnosis and treatment to positively influence long-term disease outcomes, even if the initial immune status is poor, given the patient's combination of early diagnostic symptoms.
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Affiliation(s)
- Yunsu Choi
- Department of Preventive Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
- Institute for Health and Society, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Bo Youl Choi
- Department of Preventive Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea.
- Institute for Health and Society, College of Medicine, Hanyang University, Seoul, Republic of Korea.
| | - Sang Il Kim
- Division of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jungsoon Choi
- Department of Mathematics, Hanyang University, Seoul, Republic of Korea
| | - Jieun Kim
- Department of Internal Medicine, College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Bo Young Park
- Department of Preventive Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
- Institute for Health and Society, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Soo Min Kim
- Institute for Health and Society, College of Medicine, Hanyang University, Seoul, Republic of Korea
- Department of Statistics and Data Science, College of Commerce and Economics, Yonsei University, Seoul, Republic of Korea
- Department of Applied Statistics, College of Commerce and Economics, Yonsei University, Seoul, Republic of Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Young Song
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Youn Jeong Kim
- Division of Infectious Disease, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Youl Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jin-Soo Lee
- Division of Infectious Diseases, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jung Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoon Hee Jun
- Division of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Myungsun Lee
- Division of Clinical Research, Center for Emerging Virus Research, National Institute of Infectious Disease, Korea National Institute of Health (KNIH), Cheongwon-gun, Republic of Korea
| | - Jaehyun Seong
- Division of Clinical Research, Center for Emerging Virus Research, National Institute of Infectious Disease, Korea National Institute of Health (KNIH), Cheongwon-gun, Republic of Korea
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Martinez AE, Frattaroli P, Vu CA, Paniagua L, Mintz J, Bravo-Gonzalez A, Zamudio P, Barco A, Rampersad A, Lichtenberger P, Gonzales-Zamora JA. Successful Outcome after Treatment with Cidofovir, Vaccinia, and Extended Course of Tecovirimat in a Newly-Diagnosed HIV Patient with Severe Mpox: A Case Report. Vaccines (Basel) 2023; 11:vaccines11030650. [PMID: 36992234 DOI: 10.3390/vaccines11030650] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
Purpose: To report a case of severe mpox in a newly diagnosed HIV patient concerning for Immune Reconstitution Inflammatory Syndrome (IRIS) and/or tecovirimat resistance and to describe the management approach in the setting of refractory disease. Case: 49-year-old man presented with 2 weeks of perianal lesions. He tested positive for mpox PCR in the emergency room and was discharged home with quarantine instructions. Three weeks later, the patient returned with disseminated firm, nodular lesions in the face, neck, scalp, mouth, chest, back, legs, arms, and rectum, with worsening pain and purulent drainage from the rectum. The patient reported being on 3 days of tecovirimat treatment, which was prescribed by the Florida department of health (DOH). During this admission, he was found to be HIV positive. A pelvic CT scan revealed a 2.5 cm perirectal abscess. Treatment with tecovirimat was continued for 14 days, along with an empiric course of antibiotics for treatment of possible superimposed bacterial infection upon discharge. He was seen in the outpatient clinic and initiated antiretroviral therapy (ART) with TAF/emtricitabine/bictegravir. Two weeks after starting ART, the patient was readmitted for worsening mpox rash and rectal pain. Urine PCR also returned positive for chlamydia, for which the patient was prescribed doxycycline. He was discharged on a second course of tecovirimat and antibiotic therapy. Ten days later, the patient was readmitted for the second time due to worsening symptoms and blockage of the nasal airway from progressing lesions. At this point, there were concerns for tecovirimat resistance, and after discussion with CDC, tecovirimat was reinitiated for the third time, with the addition of Cidofovir and Vaccinia, and showed an improvement in his symptoms. He received three doses of cidofovir and two doses of Vaccinia, and the patient was then discharged to complete 30 days of tecovirimat. Outpatient follow-up showed favorable outcomes and near resolution. Conclusion: We reported a challenging case of worsening mpox after Tecovirimat treatment in the setting of new HIV and ART initiation concerning IRIS vs. Tecovirimat resistance. Clinicians should consider the risk of IRIS and weigh the pros and cons of initiating or delaying ART. In patients not responding to first-line treatment with tecovirimat, resistance testing should be performed, and alternative options should be considered. Future research is needed to establish guidance on the role of Cidofovir and Vaccinia immune globulin and the continuation of tecovirimat for refractory mpox.
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Affiliation(s)
- Andres E Martinez
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Paola Frattaroli
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Christine A Vu
- Department of Pharmacy, Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Lizy Paniagua
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Joel Mintz
- Department of Internal Medicine, University of Miami, Jackson Memorial Hospital, Miami, FL 33136, USA
| | | | - Paola Zamudio
- Universidad Anáhuac Querétaro, Querétaro 76246, Mexico
| | - Astrid Barco
- Universidad de Especialidades Espíritu Santo, Guayas 092301, Ecuador
| | - Aruna Rampersad
- Couva Hospital and Multi Training Facility, Couva 550214, Trinidad and Tobago
| | - Paola Lichtenberger
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
| | - Jose A Gonzales-Zamora
- Division of Infectious Diseases, Department of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33146, USA
- Peruvian American Medical Society (PAMS), Albuquerque, NM 87111, USA
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Schaberg T, Brinkmann F, Feiterna-Sperling C, Geerdes-Fenge H, Hartmann P, Häcker B, Hauer B, Haas W, Heyckendorf J, Lange C, Maurer FP, Nienhaus A, Otto-Knapp R, Priwitzer M, Richter E, Salzer HJ, Schoch O, Schönfeld N, Stahlmann R, Bauer T. Tuberkulose im Erwachsenenalter. Pneumologie 2022; 76:727-819. [DOI: 10.1055/a-1934-8303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ZusammenfassungDie Tuberkulose ist in Deutschland eine seltene, überwiegend gut behandelbare Erkrankung. Weltweit ist sie eine der häufigsten Infektionserkrankungen mit ca. 10 Millionen Neuerkrankungen/Jahr. Auch bei einer niedrigen Inzidenz in Deutschland bleibt Tuberkulose insbesondere aufgrund der internationalen Entwicklungen und Migrationsbewegungen eine wichtige Differenzialdiagnose. In Deutschland besteht, aufgrund der niedrigen Prävalenz der Erkrankung und der damit verbundenen abnehmenden klinischen Erfahrung, ein Informationsbedarf zu allen Aspekten der Tuberkulose und ihrer Kontrolle. Diese Leitlinie umfasst die mikrobiologische Diagnostik, die Grundprinzipien der Standardtherapie, die Behandlung verschiedener Organmanifestationen, den Umgang mit typischen unerwünschten Arzneimittelwirkungen, die Besonderheiten in der Diagnostik und Therapie resistenter Tuberkulose sowie die Behandlung bei TB-HIV-Koinfektion. Sie geht darüber hinaus auf Versorgungsaspekte und gesetzliche Regelungen wie auch auf die Diagnosestellung und präventive Therapie einer latenten tuberkulösen Infektion ein. Es wird ausgeführt, wann es der Behandlung durch spezialisierte Zentren bedarf.Die Aktualisierung der S2k-Leitlinie „Tuberkulose im Erwachsenenalter“ soll allen in der Tuberkuloseversorgung Tätigen als Richtschnur für die Prävention, die Diagnose und die Therapie der Tuberkulose dienen und helfen, den heutigen Herausforderungen im Umgang mit Tuberkulose in Deutschland gewachsen zu sein.
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Affiliation(s)
- Tom Schaberg
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | - Folke Brinkmann
- Abteilung für pädiatrische Pneumologie/CF-Zentrum, Universitätskinderklinik der Ruhr-Universität Bochum, Bochum
| | - Cornelia Feiterna-Sperling
- Klinik für Pädiatrie mit Schwerpunkt Pneumologie, Immunologie und Intensivmedizin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin
| | | | - Pia Hartmann
- Labor Dr. Wisplinghoff Köln, Klinische Infektiologie, Köln
- Department für Klinische Infektiologie, St. Vinzenz-Hospital, Köln
| | - Brit Häcker
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | - Jan Heyckendorf
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Christoph Lange
- Klinische Infektiologie, Forschungszentrum Borstel
- Deutsches Zentrum für Infektionsforschung (DZIF), Standort Hamburg-Lübeck-Borstel-Riems
- Respiratory Medicine and International Health, Universität zu Lübeck, Lübeck
- Baylor College of Medicine and Texas Childrenʼs Hospital, Global TB Program, Houston, TX, USA
| | - Florian P. Maurer
- Nationales Referenzzentrum für Mykobakterien, Forschungszentrum Borstel, Borstel
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Albert Nienhaus
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg
| | - Ralf Otto-Knapp
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | | | | | | | - Ralf Stahlmann
- Institut für klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin, Berlin
| | - Torsten Bauer
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
- Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin
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6
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Summary of 2021 Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS in HIV-infected Koreans. Infect Chemother 2021; 53:592-616. [PMID: 34405598 PMCID: PMC8511382 DOI: 10.3947/ic.2021.0305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Indexed: 12/15/2022] Open
Abstract
Since the establishment of the Committee for Clinical Guidelines for the Diagnosis and Treatment of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) by the Korean Society for AIDS in 2010, clinical guidelines have been prepared in 2011, 2013, 2015, and 2018. As new research findings on the epidemiology, diagnosis, and treatment of AIDS have been published in and outside of Korea along with the development and introduction of new antiretroviral medications, a need has arisen to revise the clinical guidelines by analyzing such new data. The clinical guidelines address the initial evaluation of patients diagnosed with HIV/AIDS, follow-up tests, appropriate timing of medication, appropriate antiretroviral medications, treatment strategies for patients who have concurrent infections with hepatitis B or C virus, recommendations for resistance testing, treatment for patients with HIV and tuberculosis coinfections, and treatment in pregnant women. Through these clinical guidelines, the Korean Society for AIDS and the Committee for Clinical Guidelines for the Diagnosis and Treatment of HIV/AIDS contributes to overcoming AIDS by delivering latest data and treatment strategies to healthcare professionals who treat AIDS in the clinic.
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Burke RM, Rickman HM, Singh V, Corbett EL, Ayles H, Jahn A, Hosseinipour MC, Wilkinson RJ, MacPherson P. What is the optimum time to start antiretroviral therapy in people with HIV and tuberculosis coinfection? A systematic review and meta-analysis. J Int AIDS Soc 2021; 24:e25772. [PMID: 34289243 PMCID: PMC8294654 DOI: 10.1002/jia2.25772] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 12/29/2022] Open
Abstract
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/mm3 , earlier ART (≤4 weeks) reduced risk of death (RD -6%, -10% to -1%). Among people with all CD4 counts earlier ART (≤4 weeks) increased the risk of IRIS (RD +6%, 95% CI +2% to +10%) and reduced the incidence of AIDS-defining events (RD -2%, 95% CI -4% to 0%). Results were similar when trials were restricted to the four trials which permitted comparison of ART within two weeks to ART between two and eight weeks. Trials were conducted between 2004 and 2014, before recommendations to treat HIV at any CD4 count or to rapidly start ART in people without TB. No trials included children or pregnant women. No trials included integrase inhibitors in ART regimens. 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.
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Affiliation(s)
- Rachael M Burke
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseaseLondon School of Hygiene and Tropical MedicineLondonUK
| | - Hannah M Rickman
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
| | - Vindi Singh
- Department HIV, Hepatitis and STIsWorld Health OrganisationGenevaSwitzerland
| | - Elizabeth L Corbett
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseaseLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- ZambartLusakaZambia
| | - Andreas Jahn
- Department of HIV and AIDSMinistry of Health MalawiLilongweMalawi
- International Training and Education Center for HealthDepartment of Global HealthUniversity of WashingtonSeattleWAUSA
| | | | - Robert J Wilkinson
- Dept Infectious DiseaseImperial College LondonLondonUK
- Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular MedicineUniversity of Cape TownObservatoryRepublic of South Africa
- Francis Crick InstituteLondonUK
| | - Peter MacPherson
- Malawi‐Liverpool‐Wellcome Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseaseLondon School of Hygiene and Tropical MedicineLondonUK
- Department of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
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8
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Pretomanid Pharmacokinetics in the Presence of Rifamycins: Interim Results from a Randomized Trial among Patients with Tuberculosis. Antimicrob Agents Chemother 2021; 65:AAC.01196-20. [PMID: 33229425 PMCID: PMC7849006 DOI: 10.1128/aac.01196-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/28/2020] [Indexed: 01/28/2023] Open
Abstract
Shorter, more potent regimens are needed for tuberculosis. The nitroimidazole pretomanid was recently approved for extensively drug-resistant tuberculosis in combination with bedaquiline and linezolid. Pretomanid may also have benefit as a treatment-shortening agent for drug-sensitive tuberculosis. It is unclear how and whether it can be used together with rifamycins, which are key sterilizing first-line drugs. In this analysis, data were pooled from two studies: the Assessing Pretomanid for Tuberculosis (APT) trial, in which patients with drug-sensitive pulmonary TB received pretomanid, isoniazid, and pyrazinamide plus either rifampin or rifabutin versus standard of care under fed conditions, and the AIDS Clinical Trials Group 5306 (A5306) trial, a phase I study in healthy volunteers receiving pretomanid alone or in combination with rifampin under fasting conditions. In our population pharmacokinetic (PK) model, participants taking rifampin had 44.4 and 59.3% reductions in pretomanid AUC (area under the concentration-time curve) compared to those taking rifabutin or pretomanid alone (due to 80 or 146% faster clearance) in the APT and A5306 trials, respectively. Median maximum concentrations (Cmax) in the rifampin and rifabutin arms were 2.14 and 3.35 mg/liter, while median AUC0-24 values were 30.1 and 59.5 mg·h/liter, respectively. Though pretomanid exposure in APT was significantly reduced with rifampin, AUC0-24 values were similar to those associated with effective treatment in registrational trials, likely because APT participants were fed with dosing, enhancing pretomanid relative bioavailability and exposures. Pretomanid concentrations with rifabutin were high but in range with prior observations. While pretomanid exposures with rifampin are unlikely to impair efficacy, our data suggest that pretomanid should be taken with food if prescribed with rifampin. (This study has been registered at ClinicalTrials.gov under identifier NCT02256696.).
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9
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Aklillu E, Zumla A, Habtewold A, Amogne W, Makonnen E, Yimer G, Burhenne J, Diczfalusy U. Early or deferred initiation of efavirenz during rifampicin-based TB therapy has no significant effect on CYP3A induction in TB-HIV infected patients. Br J Pharmacol 2020; 178:3294-3308. [PMID: 33155675 PMCID: PMC8359173 DOI: 10.1111/bph.15309] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 12/18/2022] Open
Abstract
Background and Purpose In TB‐HIV co‐infection, prompt initiation of TB therapy is recommended but anti‐retroviral treatment (ART) is often delayed due to potential drug–drug interactions between rifampicin and efavirenz. In a longitudinal cohort study, we evaluated the effects of efavirenz/rifampicin co‐treatment and time of ART initiation on CYP3A induction. Experimental Approach Treatment‐naïve TB‐HIV co‐infected patients (n = 102) were randomized to efavirenz‐based‐ART after 4 (n = 69) or 8 weeks (n = 33) of commencing rifampicin‐based anti‐TB therapy. HIV patients without TB (n = 94) receiving efavirenz‐based‐ART only were enrolled as control. Plasma 4β‐hydroxycholesterol/cholesterol (4β‐OHC/Chol) ratio, an endogenous biomarker for CYP3A activity, was determined at baseline, at 4 and 16 weeks of ART. Key Results In patients treated with efavirenz only, median 4β‐OHC/Chol ratios increased from baseline by 269% and 275% after 4 and 16 weeks of ART, respectively. In TB‐HIV patients, rifampicin only therapy for 4 and 8 weeks increased median 4β‐OHC/Chol ratios from baseline by 378% and 576% respectively. After efavirenz/rifampicin co‐treatment, 4β‐OHC/Chol ratios increased by 560% of baseline (4 weeks) and 456% of baseline (16 weeks). Neither time of ART initiation, sex, genotype nor efavirenz plasma concentration were significant predictors of 4β‐OHC/Chol ratios after 4 weeks of efavirenz/rifampicin co‐treatment. Conclusion and Implications Rifampicin induced CYP3A more potently than efavirenz, with maximum induction occurring within the first 4 weeks of rifampicin therapy. We provide pharmacological evidence that early (4 weeks) or deferred (8 weeks) ART initiation during anti‐TB therapy has no significant effect on CYP3A induction. LINKED ARTICLES This article is part of a themed issue on Oxysterols, Lifelong Health and Therapeutics. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.16/issuetoc
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Affiliation(s)
- Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital Huddinge C1:68, Karolinska Institutet, Stockholm, Sweden
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, NIHR Biomedical Research Centre at UCL Hospitals NHS Foundation Trust, London, UK.,UNZA-UCLMS Research and Training Program, Department of Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Abiy Habtewold
- Department of Pharmaceutical Sciences, School of Pharmacy, William Carey University, Biloxi, MS, USA
| | - Wondwossen Amogne
- Department of Internal Medicine, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Department of Pharmacology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Yimer
- Department of Pharmacology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Ulf Diczfalusy
- Division of Clinical Chemistry, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
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10
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Auld AF, Fielding K, Agizew T, Maida A, Mathoma A, Boyd R, Date A, Pals SL, Bicego G, Liu Y, Shiraishi RW, Ehrenkranz P, Serumola C, Mathebula U, Alexander H, Charalambous S, Emerson C, Rankgoane-Pono G, Pono P, Finlay A, Shepherd JC, Holmes C, Ellerbrock TV, Grant AD. Risk scores for predicting early antiretroviral therapy mortality in sub-Saharan Africa to inform who needs intensification of care: a derivation and external validation cohort study. BMC Med 2020; 18:311. [PMID: 33161899 PMCID: PMC7650165 DOI: 10.1186/s12916-020-01775-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Clinical scores to determine early (6-month) antiretroviral therapy (ART) mortality risk have not been developed for sub-Saharan Africa (SSA), home to 70% of people living with HIV. In the absence of validated scores, WHO eligibility criteria (EC) for ART care intensification are CD4 < 200/μL or WHO stage III/IV. METHODS We used Botswana XPRES trial data for adult ART enrollees to develop CD4-independent and CD4-dependent multivariable prognostic models for 6-month mortality. Scores were derived by rescaling coefficients. Scores were developed using the first 50% of XPRES ART enrollees, and their accuracy validated internally and externally using South African TB Fast Track (TBFT) trial data. Predictive accuracy was compared between scores and WHO EC. RESULTS Among 5553 XPRES enrollees, 2838 were included in the derivation dataset; 68% were female and 83 (3%) died by 6 months. Among 1077 TBFT ART enrollees, 55% were female and 6% died by 6 months. Factors predictive of 6-month mortality in the derivation dataset at p < 0.01 and selected for the CD4-independent score included male gender (2 points), ≥ 1 WHO tuberculosis symptom (2 points), WHO stage III/IV (2 points), severe anemia (hemoglobin < 8 g/dL) (3 points), and temperature > 37.5 °C (2 points). The same variables plus CD4 < 200/μL (1 point) were included in the CD4-dependent score. Among XPRES enrollees, a CD4-independent score of ≥ 4 would provide 86% sensitivity and 66% specificity, whereas WHO EC would provide 83% sensitivity and 58% specificity. If WHO stage alone was used, sensitivity was 48% and specificity 89%. Among TBFT enrollees, the CD4-independent score of ≥ 4 would provide 95% sensitivity and 27% specificity, whereas WHO EC would provide 100% sensitivity but 0% specificity. Accuracy was similar between CD4-independent and CD4-dependent scores. Categorizing CD4-independent scores into low (< 4), moderate (4-6), and high risk (≥ 7) gave 6-month mortality of 1%, 4%, and 17% for XPRES and 1%, 5%, and 30% for TBFT enrollees. CONCLUSIONS Sensitivity of the CD4-independent score was nearly twice that of WHO stage in predicting 6-month mortality and could be used in settings lacking CD4 testing to inform ART care intensification. The CD4-dependent score improved specificity versus WHO EC. Both scores should be considered for scale-up in SSA.
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Nico House, City Centre, P.O. Box 30016, Lilongwe 3, Malawi.
| | - Katherine Fielding
- TB Centre, London Sch. of Hygiene & Tropical Med, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Tefera Agizew
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Alice Maida
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Nico House, City Centre, P.O. Box 30016, Lilongwe 3, Malawi
| | - Anikie Mathoma
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Rosanna Boyd
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Anand Date
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sherri L Pals
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - George Bicego
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yuliang Liu
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ray W Shiraishi
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Christopher Serumola
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Unami Mathebula
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Heather Alexander
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Courtney Emerson
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Pontsho Pono
- Ministry of Health and Wellness, Gaborone, Botswana
| | - Alyssa Finlay
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - James C Shepherd
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana.,Yale University School of Medicine, New Haven, CT, USA
| | - Charles Holmes
- Center for Global Health Practice and Impact, Georgetown University Medical Center, Washington D.C, USA
| | - Tedd V Ellerbrock
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alison D Grant
- TB Centre, London Sch. of Hygiene & Tropical Med, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, School of Nursing and Public Heath, University of KwaZulu-Natal, Durban, South Africa
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11
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Quinn CM, Poplin V, Kasibante J, Yuquimpo K, Gakuru J, Cresswell FV, Bahr NC. Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease. Life (Basel) 2020; 10:E262. [PMID: 33138069 PMCID: PMC7693460 DOI: 10.3390/life10110262] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Antiretroviral therapy (ART), while essential in combatting tuberculosis (TB) and HIV coinfection, is often complicated by the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Depending on the TB disease site and treatment status at ART initiation, this immune-mediated worsening of TB pathology can take the form of paradoxical TB-IRIS, unmasking TB-IRIS, or CNS TB-IRIS. Each form of TB-IRIS has unique implications for diagnosis and treatment. Recently published studies have emphasized the importance of neutrophils and T cell subtypes in TB-IRIS pathogenesis, alongside the recognized role of CD4 T cells and macrophages. Research has also refined our prognostic understanding, revealing how the disease can impact lung function. While corticosteroids remain the only trial-supported therapy for prevention and management of TB-IRIS, increasing interest has been given to biologic therapies directly targeting the immune pathology. TB-IRIS, especially its unmasking form, remains incompletely described and more data is needed to validate biomarkers for diagnosis. Management strategies remain suboptimal, especially in the highly morbid central nervous system (CNS) form of the disease, and further trials are necessary to refine treatment. In this review we will summarize the current understanding of the immunopathogenesis, the presentation of TB-IRIS and the evidence for management recommendations.
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Affiliation(s)
- Carson M. Quinn
- School of Medicine, University of California, San Francisco, CA 94143, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Victoria Poplin
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas, Kansas City, KS 66045, USA;
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Medical Research Council, Uganda Virus Research Unit, London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
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12
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Low mortality rates at two years in HIV-infected individuals undergoing systematic tuberculosis testing with rapid assays at initiation of antiretroviral treatment in Mozambique. Int J Infect Dis 2020; 99:386-392. [PMID: 32791208 DOI: 10.1016/j.ijid.2020.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/30/2020] [Accepted: 08/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Few studies have evaluated the mortality rate in individuals with HIV initiating antiretroviral therapy (ART), undergoing screening with combined or repeated rapid tests for tuberculosis (TB). METHODS All individuals with HIV starting ART, irrespective of the presence of TB-related symptoms, received two consecutive Xpert tests plus a rapid test for the detection of mycobacterial lipoarabinomannan in urine (LAM). Mortality was evaluated by Kaplan-Meier analysis using the log-rank test in univariate analyses and Cox regression models with time-dependent covariates in multivariate analyses. RESULTS Among 972 individuals screened with combined tests, 98 (10.1%) tested positive for TB with Xpert, LAM, or both. At the end of the study, 780 (80.2%) had completed 2 years of follow-up, 39 (4.0%) had died, and 153 (15.7%) were lost to follow-up. In the multivariate analyses, the factors significantly associated with mortality were missed ART (hazard ratio (HR) 7.05, 95% confidence interval (CI) 2.33-21.35), symptomatic HIV disease (WHO-HIV stage >1) (HR 3.31, 95% CI 1.28-8.54), and low CD4 count (<200/mm3) (HR 2.72, 95% CI 1.21-6.13), with no significant effect of TB status. In the subgroup of the 98 TB-positive individuals, only missed ART (HR 4.12, 95% CI 1.03-16.46) and missed anti-TB treatment (HR 9.25, 95% CI 2.65-32.28) were significantly associated with mortality. CONCLUSIONS A low mortality rate was observed among individuals with HIV undergoing systematic testing for TB at initiation of ART. After adjusting for confounders, mortality was significantly associated with missed ART, advanced disease, and missed anti-TB treatment. These findings reinforce the need to promote early diagnosis of HIV and the adoption of screening strategies for TB that prevent presentation with severe disease.
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13
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Blanc FX, Laureillard D, Goldfeld AE. Comment on: Effects of time of initiation of antiretroviral therapy in the treatment of patients with HIV/TB co-infection, by Chelkeba L. et al. Ann Med Surg (Lond) 2020; 57:22-23. [PMID: 32714522 PMCID: PMC7371596 DOI: 10.1016/j.amsu.2020.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/26/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- François-Xavier Blanc
- Department of Respiratory Medicine, L'Institut du Thorax, Nantes University Hospital, & Medical School, University of Nantes, Nantes, France
| | - Didier Laureillard
- Department of Infectious and Tropical Diseases, Nîmes University Hospital, Nîmes, France.,Pathogenesis and Control of Chronic Infections, INSERM, EFS, Montpellier University, Montpellier, France
| | - Anne E Goldfeld
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, MA, USA
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14
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Letang E, Ellis J, Naidoo K, Casas EC, Sánchez P, Hassan-Moosa R, Cresswell F, Miró JM, García-Basteiro AL. Tuberculosis-HIV Co-Infection: Progress and Challenges After Two Decades of Global Antiretroviral Treatment Roll-Out. Arch Bronconeumol 2020; 56:446-454. [PMID: 35373756 DOI: 10.1016/j.arbr.2019.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/02/2019] [Indexed: 06/14/2023]
Abstract
Despite wide antiretroviral scale-up during the past two decades resulting in declining new infections and mortality globally, HIV-associated tuberculosis remains as a major public health concern. Tuberculosis is the leading HIV-associated opportunistic infection and the main cause of death globally and, particularly, in resource-limited settings. Several challenges exist regarding diagnosis, global implementation of latent tuberculosis treatment, management of active tuberculosis, delivery of optimal patient-centered TB and HIV prevention and care in high burden countries. In this article we review the advances on pathogenesis, diagnosis, and treatment after nearly two decades of global roll-out of antiretroviral therapy and discuss the current challenges for the global control of tuberculosis-HIV co-infection.
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Affiliation(s)
- Emilio Letang
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Infectious Diseases Department, Hospital del Mar, Hospital del Mar Research Institute, Barcelona, Spain.
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Hospital for Tropical Diseases, University College London, London, UK
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, South Africa
| | - Esther C Casas
- Southern Africa Medical Unit, Médecins sans Frontières, Cape Town, South Africa
| | - Paquita Sánchez
- Infectious Diseases Department, Hospital del Mar, Hospital del Mar Research Institute, Barcelona, Spain
| | - Razia Hassan-Moosa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, South Africa
| | - Fiona Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK; MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jose M Miró
- Infectious Diseases Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alberto L García-Basteiro
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
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15
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Chelkeba L, Fekadu G, Tesfaye G, Belayneh F, Melaku T, Mekonnen Z. Effects of time of initiation of antiretroviral therapy in the treatment of patients with HIV/TB co-infection: A systemic review and meta-analysis. Ann Med Surg (Lond) 2020; 55:148-158. [PMID: 32477514 PMCID: PMC7251303 DOI: 10.1016/j.amsu.2020.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 01/08/2023] Open
Abstract
This systemic review and meta-analysis aimed to investigate the burden of tuberculosis immune reconstitution syndrome (TB-IRIS) and associated mortality to highlight the importance of future direction in preventing and treatment of TB-IRIS. Randomized clinical trials (RCTs) that compared early antiretroviral therapy (ART) versus late ART were included. PubMed, EMBASE, Science Direct and Cochrane Central Register of Controlled Trials electronic databases were searched. This meta-analysis included 8 RCTs with a total of 4, 425 participants. The result of analysis showed that early initiation of ART was associated with increase in TB-IRIS (RR = 1.83; 95% CI: 1.24-2.70, p = 0.002; I2 = 74%, p = 0.0007) and TB-IRIS associated mortality (RR = 6.05; 95% CI: 1.06-34.59, p = 0.04; I2 = 0%, p = 0.78). Early ART was associated with overall mortality compared with late ART initiation. Grade 3 or 4 adverse events, achieving lower viral load and development of new AIDS-defining illness were not associated with the time of ART initiation. Early ART in HIV/TB co-infected patients resulted conclusive evidence of increased TB-IRIS incidence and TB-IRIS associated mortality. Hence, the finding calls for clinical judgment as to the benefits of initiating ART earlier against the risk of TB-IRIS and associated mortality.
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Affiliation(s)
- Legese Chelkeba
- School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Ginenus Fekadu
- School of Pharmacy, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Gurmu Tesfaye
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Firehiwot Belayneh
- Department of Pharmacy, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Tsegaye Melaku
- School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Zeleke Mekonnen
- School of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
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16
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Naidoo K, Hassan-Moosa R, Mlotshwa P, Yende-Zuma N, Govender D, Padayatchi N, Abdool-Karim SSS. High Rates of Drug-induced Liver Injury in People Living With HIV Coinfected With Tuberculosis (TB) Irrespective of Antiretroviral Therapy Timing During Antituberculosis Treatment: Results From the Starting Antiretroviral Therapy at Three Points in TB Trial. Clin Infect Dis 2020; 70:2675-2682. [PMID: 31622456 PMCID: PMC7931836 DOI: 10.1093/cid/ciz732] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND New onset or worsening drug-induced liver injury challenges coinfected patients on antiretroviral therapy (ART) initiation during antituberculosis (TB) treatment. METHODS Post hoc analysis within a randomized trial, the Starting Antiretroviral Therapy at Three Points in Tuberculosis trial, was conducted. Patients were randomized to initiate ART either early or late during TB treatment or after TB treatment completion. Liver enzymes were measured at baseline, 6-month intervals, and when clinically indicated. RESULTS Among 642 patients enrolled, the median age was 34 years (standard deviation, 28-40), and 17.6% had baseline CD4+ cell counts <50 cells/mm3. Overall, 146/472 patients (52, 47, and 47: early, late, and sequential arms) developed new-onset liver injury following TB treatment initiation. The incidence of liver injury post-ART initiation in patients with CD4+ cell counts <200 cells/mm3 and ≥200 cells/ mm3 was 27.4 (95% confidence interval [CI], 18.0-39.8), 19.0 (95% CI, 10.9-30.9), and 18.4 (95% CI, 8.8-33.8) per 100 person-years, and 32.1 (95% CI, 20.1-48.5), 11.8 (95% CI, 4.3-25.7), and 28.2 (95% CI, 13.5-51.9) per 100 person-years in the early, late integrated, and sequential treatment arms, respectively. Severe and life-threatening liver injury occurred in 2, 7, and 3 early, late, and sequential treatment arm patients, respectively. Older age and hepatitis B positivity predicted liver injury. CONCLUSIONS High incidence rates of liver injury among cotreated human immunodeficiency virus (HIV)-TB coinfected patients were observed. Clinical guidelines and policies must provide guidance on frequency of liver function monitoring for HIV-TB coinfected patients.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa
- Medical Research Council, New York, New York-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | | | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa
- Medical Research Council, New York, New York-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa
- Medical Research Council, New York, New York-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Salim S S Abdool-Karim
- Centre for the AIDS Programme of Research in South Africa
- Medical Research Council, New York, New York-Centre for the AIDS Programme of Research in South Africa HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, New York
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17
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Meintjes G, Brust JCM, Nuttall J, Maartens G. Management of active tuberculosis in adults with HIV. Lancet HIV 2020; 6:e463-e474. [PMID: 31272663 DOI: 10.1016/s2352-3018(19)30154-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 12/11/2022]
Abstract
Every year, about 1 million people living with HIV worldwide develop tuberculosis. Although the drug regimens used to treat tuberculosis in these patients are the same as those used in HIV-negative patients, cotreatment of tuberculosis with antiretroviral therapy involves challenges including the optimal timing of antiretroviral initiation, drug-drug interactions, drug tolerability, and the prevention and treatment of tuberculosis-associated immune reconstitution syndrome. Furthermore, mortality is high in people with HIV who are diagnosed with tuberculosis during a hospital admission, and in those with tuberculous meningitis. Studies in this field have better characterised these challenges and informed optimal management and guideline revisions. In patients with tuberculosis, antiretroviral therapy improves survival, is well tolerated, and can be adjusted to manage drug-drug interactions with rifampicin. Prednisone is effective in both preventing and treating the paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Infectious Diseases and HIV Medicine, Department of Medicine, South Africa.
| | - James C M Brust
- University of Cape Town, Observatory, South Africa; Divisions of General Internal Medicine and Infectious Diseases, Albert Einstein College of Medicine, New York, NY, USA
| | - James Nuttall
- Department of Paediatrics and Child Health, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Clinical Pharmacology, Department of Medicine, South Africa
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18
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Bracchi M, van Halsema C, Post F, Awosusi F, Barbour A, Bradley S, Coyne K, Dixon-Williams E, Freedman A, Jelliman P, Khoo S, Leen C, Lipman M, Lucas S, Miller R, Seden K, Pozniak A. British HIV Association guidelines for the management of tuberculosis in adults living with HIV 2019. HIV Med 2020; 20 Suppl 6:s2-s83. [PMID: 31152481 DOI: 10.1111/hiv.12748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
| | - Clare van Halsema
- North Manchester General Hospital, Liverpool School of Tropical Medicine
| | - Frank Post
- King's College Hospital NHS Foundation Trust
| | | | | | | | | | | | | | - Pauline Jelliman
- Royal Liverpool and Broadgreen University Hospital Trust, NHIVNA
| | | | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London School of Hygiene and Tropical Medicine
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19
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Naidoo K, Rampersad S, Karim SA. Improving survival with tuberculosis & HIV treatment integration: A mini-review. Indian J Med Res 2020; 150:131-138. [PMID: 31670268 PMCID: PMC6829777 DOI: 10.4103/ijmr.ijmr_660_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Tuberculosis (TB) is a leading cause of morbidity and mortality among HIV-infected patients while HIV remains a key risk factor for the development of active TB infection. Treatment integration is a key in reducing mortality in patients with HIV-TB co-infection. However, this opportunity to improve outcomes of both infections is often missed or poorly implemented. Challenges in TB-HIV treatment integration range from complexities involving clinical management of co-infected patients to obstacles in health service-organization and prioritization. This is evident in high prevalence settings such as in sub-Saharan Africa where TB-HIV co-infection rates reach up to 80 per cent. This review discusses published literature on clinical trials and cohort studies of strategies for TB-HIV treatment integration aimed at reducing co-infection mortality. Studies published since 2009, when several treatment guidelines recommended treatment integration, were included. A total of 43 articles were identified, of which a total of 23 observational studies and nine clinical trials were informative on TB-HIV treatment integration. The data show that the survival benefit of AIDS therapy in patients infected with TB can be maximized among patients with advanced immunosuppression by starting antiretroviral therapy (ART) soon after TB treatment initiation, i.e. in patients with CD4+ cell counts <50 cells/μl. However, patients with greater CD4+ cell counts should defer initiation of ART to no less than eight weeks after initiation of TB treatment to reduce the occurrence and extent of immune reconstitution disease and subsequent hospitalization. Addressing operational challenges in integrating TB-HIV care can significantly improve patient outcomes, generate substantial public health impact by decreasing morbidity and death in settings with a high burden of HIV and TB.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA); MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Sanisha Rampersad
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Salim Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA); MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
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20
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Abstract
Mycobacterium tuberculosis is a major public health concern and requires prompt treatment. Goals of treatment include curing the individual patient and protecting the community from ongoing tuberculosis transmission. To achieve durable cure, regimens must include multiple agents given concurrently and in a manner to ensure completion of therapy. This article focuses on preferred regimens of drug-susceptible tuberculosis under current guidelines by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America and World Health Organization. In addition, topics including patient centered care, poor treatment outcomes, and adverse effects are also discussed.
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Affiliation(s)
- Beth Shoshana Zha
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0111, 513 Parnassus Avenue, San Francisco, CA 94117, USA
| | - Payam Nahid
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0841 MD, 1001 Potrero Avenue, 5J6, San Francisco, CA 94110, USA.
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21
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Abstract
Guidelines on the treatment of tuberculosis (TB) have essentially remained the same for the past 35 years, but are now starting to change. Ongoing clinical trials will hopefully transform the landscape for treatment of drug sensitive TB, drug resistant TB, and latent TB infection. Multiple trials are evaluating novel agents, repurposed agents, adjunctive host directed therapies, and novel treatment strategies that will increase the probability of success of future clinical trials. Guidelines for HIV-TB co-infection treatment continue to be updated and drug resistance testing has been revolutionized in recent years with the shift from phenotypic to genotypic testing and the concomitant increased speed of results. These coming changes are long overdue and are sorely needed to address the vast disparities in global TB incidence rates. TB is currently the leading cause of death globally from a single infectious agent, but the work of many researchers and the contributions of many patients in clinical trials will reduce the substantial global morbidity and mortality of the disease.
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Affiliation(s)
- Anthony Lee
- Medical Research Scholars Program, National Institutes of Health, Bethesda, MD, USA
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Yingda Linda Xie
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Division of Infectious Diseases, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Clifton E Barry
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Medicine, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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22
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Letang E, Ellis J, Naidoo K, Casas EC, Sánchez P, Hassan-Moosa R, Cresswell F, Miró JM, García-Basteiro AL. Tuberculosis-HIV Co-Infection: Progress and Challenges After Two Decades of Global Antiretroviral Treatment Roll-Out. Arch Bronconeumol 2020. [PMID: 31932150 DOI: 10.1016/j.arbres.2019.11.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite wide antiretroviral scale-up during the past two decades resulting in declining new infections and mortality globally, HIV-associated tuberculosis remains as a major public health concern. Tuberculosis is the leading HIV-associated opportunistic infection and the main cause of death globally and, particularly, in resource-limited settings. Several challenges exist regarding diagnosis, global implementation of latent tuberculosis treatment, management of active tuberculosis, delivery of optimal patient-centered TB and HIV prevention and care in high burden countries. In this article we review the advances on pathogenesis, diagnosis, and treatment after nearly two decades of global roll-out of antiretroviral therapy and discuss the current challenges for the global control of tuberculosis-HIV co-infection.
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Affiliation(s)
- Emilio Letang
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Infectious Diseases Department, Hospital del Mar, Hospital del Mar Research Institute, Barcelona, Spain.
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Hospital for Tropical Diseases, University College London, London, UK
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, South Africa
| | - Esther C Casas
- Southern Africa Medical Unit, Médecins sans Frontières, Cape Town, South Africa
| | - Paquita Sánchez
- Infectious Diseases Department, Hospital del Mar, Hospital del Mar Research Institute, Barcelona, Spain
| | - Razia Hassan-Moosa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa; MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, South Africa
| | - Fiona Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK; MRC-UVRI-London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jose M Miró
- Infectious Diseases Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alberto L García-Basteiro
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
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23
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Cerrone M, Bracchi M, Wasserman S, Pozniak A, Meintjes G, Cohen K, Wilkinson RJ. Safety implications of combined antiretroviral and anti-tuberculosis drugs. Expert Opin Drug Saf 2020; 19:23-41. [PMID: 31809218 PMCID: PMC6938542 DOI: 10.1080/14740338.2020.1694901] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/15/2019] [Indexed: 01/01/2023]
Abstract
Introduction: Antiretroviral and anti-tuberculosis (TB) drugs are often co-administered in people living with HIV (PLWH). Early initiation of antiretroviral therapy (ART) during TB treatment improves survival in patients with advanced HIV disease. However, safety concerns related to clinically significant changes in drug exposure resulting from drug-drug interactions, development of overlapping toxicities and specific challenges related to co-administration during pregnancy represent barriers to successful combined treatment for HIV and TB.Areas covered: Pharmacokinetic interactions of different classes of ART when combined with anti-TB drugs used for sensitive-, drug-resistant (DR) and latent TB are discussed. Overlapping drug toxicities, implications of immune reconstitution inflammatory syndrome (IRIS), safety in pregnancy and research gaps are also explored.Expert opinion: New antiretroviral and anti-tuberculosis drugs have been recently introduced and international guidelines updated. A number of effective molecules and clinical data are now available to build treatment regimens for PLWH with latent or active TB. Adopting a systematic approach that also takes into account the need for individualized variations based on the available evidence is the key to successfully integrate ART and TB treatment and improve treatment outcomes.
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Affiliation(s)
- Maddalena Cerrone
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- Francis Crick Institute, London, NW1 1AT, UK
| | - Margherita Bracchi
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Pozniak
- Department of HIV, Chelsea and Westminster Hospital NHS Trust, London, UK
- The London School of Hygiene & Tropical Medicine
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, W2 1PG, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory 7925, South Africa
- Francis Crick Institute, London, NW1 1AT, UK
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24
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Djimeu EW, Heard AC. Treatment of HIV among tuberculosis patients: A replication study of timing of antiretroviral therapy for HIV-1-associated tuberculosis. PLoS One 2019; 14:e0210327. [PMID: 30707696 PMCID: PMC6358155 DOI: 10.1371/journal.pone.0210327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/20/2018] [Indexed: 11/18/2022] Open
Abstract
Co-diagnosis of HIV and tuberculosis presents a treatment dilemma. Starting both treatments at the same time can cause a flood of immune response called immune reconstitution inflammatory syndrome (IRIS) which can be lethal. But, how long to delay HIV treatment is less understood. In 2011, based on the conclusions of three separate studies, WHO recommended starting HIV treatment earlier for those with later HIV disease progression. This paper conducts a replication study of one of the three studies, by Havlir and colleagues. Using their publicly available data, we were able to replicate most of the results presented in the original paper. In our measurement and estimation analyses we use different estimation techniques to assess the robustness of the results. We find that adjusting for loss to follow-up does not affect the main results of the paper. However, an ANCOVA estimation and an instrumental variable model weaken the main result of the paper of better outcomes with early HIV treatment only for those who are sicker, reducing significance from the 5% to the 10% level. A change-point analysis also detects no changes in effect by timing of HIV treatment initiation or different thresholds of CD4 count for the primary outcome. This result suggests that the choice of start time for HIV treatment initiation should be based on other factors including potential drug interactions, overlapping side effects, a high pill burden and severity of illness rather than CD4 threshold and preset timeframes. While we caution against overgeneralizing, the result of this replication is aligned with more recent studies that show no evidence that early initiation of HIV treatment reduces mortality for any patients.
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Affiliation(s)
- Eric W. Djimeu
- International Initiative for Impact Evaluation (3ie), Washington, DC, United States of America
- CEREG, University of Yaoundé II, Yaoundé, Cameroon
| | - Anna C. Heard
- International Initiative for Impact Evaluation (3ie), Washington, DC, United States of America
- * E-mail:
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25
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Abstract
Tuberculosis (TB) remains a common cause of infection and disease in much of the world. The majority of disease occurs from reactivation months or years after initial infection and most often involves the lungs. Sputum smears for acid-fast bacilli remain the initial diagnostic test but have limited sensitivity and specificity. Nucleic acid amplification tests are more sensitive and specific and can detect some mutations that cause drug resistance. Treatment of TB resistant to rifamycins alone or in combination with isoniazid and other drugs remains difficult and should be done in consultation with an expert in treating drug-resistant disease.
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26
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McIlleron H, Chirehwa MT. Current research toward optimizing dosing of first-line antituberculosis treatment. Expert Rev Anti Infect Ther 2018; 17:27-38. [PMID: 30501530 PMCID: PMC6364307 DOI: 10.1080/14787210.2019.1555031] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Drug concentrations in tuberculosis patients on standard regimens vary widely with clinically important consequences. Areas covered: We review the available literature identifying factors correlated with pharmacokinetic variability of antituberculosis drugs. Based on population pharmacokinetic models and the weight, height, and sex distributions in a large data base of African tuberculosis patients, we propose simplified weight-based doses of the available fixed dose combination(FDC) for adults with drug susceptible tuberculosis. Emerging studies will support optimized weight-based dosing for children. Other sources of important pharmacokinetic variability include genetic variants, drug-drug interactions, formulation quality, and methods of preparation and administration. Expert commentary: Optimized weight band-based dosing will result in more equitable distribution of drug exposures by weight. The use of high doses of isoniazid in patients with drug-resistant tuberculosis would be safer and more effective if a feasible test was developed to allow stratified dosing according to acetylator type. There is an urgent need for more suitable formulations of many second-line drugs for children. The adoption of new technologies and efficient FDC design may allow further advances for patients and treatment programs. Lastly, current efforts to ensure adequate quality of antituberculosis drug products are not preventing the use of substandard products to treat patients with tuberculosis.
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Affiliation(s)
- Helen McIlleron
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
| | - Maxwell T Chirehwa
- a Division of Clinical Pharmacology, Department of Medicine , University of Cape Town , Cape Town , South Africa
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27
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Romanowski K, Balshaw RF, Benedetti A, Campbell JR, Menzies D, Ahmad Khan F, Johnston JC. Predicting tuberculosis relapse in patients treated with the standard 6-month regimen: an individual patient data meta-analysis. Thorax 2018; 74:291-297. [PMID: 30420407 DOI: 10.1136/thoraxjnl-2017-211120] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 08/14/2018] [Accepted: 10/08/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Relapse continues to place significant burden on patients and tuberculosis (TB) programmes worldwide. We aimed to determine clinical and microbiological factors associated with relapse in patients treated with the WHO standard 6-month regimen and then evaluate the accuracy of each factor at predicting an outcome of relapse. METHODS A systematic review was performed to identify randomised controlled trials reporting treatment outcomes on patients receiving the standard regimen. Authors were contacted and invited to share patient-level data (IPD). A one-step IPD meta-analysis, using random intercept logistic regression models and receiver operating characteristic curves, was performed to evaluate the predictive performance of variables of interest. RESULTS Individual patient data were obtained from 3 of the 12 identified studies. Of the 1189 patients with confirmed pulmonary TB who completed therapy, 67 (5.6%) relapsed. In multipredictor analysis, the presence of baseline cavitary disease with positive smear at 2 months was associated with an increased odds of relapse (OR 2.3(95% CI 1.3 to 4.2)) and a relapse risk of 10%. When area under the curve for each multipredictor model was compared, discrimination between low-risk and higher-risk patients was modest and similar to that of the reference model which accounted for age, sex and HIV status. CONCLUSION Despite its poor predictive value, our results indicate that the combined presence of cavitary disease and 2-month positive smear status may be the best currently available marker for identifying individuals at an increased risk of relapse, particularly in resource-limited setting. Further investigation is required to assess whether this combined factor can be used to indicate different treatment requirements in clinical practice.
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Affiliation(s)
- Kamila Romanowski
- TB Services, British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Robert F Balshaw
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathon R Campbell
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Faiz Ahmad Khan
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - James C Johnston
- TB Services, British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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28
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Finocchio T, Coolidge W, Johnson T. The ART of Antiretroviral Therapy in Critically Ill Patients With HIV. J Intensive Care Med 2018; 34:897-909. [PMID: 30309292 DOI: 10.1177/0885066618803871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The management of patients with human immunodeficiency virus (HIV) can be a complicated specialty within itself, made even more complex when there are so many unanswered questions regarding the care of critically ill patients with HIV. The lack of consensus on the use of antiretroviral medications in the critically ill patient population has contributed to an ongoing clinical debate among intensivists. This review focuses on the pharmacological complications of antiretroviral therapy (ART) in the intensive care setting, specifically the initiation of ART in patients newly diagnosed with HIV, immune reconstitution inflammatory syndrome (IRIS), continuation of ART in those who were on a complete regimen prior to intensive care unit admission, barriers of drug delivery alternatives, and drug-drug interactions.
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Affiliation(s)
- Tyler Finocchio
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
| | - William Coolidge
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
| | - Thomas Johnson
- Avera McKennan Hospital & University Health Center, Sioux Falls, SD, USA
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29
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Worodria W, Ssempijja V, Hanrahan C, Ssegonja R, Muhofwa A, Mazapkwe D, Mayanja-Kizza H, Reynolds SJ, Colebunders R, Manabe YC. Opportunistic diseases diminish the clinical benefit of immediate antiretroviral therapy in HIV-tuberculosis co-infected adults with low CD4+ cell counts. AIDS 2018; 32:2141-2149. [PMID: 30005014 PMCID: PMC6136949 DOI: 10.1097/qad.0000000000001941] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION HIV-tuberculosis (TB) co-infection remains an important cause of mortality in sub-Saharan Africa. Clinical trials have reported early (within 2 weeks of TB therapy) antiretroviral therapy (ART) reduces mortality among HIV-TB co-infected research participants with low CD4 cell counts, but this has not been consistently observed. We aimed to evaluate the current WHO recommendations for ART in HIV-TB co-infected patients on mortality in routine clinical settings. METHODS We compared two cohorts before (2008-2010) and after (2012-2013) policy change on ART timing after TB and examined the effectiveness of early versus delayed ART on mortality in HIV-TB co-infected participants with CD4 cell count 100 cells/μl or less. We used inverse probability censoring-weighted Cox models on baseline characteristics to balance the study arms and generated hazard ratios for mortality. RESULTS Of 356 participants with CD4 cell counts 100 cells/μl or less, 180 were in the delayed ART cohorts whereas 176 were in the early ART cohorts. Their median age (32.5 versus 32 years) and baseline CD4 cell counts (26.5 versus 26 cells/μl) respectively were similar. There was no difference in mortality rates of both cohorts. The risk of death increased in participants with a positive Cryptococcal antigen (CrAg) test in both the early ART cohort (aHR = 2.6, 95% CI 1.0-6.8; P = 0.045) and the delayed ART cohort (aHR = 4.2, 95% CI 1.9-9.0; P < 0.001 CONCLUSION:: Early ART in patients with HIV-TB co-infection was not associated with reduced risk of mortality in routine care. Asymptomatic Cryptococcal antigenaemia increased the risk of mortality in both cohorts.
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Affiliation(s)
- William Worodria
- Infectious Disease Institute, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Victor Ssempijja
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc, NCI Campus at Frederick, Frederick
| | - Coleen Hanrahan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Richard Ssegonja
- Department of Public Health and Caring Services, Uppsala University, Uppsala, Sweden
| | | | | | - Harriet Mayanja-Kizza
- Infectious Disease Institute, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Steven J Reynolds
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Yukari C Manabe
- Infectious Disease Institute, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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30
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Naidoo K, Yende-Zuma N, Augustine S. A retrospective cohort study of body mass index and survival in HIV infected patients with and without TB co-infection. Infect Dis Poverty 2018; 7:35. [PMID: 29690932 PMCID: PMC5937835 DOI: 10.1186/s40249-018-0418-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 04/05/2018] [Indexed: 12/05/2022] Open
Abstract
Background High early morbidity and mortality following antiretroviral therapy (ART) initiation has been a distinguishing feature of ART programmes in resource limited settings (RLS) compared to high-income countries. This study assessed how well body mass index (BMI: kg/m2) correlated with survival among HIV infected patients with and without TB co-infection. Methods We retrospectively evaluated clinical data from 1000 HIV infected patients, among whom 389 were also co-infected with TB, between January 2008 and December 2010, in KwaZulu-Natal, South Africa. Results Among 948 patients eligible for analysis, 15.7% (149/948) were underweight (< 18.50), 55.9% (530/948) had normal BMI (≥18.50–24.90), 18.7% (177/948) were overweight (25.00–29.00) and 9.7% (92/948) were obese (≥30.00). Irrespective of TB status, underweight patients, had significantly higher risk of death compared to those with normal BMI at baseline (aHR = 2.9; 95% CI: 1.5–5.7; P = 0.002). Conclusions Irrespective of TB co-infection, low BMI correlated with mortality in HIV infected patients. Trial registration UKZN Biomedical Research Ethics Committee Reference number E 248/05, 23 September 2005. Electronic supplementary material The online version of this article (10.1186/s40249-018-0418-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, 2nd Floor Doris Duke Medical Research Institute, Private Bag X7, Durban, Congella, 4013, South Africa. .,MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, 2nd Floor Doris Duke Medical Research Institute, Private Bag X7, Durban, Congella, 4013, South Africa.,MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Stanton Augustine
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, 2nd Floor Doris Duke Medical Research Institute, Private Bag X7, Durban, Congella, 4013, South Africa
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31
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Ji YJ, Liang PP, Shen JY, Sun JJ, Yang JY, Chen J, Qi TK, Wang ZY, Song W, Tang Y, Liu L, Zhang RF, Shen YZ, Lu HZ. Risk factors affecting the mortality of HIV-infected patients with pulmonary tuberculosis in the cART era: a retrospective cohort study in China. Infect Dis Poverty 2018; 7:25. [PMID: 29587840 PMCID: PMC5870507 DOI: 10.1186/s40249-018-0405-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 03/12/2018] [Indexed: 01/10/2023] Open
Abstract
Background Tuberculosis infection still places a great burden on HIV-infected individuals in China and other developing countries. Knowledge of the survival of HIV-infected patients with pulmonary tuberculosis (PTB) would provide important insights for the clinical management of this population, which remains to be well described in current China. Methods HIV-infected patients with PTB admitted to Shanghai Public Health Clinical Center from January 2011 to December 2015 were retrospectively enrolled. In this cohort, the survival prognosis was estimated by the Kaplan-Meier method, while univariate and multivariate Cox proportional hazards models were used to determine the risk factors affecting mortality. Results After reviewing 4914 admitted patients with HIV infection, 359 PTB cases were identified. At the time of PTB diagnosis, the patients’ median CD4+ T cell count was 51 /mm3 (IQR: 23–116), and 27.30% of patients (98/359) were on combination antiretroviral therapy (cART). For the 333 cases included in the survival analysis, the overall mortality was 15.92% (53/333) during a median 27-month follow-up. The risk factors, including age older than 60 years (HR: 3.18; 95% CI: 1.66–6.10), complication with bacterial pneumonia (HR: 2.64; 95% CI: 1.30–5.35), diagnosis delay (HR: 2.60; 95% CI: 1.42–4.78), CD4+ T cell count less than 50/mm3 (HR: 2.38; 95% CI: 1.27–4.43) and pulmonary atelectasis (HR: 2.20; 95% CI: 1.05–4.60), might independently contribute to poor survival. Among patients without cART before anti-TB treatment, the later initiation of cART (more than 8 weeks after starting anti-TB treatment) was found to increase the mortality rate (OR: 4.33; 95% CI: 1.22–15.36), while the initiation of cART within 4–8 weeks after starting anti-TB treatment was associated with the fewest deaths (0/14). Conclusions The subjects in this study conducted in the cART era were still characterized by depressed immunological competence and low rates of cART administration, revealing possible intervention targets for preventing TB reactivation in HIV-infected individuals under current circumstances. Furthermore, our study indicated that the timely diagnosis of PTB, prevention of secondary bacterial pneumonia by prophylactic management and optimization of the timing of cART initiation could have significant impacts on decreasing mortality among HIV/PTB co-infected populations. These findings deserve further prospective investigations to optimize the management of HIV/PTB-co-infected patients. Trial registration NCT01344148, Registered September 14, 2010. Electronic supplementary material The online version of this article (10.1186/s40249-018-0405-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yong-Jia Ji
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Pei-Pei Liang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Jia-Yin Shen
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Jian-Jun Sun
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Jun-Yang Yang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Jun Chen
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Tang-Kai Qi
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Zhen-Yan Wang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Wei Song
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Yang Tang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Li Liu
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Ren-Fang Zhang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Yin-Zhong Shen
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China
| | - Hong-Zhou Lu
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, No. 2901 Cao Lang Rd, Jinshan District, Shanghai, 201508, China. .,Department of Infectious Disease, Huashan Hospital Affiliated to Fudan University, Shanghai, 200040, China. .,Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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Tagne Nouemssi AB. Disseminated tuberculous lymphadenitis presenting as cervical mass in patient with HIV infection, worsening after antiretroviral initiation: diagnosis and treatment challenges. BMJ Case Rep 2018; 2018:bcr-2017-221775. [PMID: 29545423 DOI: 10.1136/bcr-2017-221775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Tuberculosis (TB) continues to represent an important public health challenge in the world and the USA, especially given its association with HIV infection and population migration. Cervical tuberculous lymphadenitis represents the most common extrapulmonary presentation of TB in the USA. Considerations for other causes of neck mass often contribute to delay in diagnosis. In this report, we describe the case of a 41-year-old man who presented with painful swelling of the neck and was diagnosed with tuberculous lymphadenitis, complicated by HIV therapy-associated immune reconstitution syndrome. Prior to this diagnosis, he presented with a chronic intermittent cough, repeatedly treated as bronchitis. Furthermore, TB is a recognised occupational risk for primary care physician, as they are often the first contact for patients. With the Patient Protection and Affordable Care Act in the USA, the risk is likely to increase with the influx of newly insured often poor,and/or immigrants.
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Affiliation(s)
- Alain Bruno Tagne Nouemssi
- Family Medicine Residency Department, NYMC at Saint Joseph Medical Center, Yonkers, NY, United States of America
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Machuca I, Vidal E, de la Torre-Cisneros J, Rivero-Román A. Tuberculosis in immunosuppressed patients. Enferm Infecc Microbiol Clin 2017; 36:366-374. [PMID: 29223319 DOI: 10.1016/j.eimc.2017.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/12/2017] [Indexed: 12/21/2022]
Abstract
Tuberculosis (TB) is one of the most significant infections in immunosuppressed patients due to its high frequency and high morbidity and mortality. TB is the leading cause of death among HIV-infected patients. The diagnosis and early treatment of latent tuberculosis infection is vital to preventing it progression to disease. Similarly, the early diagnosis of TB is key to improving the prognosis of patients and preventing its transmission. The clinical expression of TB in immunosuppressed patients is conditioned by the patient's degree of immunosuppression. It is important to keep this peculiarity in mind so as not to delay the diagnosis of suspected TB. TB treatment is basically the same in immunosuppressed patients as in the general population and any differences mainly derive from pharmacological interactions. We examined the diagnosis and treatment of TB and latent tuberculosis infection in immunosuppressed patients.
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Affiliation(s)
- Isabel Machuca
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, España
| | - Elisa Vidal
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, España
| | | | - Antonio Rivero-Román
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, España.
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Abstract
PURPOSE OF REVIEW It is 20 years since the start of the combination antiretroviral therapy (cART) era and more than 10 years since cART scale-up began in resource-limited settings. We examined survival of vertically HIV-infected infants and children in the cART era. RECENT FINDINGS Good survival has been achieved on cART in all settings with up to 10-fold mortality reductions compared with before cART availability. Although mortality risk remains high in the first few months after cART initiation in young children with severe disease, it drops rapidly thereafter even for those who started with advanced disease, and longer term mortality risk is low. However, suboptimal retention on cART in routine programs threatens good survival outcomes and even on treatment children continue to experience high comorbidity risk; infections remain the major cause of death. Interventions to address infection risk include a cotrimoxazole prophylaxis, isoniazid preventive therapy, routine childhood and influenza immunization, and improving maternal survival. SUMMARY Pediatric survival has improved substantially with cART and HIV-infected children are aging into adulthood. It is important to ensure access to diagnosis and early cART, good program retention as well as optimal comorbidity prophylaxis and treatment to achieve the best possible long-term survival and health outcomes for vertically infected children.
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Abstract
Tuberculosis (TB) has recently surpassed HIV as the primary infectious disease killer worldwide, but the two diseases continue to display lethal synergy. The burden of TB is disproportionately borne by people living with HIV, particularly where HIV and poverty coexist. The impact of these diseases on one another is bidirectional, with HIV increasing risk of TB infection and disease progression and TB slowing CD4 recovery and increasing progression to AIDS and death among the HIV infected. Both antiretroviral therapy (ART) and latent TB infection (LTBI) treatment mitigate the impact of coinfection, and ART is now recommended for HIV-infected patients independent of CD4 count. LTBI screening should be performed for all HIV-positive people at the time of diagnosis, when their CD4 count rises above 200, and yearly if there is repeated exposure. Tuberculin skin tests (TSTs) may perform better with serial testing than interferon gamma release assays (IGRAs). Any patient with HIV and a TST induration of ≥5 mm should be evaluated for active TB disease and treated for LTBI if active disease is ruled out. Because HIV impairs multiple aspects of immune function, progressive HIV is associated with lower rates of cavitary pulmonary TB and higher rates of disseminated and extrapulmonary disease, so a high index of suspicion is important, and sputum should be obtained for evaluation even if chest radiographs are negative. TB diagnosis is similar in patients with and without TB, relying on smear, culture, and nucleic acid amplification tests, which are the initial tests of choice. TSTs and IGRAs should not be used in the evaluation of active TB disease since these tests are often negative with active disease. Though not always performed in resource-limited settings, drug susceptibility testing should be performed on all TB isolates from HIV-positive patients. Urine lipoarabinomannan testing may also be helpful in HIV-positive patients with disseminated disease. Treatment of TB in HIV-infected patients is similar to that of TB in HIV-negative patients except that daily therapy is required for all coinfected patients, vitamin B6 supplementation should be given to all coinfected patients receiving isoniazid to reduce peripheral neuropathy, and specific attention needs to be paid to drug-drug interactions between rifamycins and many classes of antiretrovirals. In patients requiring ART that contains ritonavir or cobicistat, this can be managed by the use of rifabutin at 150 mg daily in place of rifampin. For newly diagnosed coinfected patients, mortality is lower if treatment is provided in parallel, rather than serially, with treatment initiation within 2 weeks preferred for those with CD4 counts of <50 and within 8 to 12 weeks for those with higher CD4 counts. When TB immune reconstitution inflammatory syndrome occurs, patients can often be treated symptomatically with nonsteroidal anti-inflammatory drugs, but a minority will benefit from steroids. Generally, patients who do not have space-occupying lesions such as occurs in TB meningitis do not require cessation of therapy.
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Tiberi S, Carvalho ACC, Sulis G, Vaghela D, Rendon A, Mello FCDQ, Rahman A, Matin N, Zumla A, Pontali E. The cursed duet today: Tuberculosis and HIV-coinfection. Presse Med 2017; 46:e23-e39. [PMID: 28256380 DOI: 10.1016/j.lpm.2017.01.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/23/2016] [Accepted: 01/17/2017] [Indexed: 01/22/2023] Open
Abstract
The tuberculosis (TB) and HIV syndemic continues to rage and are a major public health concern worldwide. This deadly association raises complexity and represent a significant barrier towards TB elimination. TB continues to be the leading cause of death amongst HIV-infected people. This paper reports the challenges that lay ahead and outlines some of the current and future strategies that may be able to address this co-epidemic efficiently. Improved diagnostics, cheaper and more effective drugs, shorter treatment regimens for both drug-sensitive and drug-resistant TB are discussed. Also, special topics on drug interactions, TB-IRIS and TB relapse are also described. Notwithstanding the defeats and meagre investments, diagnosis and management of the two diseases have seen significant and unexpected improvements of late. On the HIV side, expansion of ART coverage, development of new updated guidelines aimed at the universal treatment of those infected, and the increasing availability of newer, more efficacious and less toxic drugs are an essential element to controlling the two epidemics. On the TB side, diagnosis of MDR-TB is becoming easier and faster thanks to the new PCR-based technologies, new anti-TB drugs active against both sensitive and resistant strains (i.e. bedaquiline and delamanid) have been developed and a few more are in the pipeline, new regimens (cheaper, shorter and/or more effective) have been introduced (such as the "Bangladesh regimen") or are being tested for MDR-TB and drug-sensitive-TB. However, still more resources will be required to implement an integrated approach, install new diagnostic tests, and develop simpler and shorter treatment regimens.
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Affiliation(s)
- Simon Tiberi
- Barts health NHS trust, Royal London hospital, division of infection, 80, Newark street, E1 2ES London, United Kingdom.
| | - Anna Cristina C Carvalho
- Oswaldo Cruz institute (IOC), laboratory of innovations in therapies, education and bioproducts, (LITEB), Fiocruz, Rio de Janeiro, Brazil.
| | - Giorgia Sulis
- University of Brescia, university department of infectious and tropical diseases, World health organization collaborating centre for TB/HIV co-infection and TB elimination, Brescia, Italy.
| | - Devan Vaghela
- Barts Health NHS Trust, Royal London hospital, department of respiratory medicine, 80, Newark street, E1 2ES London, United Kingdom.
| | - Adrian Rendon
- Hospital universitario de Monterrey, centro de investigación, prevención y tratamiento de infecciones respiratorias, Monterrey, Nuevo León UANL, Mexico.
| | - Fernanda C de Q Mello
- Federal university of Rio de Janeiro, instituto de Doenças do Tórax (IDT)/Clementino Fraga Filho hospital (CFFH), rua Professor Rodolpho Paulo Rocco, n° 255 - 1° Andar - Cidade Universitária - Ilha do Fundão, 21941-913, Rio De Janeiro, Brazil.
| | - Ananna Rahman
- Papworth hospital NHS foundation trust, department of respiratory medicine, Papworth Everard, Cambridge, United Kingdom.
| | - Nashaba Matin
- Barts Health NHS Trust, Royal London hospital, HIV medicine, infection and immunity, London, United Kingdom.
| | - Ali Zumla
- UCL hospitals NHS Foundation Trust, university college London, NIHR biomedical research centre, division of infection and immunity, London, United Kingdom.
| | - Emanuele Pontali
- Galliera hospital, department of infectious diseases, Genoa, Italy.
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Johnston JC, Campbell JR, Menzies D. Effect of Intermittency on Treatment Outcomes in Pulmonary Tuberculosis: An Updated Systematic Review and Metaanalysis. Clin Infect Dis 2017; 64:1211-1220. [DOI: 10.1093/cid/cix121] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/06/2017] [Indexed: 11/14/2022] Open
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Tuberculosis associated mortality in a prospective cohort in Sub Saharan Africa: Association with HIV and antiretroviral therapy. Int J Infect Dis 2017; 56:39-44. [PMID: 28161460 DOI: 10.1016/j.ijid.2017.01.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/19/2017] [Accepted: 01/22/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Nine out of ten tuberculosis deaths occur in tuberculosis-burdened countries, particularly Sub Saharan Africa. In these setting mortality has not been fully described. We describe the magnitude and pattern of TB mortality in Tanzania. METHODS A multicenter prospective cohort study was conducted among HIV infected and uninfected pulmonary tuberculosis patients from time of anti-TB treatment initiation to completion. Patients were censored at the time of treatment completion, or at their last visit for those who did not complete TB treatment. Kaplan-Meier curves were used to estimate time to death; cox proportional hazards model was used to examine risk factors for mortality. RESULTS A total of 58 deaths out of 1696 patients (3.4%) occurred, two thirds (n=39) during the first two months of treatment. Compared to HIV un-infected TB patients, mortality risk for TB/HIV co-infected patients was least when antiretroviral therapy (ART) was initiated after 14 days of anti-TB (RR=3.55; 95% CI: 1.44, 8.73 p<0.0001) and highest when ART was initiated 90 days or less prior to anti-TB and within the first 14 days of anti-TB therapy (RR=10; 95% CI: 3.28, 30.54; p<0.0001). CONCLUSION Meticulously planned and supervised antiretroviral therapy reduces mortality among TB/HIV patients. Among patients with TB/HIV naïve of ART, withholding ART until the third week of anti-tuberculosis therapy will likely reduce TB mortality in Tanzania. Patients on ART and later develop tuberculosis should be closely monitored.
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39
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Ndounga Diakou LA, Ntoumi F, Ravaud P, Boutron I. Published randomized trials performed in Sub-Saharan Africa focus on high-burden diseases but are frequently funded and led by high-income countries. J Clin Epidemiol 2017; 82:29-36.e6. [DOI: 10.1016/j.jclinepi.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/10/2016] [Accepted: 10/26/2016] [Indexed: 01/05/2023]
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40
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Wong CS, Richards ES, Pei L, Sereti I. Immune reconstitution inflammatory syndrome in HIV infection: taking the bad with the good. Oral Dis 2016; 23:822-827. [PMID: 27801977 DOI: 10.1111/odi.12606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 12/27/2022]
Abstract
In this review, we will describe the immunopathogies of immune reconstitution inflammatory syndrome, IRIS. IRIS occurs in a small subset of HIV patient, initiating combination antiretroviral therapy (ART), where immune reconstitution becomes dysregulated, resulting in an overly robust antigen-specific inflammatory reaction. We will discuss IRIS in terms of the associated coinfections: mycobacteria, cryptococci, and viruses.
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Affiliation(s)
- C-S Wong
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
| | - E S Richards
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
| | - L Pei
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
| | - I Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
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41
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Egelund EF, Dupree L, Huesgen E, Peloquin CA. The pharmacological challenges of treating tuberculosis and HIV coinfections. Expert Rev Clin Pharmacol 2016; 10:213-223. [PMID: 27828731 DOI: 10.1080/17512433.2017.1259066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Tuberculosis (TB) is the most prevalent opportunistic infection among HIV patients, and the leading cause of death among HIV patients worldwide. Simultaneous treatment of both diseases is recommended by current guidelines, but can be challenging due to the potential for drug-drug interactions, overlapping toxicities, difficulty adhering to medications, and an increased risk for immune reconstitution inflammatory syndrome (IRIS). Clinical manifestations of TB can also vary between HIV-infected patients and uninfected patients, which can increase the risk for delayed diagnosis. Areas covered: Topics covered in this review include the following: the inter-related pathophysiology of HIV and TB; clinical manifestations and diagnosis; drug-drug interactions, particularly the rifamycins with the antiretrovirals; IRIS presentation and treatment, as well as a discussion on overlapping toxicity between the two disease states. Expert commentary: The complexity of managing these two disease states simultaneously requires a multidisciplinary approach to care and dedicated resources. If properly funded, TB/HIV co-infection will continue to decline over the coming years.
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Affiliation(s)
- Eric F Egelund
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory
| | - Lori Dupree
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Emily Huesgen
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy
| | - Charles A Peloquin
- a Department of Pharmacotherapy and Translational Research , College of Pharmacy.,b Infectious Disease Pharmacokinetics Laboratory.,c Emerging Pathogens Institute , University of Florida , Gainesville , FL , USA
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Abstract
Tuberculosis (TB) is an airborne infectious disease caused by organisms of the Mycobacterium tuberculosis complex. Although primarily a pulmonary pathogen, M. tuberculosis can cause disease in almost any part of the body. Infection with M. tuberculosis can evolve from containment in the host, in which the bacteria are isolated within granulomas (latent TB infection), to a contagious state, in which the patient will show symptoms that can include cough, fever, night sweats and weight loss. Only active pulmonary TB is contagious. In many low-income and middle-income countries, TB continues to be a major cause of morbidity and mortality, and drug-resistant TB is a major concern in many settings. Although several new TB diagnostics have been developed, including rapid molecular tests, there is a need for simpler point-of-care tests. Treatment usually requires a prolonged course of multiple antimicrobials, stimulating efforts to develop shorter drug regimens. Although the Bacillus Calmette-Guérin (BCG) vaccine is used worldwide, mainly to prevent life-threatening TB in infants and young children, it has been ineffective in controlling the global TB epidemic. Thus, efforts are underway to develop newer vaccines with improved efficacy. New tools as well as improved programme implementation and financing are necessary to end the global TB epidemic by 2035.
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Mutembo S, Mutanga JN, Musokotwane K, Alisheke L, Whalen CC. Antiretroviral therapy improves survival among TB-HIV co-infected patients who have CD4+ T-cell count above 350cells/mm 3. BMC Infect Dis 2016; 16:572. [PMID: 27751168 PMCID: PMC5067898 DOI: 10.1186/s12879-016-1916-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 10/11/2016] [Indexed: 12/11/2022] Open
Abstract
Background Co-infection with Mycobacterium tuberculosis remains a leading cause of morbidity and mortality among HIV infected individuals especially in developing countries. Early initiation of cART in these patients when CD4+ T cell count is less than 200cells/mm3 has reduced disease progression and mortality. However for patients with higher CD4+ T cell counts greater than 350cells/mm3 evidence is conflicting. In this study we seek to evaluate the effectiveness of cART in reducing mortality among TB-HIV co-infected patients with CD4 + T cells above 350cells/mm3 at the time of TB diagnosis. Method In a retrospective cohort study we analyzed 337 HIV-TB co-infected patients with CD4+ T cells above 350cells/mm3 at baseline who were diagnosed between 2006 and 2012 in the southern province of Zambia. The primary outcome was all-cause mortality. We estimated the effect of cART by comparing survival according to cART and controlling for differential loss to follow-up. Results Of the 257 patients on cART, 22 died (9 %) and 20 (8 %) were lost to follow-up; of 80 patients not on cART, 20 died (25 %) and 19 (24 %) were lost to follow-up. Patients treated with cART had better survival compared to those not treated (P < 0 · 0001, log-rank test). In a proportional hazard regression adjusting for Cotrimoxazole, the risk of death was reduced by 78 % with cART (95 % CI: 0 · 47, 0 · 91). In a propensity score analysis, the effect of cART was still beneficial. Conclusion In patients with HIV-associated TB and CD4+ T cells above 350cells/mm3, treatment with cART reduced mortality for up to 4 years as compared to no cART and was associated with better retention in care. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1916-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Simon Mutembo
- Ministry of Health, Southern Provincial Medical Office, Choma, Zambia.
| | - Jane N Mutanga
- Ministry of Health, Southern Provincial Medical Office, Choma, Zambia
| | - Kebby Musokotwane
- Ministry of Health, Southern Provincial Medical Office, Choma, Zambia
| | - Lutangu Alisheke
- Ministry of Health, Southern Provincial Medical Office, Choma, Zambia
| | - Christopher C Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Health Sciences Campus, 101 Buck Road, Athens, Georgia, 30602, USA
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Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147-e195. [PMID: 27516382 PMCID: PMC6590850 DOI: 10.1093/cid/ciw376] [Citation(s) in RCA: 655] [Impact Index Per Article: 81.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Julie M. Higashi
- Tuberculosis Control Section, San Francisco Department
of Public Health, California
| | - Christine S. Ho
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Masahiro Narita
- Tuberculosis Control Program, Seattle and King County Public Health, and
University of Washington, Seattle
| | - Rick O'Brien
- Ethics Advisory Group, International Union Against TB
and Lung Disease, Paris,
France
| | | | | | | | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Stellenbosch University, Cape
Town, South Africa
| | | | | | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri Care and
Research Institute, Tradate, Italy
| | - Andrew Vernon
- Division of Tuberculosis Elimination, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and
Prevention, Atlanta, Georgia
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45
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Günthard HF, Saag MS, Benson CA, del Rio C, Eron JJ, Gallant JE, Hoy JF, Mugavero MJ, Sax PE, Thompson MA, Gandhi RT, Landovitz RJ, Smith DM, Jacobsen DM, Volberding PA. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel. JAMA 2016; 316:191-210. [PMID: 27404187 PMCID: PMC5012643 DOI: 10.1001/jama.2016.8900] [Citation(s) in RCA: 477] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE New data and therapeutic options warrant updated recommendations for the use of antiretroviral drugs (ARVs) to treat or to prevent HIV infection in adults. OBJECTIVE To provide updated recommendations for the use of antiretroviral therapy in adults (aged ≥18 years) with established HIV infection, including when to start treatment, initial regimens, and changing regimens, along with recommendations for using ARVs for preventing HIV among those at risk, including preexposure and postexposure prophylaxis. EVIDENCE REVIEW A panel of experts in HIV research and patient care convened by the International Antiviral Society-USA reviewed data published in peer-reviewed journals, presented by regulatory agencies, or presented as conference abstracts at peer-reviewed scientific conferences since the 2014 report, for new data or evidence that would change previous recommendations or their ratings. Comprehensive literature searches were conducted in the PubMed and EMBASE databases through April 2016. Recommendations were by consensus, and each recommendation was rated by strength and quality of the evidence. FINDINGS Newer data support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count. Recommended optimal initial regimens for most patients are 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs. Recommendations for special populations and in the settings of opportunistic infections and concomitant conditions are provided. Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities. Laboratory assessments are recommended before treatment, and monitoring during treatment is recommended to assess response, adverse effects, and adherence. Approaches are recommended to improve linkage to and retention in care are provided. Daily tenofovir disoproxil fumarate/emtricitabine is recommended for use as preexposure prophylaxis to prevent HIV infection in persons at high risk. When indicated, postexposure prophylaxis should be started as soon as possible after exposure. CONCLUSIONS AND RELEVANCE Antiretroviral agents remain the cornerstone of HIV treatment and prevention. All HIV-infected individuals with detectable plasma virus should receive treatment with recommended initial regimens consisting of an InSTI plus 2 NRTIs. Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals. When used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. With these treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults.
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Affiliation(s)
- Huldrych F Günthard
- University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | | | | | - Carlos del Rio
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Joseph J Eron
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | | | - Jennifer F Hoy
- Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Paul E Sax
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston
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46
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Zhang G, Gong Y, Wang Q, Deng L, Zhang S, Liao Q, Yu G, Wang K, Wang J, Ye S, Liu Z. Outcomes and factors associated with survival of patients with HIV/AIDS initiating antiretroviral treatment in Liangshan Prefecture, southwest of China: A retrospective cohort study from 2005 to 2013. Medicine (Baltimore) 2016; 95:e3969. [PMID: 27399071 PMCID: PMC5058800 DOI: 10.1097/md.0000000000003969] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/22/2016] [Accepted: 05/25/2016] [Indexed: 11/27/2022] Open
Abstract
Human immunodeficiency virus (HIV)-positive cases have been reported among people who injected drugs in Liangshan Prefecture in southwest of China since 1995 and Liangshan has become one of the most seriously affected epidemic areas in China. In 2004, several patients with HIV/acquired immunodeficiency syndrome (AIDS) initiated antiretroviral treatment (ART) at the Central Hospital of Liangshan Prefecture. From 2005 to 2013, the number of patients receiving ART dramatically increased.We conducted a retrospective cohort study to analyze the long-term survival time and associated factors among patients with HIV/AIDS who received ART in Liangshan Prefecture for the first time. Data were collected from the Chinese AIDS Antiretroviral Therapy DATAFax Information System. A life table and the Kaplan-Meier and Cox proportion hazard regression were used to calculate the survival time and its associated factors, respectively.Among 8310 ART-naïve patients with HIV/AIDS who initiated ART, 436 patients died of AIDS-related diseases, and their median time of receiving ART was 15.0 ± 12.3 months, whereas 28.7% of them died within the first 6 months after treatment. The cumulative survival rates of those receiving ART in 1, 2, 3, 4, and 5 years were 97.1%, 93.4%, 90.6%, 88.8%, and 86.0%, respectively. Multivariate Cox regression analysis showed that male patients on ART were at a higher risk of death from AIDS-related diseases (adjusted hazard ratio [AHR] = 1.5, 95% confidence interval [CI]: 1.1-2.1) than female patients. Patients infected with HIV through injection drug use (IDU) were at a higher risk of death (AHR = 1.6, 95% CI: 1.2-2.2) than those infected through heterosexual transmission. Patients with a baseline CD4 cell count <50/mm (AHR = 9.8, 95% CI: 6.0-15.9), 50-199/mm (AHR = 3.3, 95% CI: 2.3-4.6), and 200-349/mm (AHR = 1.7, 95% CI: 1.2-2.3) were at a higher risk of death than those with a CD4 cell count ≥350/mm.ART prolonged survival time of patients with HIV/AIDS and improved their survival probability. Patients with HIV/AIDS should be consistently followed up and the CD4 T-cell count regularly monitored, and timely and early antiretroviral therapy initiated in order to achieve a better survival rate.
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Affiliation(s)
- Guang Zhang
- National Center for AIDS/STD Control and Prevention, China CDC, Beijing
| | - Yuhan Gong
- Liangshan Prefecture Center for Disease Control and Prevention, Xichang
| | - Qixing Wang
- Liangshan Prefecture Center for Disease Control and Prevention, Xichang
| | - Ling Deng
- Fengtai District Center for Disease Control and Prevention, Beijing, China
| | - Shize Zhang
- Liangshan Prefecture Center for Disease Control and Prevention, Xichang
| | - Qiang Liao
- Liangshan Prefecture Center for Disease Control and Prevention, Xichang
| | - Gang Yu
- Liangshan Prefecture Center for Disease Control and Prevention, Xichang
| | - Ke Wang
- Liangshan Prefecture Center for Disease Control and Prevention, Xichang
| | - Ju Wang
- Liangshan Prefecture Center for Disease Control and Prevention, Xichang
| | - Shaodong Ye
- National Center for AIDS/STD Control and Prevention, China CDC, Beijing
| | - Zhongfu Liu
- National Center for AIDS/STD Control and Prevention, China CDC, Beijing
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47
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Sánchez-González G. The cost-effectiveness of treating triple coinfection with HIV, tuberculosis and hepatitis C virus. HIV Med 2016; 17:674-82. [PMID: 27279355 DOI: 10.1111/hiv.12372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective of this study was to estimate the cost-effectiveness of treating patients infected with HIV and simultaneously coinfected with tuberculosis (TB) and hepatitis C virus (HCV). METHODS A mathematical model for HIV coinfection with TB and HCV is introduced. The model was designed to incorporate parameters of control for the coverage of care, which makes it useful for performing cost-effectiveness analysis of public policies. A cost-effectiveness analysis of early medical care of patients with TB and HCV coinfection, with coverage of 0 (basal), 25, 50, 75 and 100%, was performed for the whole cohort of patients and a special analysis was performed in a selected population with triple infection. RESULTS The cost per resolved infection and the cost per year of life gained were found to be very cost-effective for the population with triple infection, for all different coverages. CONCLUSIONS It is known that treating patients with HIV who are coinfected with TB or HCV implies high cost and low efficacy, but it is possible that the population with triple infections could achieve important benefits in terms of years of life gained.
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Affiliation(s)
- G Sánchez-González
- Immunology Division, National Institute of Public Health, Cuernavaca, Mexico
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48
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Manosuthi W, Wiboonchutikul S, Sungkanuparph S. Integrated therapy for HIV and tuberculosis. AIDS Res Ther 2016; 13:22. [PMID: 27182275 PMCID: PMC4866405 DOI: 10.1186/s12981-016-0106-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/02/2016] [Indexed: 01/11/2023] Open
Abstract
Tuberculosis (TB) has been the most common opportunistic infection and cause of mortality among HIV-infected patients, especially in resource-limited countries. Clinical manifestations of TB vary and depend on the degree of immunodeficiency. Sputum microscopy and culture with drug-susceptibility testing are recommended as a standard method for diagnosing active TB. TB-related mortality in HIV-infected patients is high especially during the first few months of treatment. Integrated therapy of both HIV and TB is feasible and efficient to control the diseases and yield better survival. Randomized clinical trials have shown that early initiation of antiretroviral therapy (ART) improves survival of HIV-infected patients with TB. A delay in initiating ART is common among patients referred from TB to HIV separate clinics and this delay may be associated with increased mortality risk. Integration of care for both HIV and TB using a single facility and a single healthcare provider to deliver care for both diseases is a successful model. For TB treatment, HIV-infected patients should receive at least the same regimens and duration of TB treatment as HIV-uninfected patients. Currently, a 2-month initial intensive phase of isoniazid, rifampin, pyrazinamide, and ethambutol, followed by 4 months of continuation phase of isoniazid and rifampin is considered as the standard treatment of drug-susceptible TB. ART should be initiated in all HIV-infected patients with TB, irrespective of CD4 cell count. The optimal timing to initiate ART is within the first 8 weeks of starting antituberculous treatment and within the first 2 weeks for patients who have CD4 cell counts <50 cells/mm(3). Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART remains a first-line regimen for HIV-infected patients with TB in resource-limited settings. Although a standard dose of both efavirenz and nevirapine can be used, efavirenz is preferred because of more favorable treatment outcomes. In the settings where raltegravir is accessible, doubling the dose to 800 mg twice daily is recommended. Adverse reactions to either antituberculous or antiretroviral drugs, as well as immune reconstitution inflammatory syndrome, are common in patients receiving integrated therapy. Early recognition and appropriate management of these consequences can reinforce the successful integrated therapy in HIV-infected patients with TB.
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Affiliation(s)
- Weerawat Manosuthi
- />Department of Disease Control, Ministry of Public Health, Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand
| | - Surasak Wiboonchutikul
- />Department of Disease Control, Ministry of Public Health, Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand
| | - Somnuek Sungkanuparph
- />Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Road, Bangkok, 10400 Thailand
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49
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Pollett S, Banner P, O’Sullivan MVN, Ralph AP. Epidemiology, Diagnosis and Management of Extra-Pulmonary Tuberculosis in a Low-Prevalence Country: A Four Year Retrospective Study in an Australian Tertiary Infectious Diseases Unit. PLoS One 2016; 11:e0149372. [PMID: 26963244 PMCID: PMC4786131 DOI: 10.1371/journal.pone.0149372] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Extra-pulmonary tuberculosis (EPTB) is relatively neglected and increasing in incidence, in comparison to pulmonary tuberculosis (PTB) in low-burden settings. It poses particular diagnostic and management challenges. We aimed to determine the characteristics of EPTB in Western Sydney, Australia, and to conduct a quality assurance investigation of adherence to guidelines among Infectious Diseases (ID) practitioners managing EPTB cases. METHODS All adult EPTB cases managed by a large ID service during 01/01/2008-31/12/2011 were eligible for inclusion in the retrospective review. Data were extracted from patient medical records on demographic, diagnostic, clinical and management details, and on clinician adherence to local and international TB guidelines. RESULTS 129 cases managed by the ID service were identified, with files available for 117. 98 cases were managed by the Respiratory service and were excluded. 98.2%(112/114) had been born in a country other than Australia. HIV status was tested or previously known in 97 people, and positive in 4 (4%). Microbiological confirmation was obtained in 68/117 (58.1%), an additional 24 had histopathological findings considered confirmatory (92/117, 78.6%), with the remainder diagnosed on clinical and/or radiological grounds. Median time to diagnosis post-migration from a high TB-burden country was 5 years (range 0-41). 95 cases were successfully treated, 11 cases defaulted, refused therapy or transferred, 2 cases relapsed and outcomes unknown or pending in 9 cases. No deaths occurred in the sample analysed. Clinician adherence to guidelines was high, but with scope for improvement in offering testing for co-infections, performing eye checks, monitoring blood glucose in patients receiving adjunctive corticosteroids, and considering drug interactions. CONCLUSIONS Despite excellent TB outcomes in this setting, the low proportion of cases with susceptibility data is worrying in this era of increasing drug resistance, and illustrates the diagnostic difficulties faced even in a well-resourced setting. Vigilance for EPTB needs to remain high in those moving from high prevalence countries to Australia, even decades after immigration.
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Affiliation(s)
- Simon Pollett
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | | | - Matthew V. N. O’Sullivan
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
- Centre for Infectious Diseases and Microbiology, Westmead, Sydney, NSW, Australia
| | - Anna P. Ralph
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Department of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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50
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Zimina VN, Kravchenko AV. [Impact of etiotropic therapy on the immune status of patients with HIV infection and tuberculosis]. TERAPEVT ARKH 2016; 87:37-41. [PMID: 26821414 DOI: 10.17116/terarkh2015871137-41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To evaluate the impact of etiotropic therapy on the immunological efficiency of treatment in patients with HIV infection in relation to the presence of active tuberculosis (TB) and the baseline count of CD4+ lymphocytes. SUBJECTS AND METHODS A total of 239 HIV-infected patients were examined and divided into 3 groups: 1) 103 HIV-infected patients with TB who received both anti-TB therapy (ATBT) and antiretroviral therapy (ART); 2) 46 HIV-infected patients with TB who did not receive ART during TB treatment; 3) 90 HIV-infected patients without TB who used ART for the first time. CD4+ lymphocyte counts were measured by flow cytofluorometry in all the patients before and 4 and 12 weeks after treatment. RESULTS Analysis of an increment in CD4+ lymphocyte counts in the HIV-infected patients with tuberculosis showed that those who had very low baseline CD4+ lymphocyte counts (median, 78 cells/μl) were noted to have significant positive changes (median, +146 cells/μl) at 12 weeks of ART. Even without ART, effective ATBT in the patients with a well preserved immune system (> 350 CD4+ cells/μl) in turn resulted in a substantial increase in CD4+ lymphocyte counts (median, +187 cells/μl following 12-week ATBT). At the same time, 10.9% of the patients showed a decrease in the baseline CD4+ lymphocyte counts during progression or delay in the tuberculosis process, which required that ART should be promptly performed. CONCLUSION The investigation of the time course of changes in the increment of CD4+ lymphocyte counts revealed a swifter response to ART as their rapid increment in patients with coinfection (HIV infection concurrent with TB) than that in those with HIV monoinfection. When the baseline CD4+ lymphocyte counts are over 350 cells/μl, the start of ART should be delayed until TB treatment is completed.
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Affiliation(s)
- V N Zimina
- Peoples' Friendship University of Russia, Moscow, Russia; Central Research Institute of Epidemiology, Russian Federal Service for Supervision of Consumer Rights Protection and Human Welfare, Moscow, Russia
| | - A V Kravchenko
- Central Research Institute of Epidemiology, Russian Federal Service for Supervision of Consumer Rights Protection and Human Welfare, Moscow, Russia
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