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Maranchick NF, Kwara A, Peloquin CA. Clinical considerations and pharmacokinetic interactions between HIV and tuberculosis therapeutics. Expert Rev Clin Pharmacol 2024; 17:537-547. [PMID: 38339997 DOI: 10.1080/17512433.2024.2317954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious disease cause of mortality worldwide, especially for people living with human immunodeficiency virus (PLWH). Treating TB in PLWH can be challenging due to numerous drug interactions. AREAS COVERED This review discusses drug interactions between antitubercular and antiretroviral drugs. Due to its clinical importance, initiation of antiretroviral therapy in patients requiring TB treatment is discussed. Special focus is placed on the rifamycin class, as it accounts for the majority of interactions. Clinically relevant guidance is provided on how to manage these interactions. An additional section on utilizing therapeutic drug monitoring (TDM) to optimize drug exposure and minimize toxicities is included. EXPERT OPINION Antitubercular and antiretroviral coadministration can be successfully managed. TDM can be used to optimize drug exposure and minimize toxicity risk. As new TB and HIV drugs are discovered, additional research will be needed to assess for clinically relevant drug interactions.
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Affiliation(s)
- Nicole F Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Awewura Kwara
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, USA
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2
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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:S0149-2918(24)00081-X. [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] [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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Choy CY, Wong CS, Kumar PA, Olszyna DP, Teh YE, Chien MFJ, Kurup A, Koh YL, Ho LP, Law HL, Chua NGS, Yong HYJ, Archuleta S. Recommendations for the use of antiretroviral therapy in adults living with human immunodeficiency virus in Singapore. Singapore Med J 2024; 65:259-273. [PMID: 35366662 PMCID: PMC11182460 DOI: 10.11622/smedj.2021174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 07/06/2021] [Indexed: 11/18/2022]
Abstract
ABSTRACT Since the advent of combination antiretroviral therapy (ART), the mortality attributable to human immunodeficiency virus (HIV) infection has decreased by 80%. Newer antiretroviral agents are highly efficacious, have minimal side effects as compared to older drugs, and can be formulated as combination tablets to reduce patients' pill burden. Despite these advances, 680,000 people worldwide died of acquired immunodeficiency syndrome-related illnesses in 2020. The National ART and Monitoring Recommendations by the National HIV Programme have been created to guide physicians on the prescribing of ART based on the patients' needs. These recommendations are based on international guidelines and tailored to the local context and unique domestic considerations. We hoped that with the publication of these recommendations, the care of people living with HIV can be enhanced, bringing us closer to ending HIV in our lifetime.
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Affiliation(s)
- Chiaw Yee Choy
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
- National Centre for Infectious Diseases, Singapore
| | - Chen Seong Wong
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
- National Centre for Infectious Diseases, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - P Arun Kumar
- National Centre for Infectious Diseases, Singapore
| | - Dariusz Piotr Olszyna
- Division of Infectious Diseases, University Medicine Cluster, National University Hospital, Singapore
| | - Yii Ean Teh
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | | | - Asok Kurup
- Infectious Diseases Care Pte Ltd, Mount Elizabeth Medical Centre, Singapore
| | - Yin Ling Koh
- The Novena Medical Specialists, Mount Elizabeth Novena Specialist Centre, Singapore
| | - Lai Peng Ho
- Department of Care and Counselling, Tan Tock Seng Hospital, Singapore
| | - Hwa Lin Law
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore
| | | | | | - Sophia Archuleta
- National Centre for Infectious Diseases, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Infectious Diseases, University Medicine Cluster, National University Hospital, Singapore
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Limenh LW, Kasahun AE, Sendekie AK, Seid AM, Mitku ML, Fenta ET, Melese M, Workye M, Simegn W, Ayenew W. Tuberculosis treatment outcomes and associated factors among tuberculosis patients treated at healthcare facilities of Motta Town, Northwest Ethiopia: a five-year retrospective study. Sci Rep 2024; 14:7695. [PMID: 38565912 PMCID: PMC10987627 DOI: 10.1038/s41598-024-58080-0] [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: 12/09/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024] Open
Abstract
Tuberculosis (TB) remains a significant public health concern, particularly in low-resource settings. The treatment outcome is a crucial indicator of the effectiveness of TB treatment programs. Assessing the current treatment outcome and its associated factors is essential for improving patient care and reducing the spread of TB. Therefore, this study aimed to assess TB treatment outcomes and their associated factors among TB patients who received treatment at public healthcare facilities in Motta Town, Northwest Ethiopia. A facility-based retrospective cross-sectional study design was employed in two TB treatment centers in Motta town from January 2017 to December 2021. The study participants were all patients diagnosed with TB who received treatment. A p-value of 0.05 with a 95% confidence interval (CI) was used to determine statistical significance. A total of 362 TB patients were included in the study. The overall treatment success rate was 88.4% (95% CI 85.1, 91.7). Male gender (AOR = 2.40, 95% CI 1.16, 4.98), normal nutritional status (AOR = 3.11, 95% CI 1.33, 7.25), HIV negative status (AOR = 3.35, 95% CI 1.31, 8.60), and non-presumptive drug resistance to TB (AOR = 3.72, 95% CI 1.74, 7.98) were significantly associated with successful TB treatment outcomes (p < 0.05). In the current study, nine out of ten study participants had successful TB treatment outcome rates. Male gender, normal nutritional status, non-presumed drug resistance to TB, and HIV-negative status were significantly associated with successful TB treatment outcomes. By taking risk factors associated with poor treatment outcomes like those found in this study into account, patient management and treatment can be optimized. Sufficient TB control measures for populations are imperative and could significantly reduce the nation's total TB burden.
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Affiliation(s)
- Liknaw Workie Limenh
- Department of Pharmaceutics, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Asmamaw Emagn Kasahun
- Department of Pharmaceutics, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ashenafi Kibret Sendekie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Abdulwase Mohammed Seid
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Melese Legesse Mitku
- Department of Pharmaceutical Chemistry, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Eneyew Talie Fenta
- Department of Public Health, College of Medicine and Health Science, Injibara University, Injibara, Ethiopia
| | - Mihret Melese
- Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mulualem Workye
- Department of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Wudneh Simegn
- Department of Social and Administrative Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Wondim Ayenew
- Department of Social and Administrative Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Le X, Shen Y. Advances in Antiretroviral Therapy for Patients with Human Immunodeficiency Virus-Associated Tuberculosis. Viruses 2024; 16:494. [PMID: 38675837 PMCID: PMC11054420 DOI: 10.3390/v16040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/09/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculosis is one of the most common opportunistic infections and a prominent cause of death in patients with human immunodeficiency virus (HIV) infection, in spite of near-universal access to antiretroviral therapy (ART) and tuberculosis preventive therapy. For patients with active tuberculosis but not yet receiving ART, starting ART after anti-tuberculosis treatment can complicate clinical management due to drug toxicities, drug-drug interactions and immune reconstitution inflammatory syndrome (IRIS) events. The timing of ART initiation has a crucial impact on treatment outcomes, especially for patients with tuberculous meningitis. The principles of ART in patients with HIV-associated tuberculosis are specific and relatively complex in comparison to patients with other opportunistic infections or cancers. In this review, we summarize the current progress in the timing of ART initiation, ART regimens, drug-drug interactions between anti-tuberculosis and antiretroviral agents, and IRIS.
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Affiliation(s)
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China;
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Coelho LE, Chazallon C, Laureillard D, Escada R, N’takpe JB, Timana I, Messou E, Eholie S, Khosa C, Chau GD, Cardoso SW, Veloso VG, Delaugerre C, Molina JM, Grinsztejn B, Marcy O, De Castro N. Incidence and Predictors of Tuberculosis-associated IRIS in People With HIV Treated for Tuberculosis: Findings From Reflate TB2 Randomized Trial. Open Forum Infect Dis 2024; 11:ofae035. [PMID: 38486816 PMCID: PMC10939434 DOI: 10.1093/ofid/ofae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/18/2024] [Indexed: 03/17/2024] Open
Abstract
Background After antiretroviral therapy (ART) initiation, people with HIV (PWH) treated for tuberculosis (TB) may develop TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Integrase inhibitors, by providing a faster HIV-RNA decline than efavirenz, might increase the risk for this complication. We sought to assess incidence and determinants of TB-IRIS in PWH with TB on raltegravir- or efavirenz-based ART. Methods We conducted a secondary analysis of the Reflate TB 2 trial, which randomized ART-naive PWH on standard TB treatment, to receive raltegravir- or efavirenz-based ART. The primary objective was to evaluate the incidence of TB-IRIS. Incidence rate ratio comparing TB-IRIS incidence in each arm was calculated. Kaplan-Meier curves were used to compare TB-IRIS-free survival probabilities by ART arm. Cox regression models were fitted to analyze baseline characteristics associated with TB-IRIS. Results Of 460 trial participants, 453 from Brazil, Côte d'Ivoire, Mozambique, and Vietnam were included in this analysis. Baseline characteristics were median age 35 years (interquartile range [IQR], 29-43), 40% female, 69% pulmonary TB only, median CD4, 102 (IQR, 38-239) cells/mm³, and median HIV RNA, 5.5 (IQR, 5.0-5.8) log copies/mL. Forty-eight participants developed TB-IRIS (incidence rate, 24.7/100 PY), 19 cases in the raltegravir arm and 29 in the efavirenz arm (incidence rate ratio 0.62, 95% confidence interval .35-1.10). Factors associated with TB-IRIS were: CD4 ≤ 100 cells/μL, HIV RNA ≥500 000 copies/mL, and extrapulmonary/disseminated TB. Conclusions We did not demonstrate that raltegravir-based ART increased the incidence of TB-IRIS compared with efavirenz-based ART. Low CD4 counts, high HIV RNA, and extrapulmonary/disseminated TB at ART initiation were associated with TB-IRIS.
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Affiliation(s)
- Lara E Coelho
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Corine Chazallon
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
| | - Didier Laureillard
- Department of Infectious and Tropical Diseases, Nimes University Hospital, Nimes, France
- Research Unit 1058, Pathogenesis and Control Chronical Infections, INSERM, French Blood Center, University of Montpellier, Montpellier, France
| | - Rodrigo Escada
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Jean-Baptiste N’takpe
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
- Programme PACCI/ANRS Research Center, Abidjan, Côte-d'Ivoire
| | | | - Eugène Messou
- Programme PACCI/ANRS Research Center, Abidjan, Côte-d'Ivoire
- Centre de Prise en Charge de Recherche et de Formation, CePReF-Aconda-VS, Abidjan, Cote D'Ivoire
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | - Serge Eholie
- Programme PACCI/ANRS Research Center, Abidjan, Côte-d'Ivoire
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | - Celso Khosa
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Giang D Chau
- Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Sandra Wagner Cardoso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Valdiléa G Veloso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Constance Delaugerre
- Virology department, APHP-Hôpital Saint-Louis, Paris, France
- INSERM U944, Paris, France
- Université Paris Cité, Paris, France
| | - Jean-Michel Molina
- INSERM U944, Paris, France
- Université Paris Cité, Paris, France
- Infectious Diseases Department, AP-HP-Hôpital Saint-Louis Lariboisière, Paris, France
| | - Beatriz Grinsztejn
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Olivier Marcy
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
| | - Nathalie De Castro
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
- Infectious Diseases Department, AP-HP-Hôpital Saint-Louis Lariboisière, Paris, France
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Yang H, Liu Q, Wu Y, He K, Zeng Q, Liu M. Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome in initiating ART among HIV-Infected patients in China-risk factors and management. BMC Infect Dis 2024; 24:5. [PMID: 38166781 PMCID: PMC10759358 DOI: 10.1186/s12879-023-08897-3] [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: 10/18/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND China is a country burdened with a high incidence of both tuberculosis (TB) and HIV, Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an important early complication in TB and HIV co-infected patients, but data from China are limited. Additionally, as an integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) regimen becomes the first-line treatment, concerns have arisen regarding the potential increase in the incidence of paradoxical TB-IRIS. Nevertheless, the existing data are inconclusive and contradictory. METHODS We conducted a retrospective study at Chongqing Public Health Clinical Center from January 2018 to December 2021. We collected demographic and clinical data of HIV/TB co-infected patients who initiated ART. We described the patient characteristics, identified predictors for TB-IRIS, and determined clinical outcomes. The Statistical Package for Social Science (SPSS 25) was used to analyse the data. Continuous variables were compared using Student's t-test or rank sum test. Counting data were compared using the chi-square test or Fisher's exact test. The variables with statistical significance in the univariate analysis were added to the binary logistic regression. A p-value less than 0.05 was considered statistically significant. RESULTS A total of 384 patients co-infected with naive HIV and pulmonary TB (PTB) who were given ATT and ART combination were included. 72 patients (18.8%) developed paradoxical TB-IRIS with a median of 15 (12, 21) days after initiating ART. Baseline age ≤ 40years, CD4 + T-cell counts ≤ 50cells/µL, HIV viral load ≥ 500,000 copies/mL were found to be significantly associated with development of paradoxical TB-IRIS. Mortality rates were similar in the TB-IRIS (n = 5, 6.9%) group and non-TB-IRIS (n = 13, 4.2%) group. Interestingly, CD4+ T-cell counts recovery post-ART was significant higher in the TB-IRIS group when compared to the non-TB-IRIS group at the end of 24 weeks (P = 0.004), as well as at 48 weeks (P = 0.015). In addition, we consider that INSTI- based ART regimen do not increased the risk of Paradoxical TB-IRIS. CONCLUSION Paradoxical TB-IRIS, while often leading to clinical deterioration and hospitalization, is generally manageable. It appears to have a positive impact on the recovery of CD4 + T-cell counts over time. Importantly, our data suggest that INSTI-based ART regimens do not elevate the risk of TB-IRIS. Thus, paradoxical TB-IRIS should not be considered an impediment to initiating ART in adults with advanced immunodeficiency, except in the case of tuberculous meningitis (TBM).
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Affiliation(s)
- Honghong Yang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Qian Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Yushan Wu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Kun He
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Qin Zeng
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China.
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9
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Mohzari YA, Musawa MA, Alrashed A, Zaeri B, Damfu N, Cahusac P, Alwafai S, Alamer A, Almulhim A. The clinical impact of rifampicin-based anti-TB therapy and tenofovir alafenamide-containing ARV regimen drug Interaction in people living with HIV: Case series report. J Infect Public Health 2023; 16:2026-2030. [PMID: 37890226 DOI: 10.1016/j.jiph.2023.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/27/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND People living with HIV (PLWH) are prone to developing tuberculosis (TB). Since tenofovir alafenamide (TAF) is the recommended tenofovir (TFV) prodrug and rifampicin is a key component of TB therapy, thus complicating HIV and TB coinfection management. However, there is little data regarding the impact of this drug-drug Interaction in PLWH, which makes health care providers reluctant to prescribe them together. METHODS This was an observational, retrospective case series carried out at King Faisal Specialist Hospital & Research Center (KFSH&RC), Jeddah, Saudi Arabia. PLWH (≥18 years old) who received the TAF-containing ARV regimen and rifampicin-based anti-TB therapy together for ≥ 4 weeks were included. The objective of this study was to report the clinical impact of this drug-drug interaction (rifampicin + TAF-containing antiretroviral (ARV) regimen) on HIV viral load control in PLWH. RESULTS A total of 7 PLWH who met the inclusion criteria, 5 (71 %) out of 7, were males. All patients received dolutegravir 50 mg twice daily (DTG) plus the combination of TAF 25 mg and emtricitabine 200 mg (FTC) once daily as their ARV regimen. Four patients had suppressed viral load levels at baseline, which was maintained throughout TB treatment. Three patients had unsuppressed viral load levels at baseline and attained viral load suppression throughout the TB treatment course CONCLUSION: Overall, the TAF-containing ARV regimen maintained it's efficacy in presence of rifampicin.
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Affiliation(s)
- Yahya Ali Mohzari
- Division of Pharmaceutical Care, Clinical Pharmacy Section, King Saud Medical City, Riyadh, Saudi Arabia
| | - Mohammed Al Musawa
- Division of Pharmaceutical Care, King Faisal Specialist Hospital, and Research Center, Jeddah, Saudi Arabia
| | - Ahmad Alrashed
- Department of Pharmacy, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Bandar Zaeri
- Department of Infectious Diseases, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nader Damfu
- Division of Pharmaceutical Care, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Peter Cahusac
- Department of Pharmacology and Biostatistics/Comparative Medicine, Alfaisal University College of Medicine and King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sana Alwafai
- Department of Pharmacy Practice, Batterjee Medical College, Jeddah, Saudi Arabia
| | - Ahmad Alamer
- Department of Clinical Pharmacy, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Abdulaziz Almulhim
- Department of Pharmacy Practice, King Faisal University, Alahsa, Saudi Arabia.
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Pean P, Madec Y, Nerrienet E, Borand L, Laureillard D, Fernandez M, Marcy O, Scott-Algara D. Natural Killer Repertoire Restoration in TB/HIV Co-Infected Individuals Experienced an Immune Reconstitution Syndrome (CAMELIA Trial, ANRS 12153). Pathogens 2023; 12:1241. [PMID: 37887757 PMCID: PMC10610037 DOI: 10.3390/pathogens12101241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
IRIS is a common complication in HIV-infected patients treated for tuberculosis (TB) and cART. Our aim was to evaluate NK cell reconstitution in HIV-infected patients with TB-IRIS compared to those without IRIS. 147 HIV-infected patients with TB from the CAMELIA trial were enrolled. HIV+TB+ patients were followed for 32 weeks. The NK cell repertoire was assessed in whole blood at different time points. As CAMELIA has two arms (early and late cART initiation), we analysed them separately. At enrolment, individuals had low CD4 cell counts (27 cells/mm3) and high plasma viral loads (5.76 and 5.50 log/mL for IRIS and non-IRIS individuals, respectively). Thirty-seven people developed IRIS (in the early and late arms). In the early and late arms, we observed similar proportions of total NK and NK cell subsets in TB-IRIS and non-IRIS individuals during follow-up, except for the CD56dimCD16pos (both arms) and CD56dimCD16neg (late arm only) subsets, which were higher in TB-IRIS and non-IRIS individuals, respectively, after cART. Regarding the repertoire and markers of NK cells, significant differences (lower expression of NKp30, NKG2A (CD159a), NKG2D (CD314) were observed in TB-IRIS compared to non-IRIS individuals after the start of cART. In the late arm, some changes (increased expression of CD69, NKG2C, CD158i) were observed in TB-IRIS compared to non-IRIS individuals, but only before cART initiation (during TB treatment). KIR expression by NK cells (CD158a and CD158i) was similar in both groups. CD69 expression by NK cells decreased in all groups. Expression of the NCR repertoire (NKp30, NKp44, NKp46) has similar kinetics in TB-IRIS subjects compared to non-IRIS subjects regardless of the arm analysed. NK cell reconstitution appeared to be better in TB-IRIS subjects. Although NK cell reconstitution is impaired in HIV infection after cART, as previously reported, it does not appear to be affected by the development of IRIS in HIV and TB-infected individuals.
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Affiliation(s)
- Polidy Pean
- Immunology Unit, Institute Pasteur du Cambodge, Phnom Pen 12000, Cambodia
| | - Yoann Madec
- Epidemiology of Emerging Diseases, Institut Pasteur, Université de Paris, 75000 Paris, France;
| | | | - Laurence Borand
- Clinical Research Team, Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phom Penh 12000, Cambodia;
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 20600, USA
| | - Didier Laureillard
- Infectious and Tropical Diseases Department, University Hospital, 30900 Nimes, France;
| | | | - Olivier Marcy
- Research Institute for Sustainable Development (IRD) EMR 271, National Institute for Health and Medical Research (INSERM) UMR 1219, University of Bordeaux, 33000 Bordeaux, France;
| | - Daniel Scott-Algara
- Unité de Biologie Cellulaire et Lymphocytes, Institut Pasteur, 75000 Paris, France;
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11
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Becker GL, Amuge P, Ssebunya R, Motevalli M, Adaku A, Juma M, Wobudeya E, Elyanu P, Jackson JB, Kekitiinwa A, Blount RJ. Predictors of mortality in Ugandan children with TB, 2016-2021. Int J Tuberc Lung Dis 2023; 27:668-674. [PMID: 37608479 PMCID: PMC10443779 DOI: 10.5588/ijtld.22.0622] [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: 11/18/2022] [Accepted: 03/13/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND: The burden of pediatric TB is high in Uganda. Our objective was to evaluate predictors of mortality during TB treatment among children at an urban and a rural referral hospital.METHODS: We designed a historical cohort study of TB cases at Mulago National Referral Hospital, Kampala; and Fort Portal Regional Referral Hospital, Fort Portal, Uganda, in children aged <15 years from 2016 to 2021. We used Kaplan-Meier models to estimate survival and fit multivariable Cox regression models to determine mortality hazards during TB treatment.RESULTS: We identified 1,658 children diagnosed with TB from 2016 to 2021. Of 1,623 children with known treatment outcomes, 127/1,623 (7.8%) died during TB treatment, 1,298/1,623 (78.3%) completed treatment, 150/1,623 (9.2%) were lost to follow-up, and two children failed treatment. Using Kaplan-Meier functions, the median time to death was 27 days following treatment initiation. In adjusted Cox models, predictors of mortality included HIV (aHR 1.68, 95% CI 1.01-2.81), moderate malnutrition (aHR 2.22, 95% CI 1.18-4.16), and severe malnutrition (aHR 2.92, 95% CI 1.75-4.87).CONCLUSION: Mortality was high at an urban and a rural referral hospital among children who initiated TB treatment from 2016 to 2021, with the majority of deaths occurring during the intensive phase of TB treatment. Malnutrition and HIV were significant predictors of death during treatment.
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Affiliation(s)
- G L Becker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - P Amuge
- Baylor College of Medicine Children's Foundation-Uganda, Kampala
| | - R Ssebunya
- Baylor College of Medicine Children's Foundation-Uganda, Kampala
| | - M Motevalli
- Baylor College of Medicine Children's Foundation-Uganda, Kampala
| | - A Adaku
- Fort Portal Regional Referral Hospital, Fort Portal, Uganda
| | - M Juma
- Baylor College of Medicine Children's Foundation-Uganda, Kampala
| | - E Wobudeya
- Directorate of Pediatrics & Child Health, Mulago National Referral Hospital, Kampala, Uganda
| | - P Elyanu
- Baylor College of Medicine Children's Foundation-Uganda, Kampala
| | - J B Jackson
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - A Kekitiinwa
- Baylor College of Medicine Children's Foundation-Uganda, Kampala
| | - R J Blount
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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12
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Bronkhorst E, Hattingh S, Poka M. Antiretroviral stewardship in a tertiary academic hospital: The need for a clinical pharmacist. Health SA 2023; 28:2135. [PMID: 38633911 PMCID: PMC11022499 DOI: 10.4102/hsag.v28i0.2135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/17/2023] [Indexed: 04/19/2024] Open
Abstract
Background South Africa has the highest prevalence of people living with HIV globally. Although antiretroviral therapy provides solutions, evidence of antiretroviral resistance emerged, requiring the application of antiretroviral-stewardship programmes to curb medication-related problems. Aim Identify and describe antiretroviral-stewardship pharmacist interventions in an active antiretroviral-stewardship programme. Setting HIV-positive adults admitted to medical wards at a tertiary academic hospital in South Africa. Methods A descriptive quantitative study was performed, utilising an antiretroviral-stewardship assessment tool to determine antiretroviral-related recommendations in the treatment of HIV-positive adults. The study employed purposive sampling. Treatment charts were evaluated to identify antiretroviral-stewardship recommendations. The number of recommendations highlighted the need for a clinical pharmacist in an active antiretroviral-stewardship programme. Descriptive data analysis with Pearson correlations was employed to display the data. Results Medication-related problems were identified in 100% of study patients (n = 41), with an average of 2.46 interventions per patient. One-hundred-and-one medication-related problems were identified by using the antiretroviral-stewardship assessment tool. The identified problems included a lack of viral load testing (41, 100%), lack of CD4 count monitoring (15; 36.6%) and lack of prophylactic treatment against opportunistic infections (10; 24.4%). Medication-related problems included the presence of clinically significant drug-drug interactions and serious side effects, CD4 count decline despite being on antiretroviral therapy, unnecessary treatment interruptions including risk for IRIS, inappropriate antiretroviral therapy regimen, non-adherence and absence of treating tuberculosis as co-morbidity. Conclusion Present study demonstrates the need of an active antiretroviral-stewardship programme's benefits. The possible role of the clinical pharmacist as active participant and leader in this programme is highlighted. Contribution Highlight the role of clinical pharmacists in antiretroviral stewardship.
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Affiliation(s)
- Elmien Bronkhorst
- School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sonja Hattingh
- School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Madan Poka
- School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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13
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Bayowa JR, Kalyango JN, Baluku JB, Katuramu R, Ssendikwanawa E, Zalwango JF, Akunzirwe R, Nanyonga SM, Amutuhaire JS, Muganga RK, Cherop A. Mortality rate and associated factors among patients co-infected with drug resistant tuberculosis/HIV at Mulago National Referral Hospital, Uganda, a retrospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001020. [PMID: 37410761 DOI: 10.1371/journal.pgph.0001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
Drug resistant tuberculosis (DR-TB)/HIV co-infection remains a growing threat to public health and threatens global TB and HIV prevention and care programs. HIV is likely to worsen the outcomes of DR-TB and DR-TB is likely to worsen the outcomes of HIV despite the scale up of TB and HIV services and advances in treatment and diagnosis. This study determined the mortality rate and factors associated with mortality among persons on treatment co-infected with drug resistant TB and HIV at Mulago National Referral Hospital. We retrospectively reviewed data of 390 persons on treatment that had a DR-TB/HIV co-infection in Mulago National Referral Hospital from January 2014 to December 2019.Modified poisson regression with robust standard errors was used to determine relationships between the independent variables and the dependent variable (mortality) at bivariate and multivariate analysis. Of the 390 participants enrolled, 201(53.9%) were males with a mean age of 34.6 (±10.6) and 129 (33.2%,95% CI = 28.7-38.1%) died. Antiretroviral therapy(ART) initiation (aIRR 0.74, 95% CI = 0.69-0.79), having a body mass index (BMI)≥18.5Kg/m2 (aIRR 1.01, 95% CI = 1.03-1.17), having a documented client phone contact (aIRR 0.85, 95% CI = 0.76-0.97), having a mid-upper arm circumference,(MUAC) ≥18.5cm (aIRR 0.90, 95% CI = 0.82-0.99), being on first and second line ART regimen (aIRR 0.83, 95% CI = 0.77-0.89),having a known viral load (aIRR 1.09, 95% CI = 1.00-1.21) and having an adverse event during the course of treatment (aIRR 0.88, 95% CI = 0.83-0.93) were protective against mortality. There was a significantly high mortality rate due to DR-TB/HIV co-infection. These results suggest that initiation of all persons living with HIV/AIDS (PLWHA) with DR-TB on ART and frequent monitoring of adverse drug events highly reduces mortality.
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Affiliation(s)
- Joan Rokani Bayowa
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joan N Kalyango
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Richard Katuramu
- Ministry of Health, Tuberculosis Control Program, Kampala, Uganda
| | - Emmanuel Ssendikwanawa
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jane Frances Zalwango
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rebecca Akunzirwe
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Stella Maris Nanyonga
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Ronald Kivumbi Muganga
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adolphus Cherop
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
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14
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Wong CS, Wei L, Kim YS. HIV Late Presenters in Asia: Management and Public Health Challenges. AIDS Res Treat 2023; 2023:9488051. [PMID: 37351535 PMCID: PMC10284655 DOI: 10.1155/2023/9488051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/19/2023] [Accepted: 04/04/2023] [Indexed: 06/24/2023] Open
Abstract
Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm3 at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34-72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.
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Affiliation(s)
- Chen Seong Wong
- National Centre for Infectious Diseases, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lyu Wei
- Department of Infectious Diseases, Peking Union Medical College Hospital in Beijing, Beijing, China
| | - Yeon-Sook Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
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15
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Abd-Ellah HS, Mudududdla R, Carter GP, Baell JB. Novel Perspectives on the Design and Development of a Long-Acting Subcutaneous Raltegravir Injection for Treatment of HIV-In Vitro and In Vivo Evaluation. Pharmaceutics 2023; 15:pharmaceutics15051530. [PMID: 37242770 DOI: 10.3390/pharmaceutics15051530] [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: 04/11/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Antiretrovirals (ARVs) are a highly effective therapy for treatment and prevention of HIV infection, when administered as prescribed. However, adherence to lifelong ARV regimens poses a considerable challenge and places HIV patients at risk. Long-acting ARV injections may improve patient adherence as well as maintaining long-term continuous drug exposure, resulting in improved pharmacodynamics. In the present work, we explored the aminoalkoxycarbonyloxymethyl (amino-AOCOM) ether prodrug concept as a potential approach to long-acting ARV injections. As a proof of concept, we synthesised model compounds containing the 4-carboxy-2-methyl Tokyo Green (CTG) fluorophore and assessed their stability under pH and temperature conditions that mimic those found in the subcutaneous (SC) tissue. Among them, probe 21 displayed very slow fluorophore release under SC-like conditions (98% of the fluorophore released over 15 d). Compound 25, a prodrug of the ARV agent raltegravir (RAL), was subsequently prepared and evaluated using the same conditions. This compound showed an excellent in vitro release profile, with a half-life (t½) of 19.3 d and 82% of RAL released over 45 d. In mice, 25 extended the half-life of unmodified RAL by 4.2-fold (t½ = 3.18 h), providing initial proof of concept of the ability of amino-AOCOM prodrugs to extend drug lifetimes in vivo. Although this effect was not as pronounced as seen in vitro-presumably due to enzymatic degradation and rapid clearance of the prodrug in vivo-the present results nevertheless pave the way for development of more metabolically stable prodrugs, to facilitate long-acting delivery of ARVs.
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Affiliation(s)
- Heba S Abd-Ellah
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Parkville, VIC 3052, Australia
- Medicinal Chemistry Department, Faculty of Pharmacy, Minia University, Minia 61519, Egypt
| | - Ramesh Mudududdla
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Parkville, VIC 3052, Australia
| | - Glen P Carter
- Microbiology and Immunology Department, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Parkville, VIC 3001, Australia
| | - Jonathan B Baell
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Parkville, VIC 3052, Australia
- School of Pharmaceutical Sciences, Nanjing Tech University, No. 30 South Puzhu Road, Nanjing 211816, China
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16
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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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17
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Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa. PLoS One 2022; 17:e0274549. [PMID: 36223365 PMCID: PMC9555649 DOI: 10.1371/journal.pone.0274549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 08/30/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV) infected individuals in South Africa. Despite the implementation of HIV/TB integration services at primary healthcare facility level, the effect of HIV on TB treatment outcomes has not been well investigated. To provide evidence base for TB treatment outcome improvement to meet End TB Strategy goal, we assessed the effect of HIV status on treatment outcomes of TB patients at a rural clinic in the Ugu Health District, South Africa. METHODS We reviewed medical records involving a cohort of 508 TB patients registered for treatment between 1 January 2013 and 31 December 2015 at rural public sector clinic in KwaZulu-Natal province, South Africa. Data were extracted from National TB Programme clinic cards and the TB case registers routinely maintained at study sites. The effect of HIV status on TB treatment outcomes was determined by using multinomial logistic regression. Estimates used were relative risk ratio (RRR) at 95% confidence intervals (95%CI). RESULTS A total of 506 patients were included in the analysis. Majority of the patients (88%) were new TB cases, 70% had pulmonary TB and 59% were co-infected with HIV. Most of HIV positive patients were on antiretroviral therapy (ART) (90% (n = 268)). About 82% had successful treatment outcome (cured 39.1% (n = 198) and completed treatment (42.9% (n = 217)), 7% (n = 39) died 0.6% (n = 3) failed treatment, 3.9% (n = 20) defaulted treatment and the rest (6.6% (n = 33)) were transferred out of the facility. Furthermore, HIV positive patients had a higher mortality rate (9.67%) than HIV negative patients (2.91%)". Using completed treatment as reference, HIV positive patients not on ART relative to negative patients were more likely to have unsuccessful outcomes [RRR, 5.41; 95%CI, 2.11-13.86]. CONCLUSIONS When compared between HIV status, HIV positive TB patients were more likely to have unsuccessful treatment outcome in rural primary care. Antiretroviral treatment seems to have had no effect on the likelihood of TB treatment success in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients emphasizing the need for enhanced integrated management of HIV/TB in rural South Africa through active screening of TB among HIV positive individuals and early access to ART among HIV positive TB cases.
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18
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Pastick KA, Kagimu E, Dobbin J, Ssebambulidde K, Gakuru J, Milln J, Nakabuye B, Meya DB, Boulware DR, Cresswell FV, Bahr NC. Pregnancy-Related Tuberculous Meningitis and Immune Reconstitution Inflammatory Syndrome: A Case Series and Systematic Review. Open Forum Infect Dis 2022; 9:ofac513. [PMID: 36267255 PMCID: PMC9578166 DOI: 10.1093/ofid/ofac513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Background Tuberculosis is a leading cause of death among women of reproductive age. However, tuberculous meningitis, the most severe form of extrapulmonary tuberculosis, is rarely discussed in pregnancy despite this being a unique period of immune modulation that may predispose women to active disease. Methods We identified and described cases of tuberculous meningitis among pregnant or postpartum women screened during meningitis clinical trials in Uganda from 2018 to 2022. We conducted a systematic literature review via PubMed/Medline and Embase for all English-language publications from 1970 to 10 July 2022, to identify additional cases. Results We identified 8 cases of pregnancy-related tuberculous meningitis in Ugandan women living with human immunodeficiency virus (HIV) and 40 additional cases via systematic literature review (none HIV-positive). Of all combined cases, 50% (24/48) were diagnosed postpartum; 50% (24/48) had initial onset during pregnancy, of which 38% (9/24) had worsening of symptoms or disease relapse following pregnancy cessation. Diagnosis was missed or delayed in 33% (16/48) of cases. For those with known outcomes, maternal mortality was 23% (11/48) and fetal/neonatal mortality was 30% (13/44). Of maternal survivors, 30% (11/37) had residual neurologic deficits. Conclusions The true incidence of tuberculous meningitis in pregnancy or the postpartum period is unclear but likely underappreciated. To date, nearly all published cases have occurred in HIV-negative or otherwise immunocompetent women. Given the well-described physiological immunosuppression during pregnancy and subsequent reconstitution postpartum, physicians must be aware of tuberculous meningitis and pregnancy-related immune reconstitution inflammatory syndrome, especially in countries with a high burden of tuberculosis and in women living with HIV.
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Affiliation(s)
- Katelyn A Pastick
- Correspondence: Katelyn A. Pastick, MD, Massachusetts General Hospital, Department of Medicine, 55 Fruit St, Boston, MA 02114 ()
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joanna Dobbin
- Primary Care and Population Health, University College London, London, United Kingdom
| | | | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jack Milln
- Department of Obstetric Medicine, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Betty Nakabuye
- Department of Obstetrics and Gynecology, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fiona V Cresswell
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
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Podany AT, Pham M, Sizemore E, Martinson N, Samaneka W, Mohapi L, Badal-Faesen S, Dawson R, Johnson JL, Mayanja H, Lalloo U, Whitworth WC, Pettit A, Campbell K, Phillips PPJ, Bryant K, Scott N, Vernon A, Kurbatova EV, Chaisson RE, Dorman SE, Nahid P, Swindells S, Dooley KE, Fletcher CV. Efavirenz Pharmacokinetics and Human Immunodeficiency Virus Type 1 (HIV-1) Viral Suppression Among Patients Receiving Tuberculosis Treatment Containing Daily High-Dose Rifapentine. Clin Infect Dis 2022; 75:560-566. [PMID: 34918028 PMCID: PMC9890454 DOI: 10.1093/cid/ciab1037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A 4-month regimen containing rifapentine and moxifloxacin has noninferior efficacy compared to the standard 6-month regimen for drug-sensitive tuberculosis. We evaluated the effect of regimens containing daily, high-dose rifapentine on efavirenz pharmacokinetics and viral suppression in patients with human immunodeficiency virus (HIV)-associated tuberculosis (TB). METHODS In the context of a Phase 3 randomized controlled trial, HIV-positive individuals already virally suppressed on efavirenz--containing antiretroviral therapy (ART) (EFV1), or newly initiating efavirenz (EFV2) received TB treatment containing rifapentine (1200 mg), isoniazid, pyrazinamide, and either ethambutol or moxifloxacin. Mid-interval efavirenz concentrations were measured (a) during ART and TB cotreatment (Weeks 4, 8, 12, and 17, different by EFV group) and (b) when ART was taken alone (pre- or post-TB treatment, Weeks 0 and 22). Apparent oral clearance (CL/F) was estimated and compared. Target mid-interval efavirenz concentrations were > 1 mg/L. Co-treatment was considered acceptable if > 80% of participants had mid-interval efavirenz concentrations meeting this target. RESULTS EFV1 and EFV2 included 70 and 41 evaluable participants, respectively. The geometric mean ratio comparing efavirenz CL/F with vs without TB drugs was 0.79 (90% confidence interval [CI] .72-.85) in EFV1 and 0.84 [90% CI .69-.97] in EFV2. The percent of participants with mid-interval efavirenz concentrations > 1mg/L in EFV1 at Weeks 0, 4, 8, and 17 was 96%, 96%, 88%, and 89%, respectively. In EFV2, at approximately 4 and 8 weeks post efavirenz initiation, the value was 98%. CONCLUSIONS TB treatment containing high-dose daily rifapentine modestly decreased (rather than increased) efavirenz clearance and therapeutic targets were met supporting the use of efavirenz with these regimens, without dose adjustment. CLINICAL TRIALS REGISTRATION NCT02410772.
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Affiliation(s)
| | - Michelle Pham
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Erin Sizemore
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Neil Martinson
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | | | - Lerato Mohapi
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
| | | | - Rod Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | | | - Harriet Mayanja
- Uganda- Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Umesh Lalloo
- Durban International Clinical Research Site, Durban, South Africa
| | | | - April Pettit
- Vanderbilt University, Nashville, Tennessee, USA
| | - Kayla Campbell
- University of Nebraska Medical Center, Omaha, Nebraska, USA
- University of Colorado, Denver, Colorado, USA
| | - Patrick P J Phillips
- University of California, San Francisco Center for Tuberculosis, San Francisco, California, USA
| | - Kia Bryant
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nigel Scott
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrew Vernon
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Susan E Dorman
- Medical University of South Carolina, Columbia, South Carolina, USA
| | - Payam Nahid
- University of California, San Francisco Center for Tuberculosis, San Francisco, California, USA
| | | | - Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Kherabi Y, de Castro N, Sellier PO, Hamet G, Brun A, Méchaï F, Joly V, Yazdanpanah Y, Molina JM. Brief Report: Efficacy and Safety of Efavirenz, Raltegravir, and Dolutegravir in HIV-1/TB Coinfection. A Multicenter Retrospective Cohort Study in France. J Acquir Immune Defic Syndr 2022; 91:85-90. [PMID: 35616997 DOI: 10.1097/qai.0000000000003024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND There are limited data comparing the efficacy and safety of raltegravir and dolutegravir to that of efavirenz in HIV-1/tuberculosis (TB) coinfected patients. METHODS We conducted a 10-year retrospective study in 4 centers in France. We included all HIV-1/tuberculosis coinfected patients starting antiretroviral therapy with a rifampicin-based regimen, with a plasma HIV RNA level (VL) > 1000 copies/mL. The primary endpoint was the proportion of patients with virological success that is, with VL <50 copies/mL at W48 using an Intention-To-Treat analysis, using last-observation-carried-forward to impute missing data. We also assessed antiretroviral therapy safety, analyzing treatment discontinuation for adverse events. RESULTS Between 2010 and 2020, 117 patients were included. Thirty-nine (33.3%) were treated with raltegravir and 2 nucleoside reverse transcriptase inhibitors (NRTIs), 19 (16.2%) with dolutegravir (and 2 NRTIs) and 59 (50.4%) with efavirenz (and 2 NRTIs). At W48, the primary endpoint was achieved in 24 patients (61.5%) in the raltegravir group, in 12 (63.2%) in the dolutegravir group, and in 41 (69.5%) in the efavirenz group using an Intention-To-Treat analysis ( P = 0.68). Emergence of drug resistance in patients with virological failure, defined as a VL >50 copies/mL, was observed in 3 patients with efavirenz and one patient with raltegravir. Rate of treatment discontinuation for drug-related adverse events was 10.3%, 10.6%, 16.9% for raltegravir, dolutegravir and efavirenz respectively ( P = 0.67). CONCLUSIONS In this retrospective cohort study, raltegravir and dolutegravir yielded similar efficacy and safety results to efavirenz for the treatment of HIV-1/TB coinfected patients.
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Affiliation(s)
- Yousra Kherabi
- Department of Infectious Diseases, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
- Department of Infectious Diseases, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
- University of Paris, Paris, France
| | - Nathalie de Castro
- Department of Infectious Diseases, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
- University of Paris, Paris, France
| | - Pierre-Olivier Sellier
- University of Paris, Paris, France
- Department of Infectious Diseases, Hôpital Lariboisière, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | | | - Frédéric Méchaï
- Department of Infectious Diseases, Hôpital Avicenne, Assistance Publique Hôpitaux de Paris, Bobigny, France
| | - Véronique Joly
- Department of Infectious Diseases, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Yazdan Yazdanpanah
- Department of Infectious Diseases, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
- University of Paris, Paris, France
- INSERM U1137, IAME, Université de Paris, France; and
| | - Jean-Michel Molina
- Department of Infectious Diseases, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
- University of Paris, Paris, France
- INSERM U944, Université de Paris, Paris, France
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21
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Kokebu DM, Ahmed S, Moodliar R, Chiang CY, Torrea G, Van Deun A, Goodall RL, Rusen ID, Meredith SK, Nunn AJ. Failure or relapse predictors for the STREAM Stage 1 short regimen for RR-TB. Int J Tuberc Lung Dis 2022; 26:753-759. [PMID: 35898125 PMCID: PMC9341498 DOI: 10.5588/ijtld.22.0073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: STREAM (Standardised Treatment Regimens of Anti-tuberculosis drugs for Multidrug-Resistant Tuberculosis) Stage 1 demonstrated non-inferior efficacy of a short regimen for rifampicin-resistant TB (RR-TB) compared to a long regimen as recommended by the WHO. The present paper analyses factors associated with a definite or probable failure or relapse (FoR) event in participants receiving the Short regimen.METHODS: This analysis is restricted to 253 participants allocated to the Short regimen and is based on the protocol-defined modified intention to treat (mITT) population. Multivariable Cox regression models were built using backwards elimination with an exit probability of P = 0.157, equivalent to the Akaike Information Criterion, to identify factors independently associated with a definite or probable FoR event.RESULTS: Four baseline factors were identified as being significantly associated with the risk of definite or probable FoR (male sex, a heavily positive baseline smear grade, HIV co-infection and the presence of costophrenic obliteration). There was evidence of association of culture positivity at Week 8 and FoR in a second model and Week 16 smear positivity, presence of diabetes and of smoking in a third model.CONCLUSION: The factors associated with FoR outcomes identified in this analysis should be considered when determining the optimal shortened treatment regimen.
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Affiliation(s)
- D. M. Kokebu
- St Peter’s Tuberculosis Specialised Hospital/Global Health Committee, Addis Ababa, Ethiopia
| | - S. Ahmed
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - R. Moodliar
- Tuberculosis & HIV Investigative Network (THINK), Doris Goodwin Hospital, Pietermaritzburg, South Africa
| | - C-Y. Chiang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wanfang Hospital, Taipei Medical University, Taipei, Taiwan
, Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
, International Union Against Tuberculosis and Lung Disease, Paris, France
| | - G. Torrea
- Institute of Tropical Medicine, Antwerp, Belgium
| | - A. Van Deun
- Institute of Tropical Medicine, Antwerp, Belgium
| | - R. L. Goodall
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - I. D. Rusen
- Research Division, Vital Strategies, New York, USA
| | - S. K. Meredith
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - A. J. Nunn
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
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22
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Wu Y, Zhang Y, Wang Y, Wei J, Wang W, Duan W, Tian Y, Ren M, Li Z, Wang W, Zhang T, Wu H, Huang X. Bedaquiline and Linezolid improve anti-TB treatment outcome in drug-resistant TB patients with HIV: A systematic review and meta-analysis. Pharmacol Res 2022; 182:106336. [PMID: 35779814 DOI: 10.1016/j.phrs.2022.106336] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES We aimed to assess the effect of second-line anti-TB treatment and determine which drugs can achieve the greatest clinical benefit for DR-TB-HIV patients by comparing multiple chemotherapy regimens, to provide a basis for evidence-based practice. METHODS We searched three electronic databases (PubMed, Web of Science and Cochrane) for related English studies published since 2010. A random-effect model was used to estimate the pooled result for the treatment outcomes. Subgroup analysis based on possible factors, such as ART, baseline CD4 T-cell count, treatment regimens, and profiles of drug resistance, was also conducted to assess factors for favorable outcome. Outcomes were treatment success and mortality. RESULTS 38 studies, 40 cohorts with 9279 patients were included. The pooled treatment success, mortality, treatment failure, and default rates were 57.5 % (95 % CI 53.1-61.9), 21 % (95 % CI 17.8-24.6), 4.8 % (95 % CI 3.5-6.5), and 10.7 % (95 % CI 8.7-13.1), respectively, in patients with DR-TB and HIV co-infection. Subgroup analysis showed that BDQ and LZD based regimen, and ≥ 2 Group A drugs were associated with a higher treatment success rate. Besides, higher CD4 T-cell count at baseline was also correlated with higher treatment success rate, too. CONCLUSIONS Suboptimal anti-TB outcomes underlining the need to expand the application of effective drugs and better regimen in high HIV setting. BDQ and LZD based all-oral regimen and early ART could contribute to higher treatment success, particularly among XDR-TB-HIV patients. Given that all included studies were observational, our findings emphasize the need for high-quality studies to further investigate the optimal treatment regimen for DR-TB-HIV.
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Affiliation(s)
- Yaxin Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Yingying Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Jiaqi Wei
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wenjing Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Wenshan Duan
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Yakun Tian
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Meixin Ren
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Zhen Li
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing100069, China
| | - Wen Wang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Tong Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Hao Wu
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China
| | - Xiaojie Huang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No 8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing 100069, China.
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Pooranagangadevi N, Padmapriyadarsini C. Treatment of Tuberculosis and the Drug Interactions Associated With HIV-TB Co-Infection Treatment. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.834013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Tuberculosis (TB) is a communicable disease that is a major source of illness, one of the ten causes of mortality worldwide, and the largest cause of death from a single infectious agent Mycobacterium tuberculosis. HIV infection and TB are a fatal combination, with each speeding up the progression of the other. Barriers to integrated treatment as well as safety concerns on the co-management of HIV- TB co-infection do exist. Many HIV TB co-infected people require concomitant anti-retroviral therapy (ART) and anti-TB medication, which increases survival but also introduces certain management issues, such as drug interactions, combined drug toxicities, and TB immune reconstitution inflammatory syndrome which has been reviewed here. In spite of considerable pharmacokinetic interactions between antiretrovirals and antitubercular drugs, when the pharmacological characteristics of drugs are known and appropriate combination regimens, dosing, and timing of initiation are used, adequate clinical response of both infections can be achieved with an acceptable safety profile. To avoid undesirable drug interactions and side effects in patients, anti TB treatment and ART must be closely monitored. To reduce TB-related mortality among HIV-TB co-infected patients, ART and ATT (Anti Tuberculosis Treatment) outcomes must improve. Clinical practise should prioritise strategies to promote adherence, such as reducing treatment duration, monitoring and treating adverse events, and improving treatment success rates, to reduce the mortality risk of HIV-TB co-infection.
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24
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Ignatius EH, Swindells S. Update on tuberculosis/HIV coinfections: across the spectrum from latent infection through drug-susceptible and drug-resistant disease. TOPICS IN ANTIVIRAL MEDICINE 2022; 30:464-472. [PMID: 36346703 PMCID: PMC9306687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Tuberculosis (TB) remains the leading cause of death among people with HIV, and annual risk of progression from latent TB infection to active disease in this population is 10%. Diagnostic tests for latent and active TB remain suboptimal for people with HIV who have a CD4+ count below 200 cells/μL, and there is an urgent need for assays that predict progression from latent to active disease, monitor treatment response, and test for cure after latent and active TB treatment. Traditional treatment duration for latent infection and active TB disease has been onerous for patients; however, shorter-course regimens are increasingly available across the spectrum of TB, including for drug-resistant TB. Simultaneous treatment of HIV and TB is complicated by drug-drug interactions, although trials are ongoing to better understand the magnitude of these interactions and guide clinicians in how to use short-course regimens, particularly for people with HIV.
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Affiliation(s)
| | - Susan Swindells
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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25
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Sutton KC, De Vente J, Leblanc R, Dejesus E, Smith G, Mills A, Baril JG, St. Clair M, Stancil BS, Vandermeulen K, Spreen WR. Long-term Efficacy, Safety, and Durability of Cabotegravir and Rilpivirine as 2-Drug Oral Maintenance Therapy After 6 Years of Study. Open Forum Infect Dis 2022; 9:ofac067. [PMID: 35350172 PMCID: PMC8946678 DOI: 10.1093/ofid/ofac067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background In the LATTE study, daily oral cabotegravir + rilpivirine demonstrated higher rates of efficacy than efavirenz + 2 nucleoside reverse-transcriptase inhibitors (NRTIs) through Week 96 in antiretroviral therapy (ART)-naive adults with human immunodeficiency virus (HIV)-1. We present the results from 6 years of continued treatment with oral cabotegravir + rilpivirine. Methods LATTE was a phase IIb, randomized, multicenter, partially blinded, dose-ranging study in ART-naive adults with HIV-1. After a 24-week induction phase with cabotegravir + 2 NRTIs, participants with HIV-1 ribonucleic acid (RNA) <50 copies/mL were randomized to receive cabotegravir (10, 30, or 60 mg) + rilpivirine (25 mg) in the maintenance phase through Week 96 and switched to cabotegravir 30 mg + rilpivirine 25 mg in the open-label phase through Week 312. Results Of 160 participants who entered the maintenance phase, 111 completed the study at Week 312. At Week 312, 105 (66%) participants maintained HIV-1 RNA <50 copies/mL, 15 (9%) had HIV-1 RNA ≥50 copies/mL, and 40 (25%) had no virologic data. Eight participants met protocol-defined virologic failure criteria through Week 312, 2 of whom met protocol-defined virologic failure criteria after Week 144. Six participants developed treatment-emergent resistance to 1 or both agents during the study, 3 of whom developed integrase inhibitor resistance substitutions. Two participants (1%) reported drug-related serious adverse events. Few adverse events led to withdrawal during the open-label phase (n = 5, 3%). Conclusions Oral cabotegravir + rilpivirine demonstrated efficacy in the majority of participants and an acceptable safety profile through 6 years of treatment, demonstrating its durability as maintenance therapy for HIV-1.
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Affiliation(s)
| | - Jerome De Vente
- Long Beach Education and Research Consultants, Long Beach, CA, USA
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26
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Naidoo K, Gengiah S, Yende-Zuma N, Mlobeli R, Ngozo J, Memela N, Padayatchi N, Barker P, Nunn A, Karim SSA. Mortality in HIV and tuberculosis patients following implementation of integrated HIV-TB treatment: Results from an open-label cluster-randomized trial. EClinicalMedicine 2022; 44:101298. [PMID: 35198922 PMCID: PMC8850328 DOI: 10.1016/j.eclinm.2022.101298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND HIV-TB treatment integration reduces mortality. Operational implementation of integrated services is challenging. This study assessed the impact of quality improvement (QI) for HIV-TB integration on mortality within primary healthcare (PHC) clinics in South Africa. METHODS An open-label cluster randomized controlled study was conducted between 2016 and 2018 in 40 rural clinics in South Africa. The study statistician randomized PHC nurse-supervisors 1:1 into 16 clusters (eight nurse-supervisors supporting 20 clinics per arm) to receive QI, supported HIV-TB integration intervention or standard of care (control). Nurse supervisors and clinics under their supervision, based in the study health districts were eligible for inclusion in this study. Nurse supervisors were excluded if their clinics were managed by municipal health (different resource allocation), did not offer co-located antiretroviral therapy (ART) and TB services, services were performed by a single nurse, did not receive non-governmental organisation (NGO) support, patient data was not available for > 50% of attendees. The analysis population consists of all patients newly diagnosed with (i) both TB and HIV (ii) HIV only (among patients previously treated for TB or those who never had TB before) and (iii) TB only (among patients already diagnosed with HIV or those who were never diagnosed with HIV) after QI implementation in the intervention arm, or enrolment in the control arm. Mortality rates was assessed 12 months post enrolment, using unpaired t-tests and cox-proportional hazards model. (Clinicaltrials.gov, NCT02654613, registered 01 June 2015, trial closed). FINDINGS Overall, 21 379 participants were enrolled between December 2016 and December 2018 in intervention and control arm clinics: 1329 and 841 HIV-TB co-infected (10·2%); 10 799 and 6 611 people living with Human Immunodeficiency Virus (HIV)/ acquired immunodeficiency syndrome (AIDS) (PLWHA) only (81·4%); 1 131 and 668 patients with TB only (8·4%), respectively. Average cluster sizes were 1657 (range 170-5782) and 1015 (range 33-2027) in intervention and control arms. By 12 months, 6529 (68·7%) and 4074 (70·4%) were alive and in care, 568 (6·0%) and 321 (5·6%) had completed TB treatment, 1078 (11·3%) and 694 (12·0%) were lost to follow-up, with 245 and 156 deaths occurring in intervention and control arms, respectively. Mortality rates overall [95% confidence interval (CI)] was 4·5 (3·4-5·9) in intervention arm, and 3·8 (2·6-5·4) per 100 person-years in control arm clusters [mortality rate ratio (MRR): 1·19 (95% CI 0·79-1·80)]. Mortality rates among HIV-TB co-infected patients was 10·1 (6·7-15·3) and 9·8 (5·0-18·9) per 100 person-years, [MRR: 1·04 (95% CI 0·51-2·10)], in intervention and control arm clusters, respectively. INTERPRETATION HIV-TB integration supported by a QI intervention did not reduce mortality in HIV-TB co-infected patients. Demonstrating mortality benefit from health systems process improvements in real-world operational settings remains challenging. Despite the study being potentially underpowered to demonstrate the effect size, integration interventions were implemented using existing facility staff and infrastructure reflecting the real-world context where most patients in similar settings access care, thereby improving generalizability and scalability of study findings. FUNDING Research reported in this publication was supported by South African Medical Research Council (SAMRC), and UK Government's Newton Fund through United Kingdom Medical Research Council (UKMRC).
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- Corresponding author at: Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa.
| | - Santhanalakshmi Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Regina Mlobeli
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
| | | | - Nhlakanipho Memela
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Pierre Barker
- Institute for Healthcare Improvement, Gilling's School of Global Public Health, UNC Chapel Hill, Chapel Hill, Cambridge, MA, USA
| | - Andrew Nunn
- Medical Research Council Clinical Trials Unit at University College, London, UK
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Private Bag X7 Congella, Durban 4013, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Impact of Integrase Sequences From HIV-1 Subtypes A6/A1 on the
In Vitro
Potency of Cabotegravir or Rilpivirine. Antimicrob Agents Chemother 2022; 66:e0170221. [PMID: 34978890 PMCID: PMC8923183 DOI: 10.1128/aac.01702-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The FLAIR study demonstrated noninferiority of monthly long-acting cabotegravir + rilpivirine versus daily oral dolutegravir/abacavir/lamivudine for maintaining virologic suppression. Three participants who received long-acting therapy had confirmed virologic failure (CVF) at Week 48, and all had HIV-1 that was originally classified as subtype A1 and contained the baseline integrase polymorphism L74I; updated classification algorithms reclassified all 3 as HIV-1 subtype A6. Retrospectively, the impact of L74I on in vitro sensitivity and durability of response to cabotegravir in HIV-1 subtype B and A6 backgrounds was studied. Site-directed L74I and mutations observed in participants with CVF were generated in HIV-1 subtype B and a consensus integrase derived from 3 subtype A6 CVF baseline sequences. Rilpivirine susceptibility was assessed in HIV-1 subtype B and A1 containing reverse transcriptase mutations observed in participants with CVF. HIV-1 subtype B L74I and L74I/G140R mutants and HIV-1 subtype A6 I74L and I74/G140R mutants remained susceptible to cabotegravir; L74I/Q148R double mutants exhibited reduced susceptibility in HIV-1 subtypes B and A6 (half maximal effective capacity fold change, 4.4 and 4.1, respectively). Reduced rilpivirine susceptibility was observed across HIV-1 subtypes B and A1 with resistance-associated mutations K101E or E138K (half maximal effective capacity fold change, 2.21 to 3.09). In cabotegravir breakthrough experiments, time to breakthrough was similar between L74 and I74 viruses across HIV-1 subtypes B and A6; Q148R was selected at low cabotegravir concentrations. Therefore, the L74I integrase polymorphism did not differentially impact in vitro sensitivity to cabotegravir across HIV-1 subtype B and A6 integrase genes (ClinicalTrials.gov identifier: NCT02938520).
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Qin Y, Zhou Y, Liu S, Lu Y, Liu M, Yuan J, Nie J, Ouyang J, Wu H, Qin Y, Jiang Z, Zhou G, Tian Q, Lan K, Zhou Y, Yang X, He K, Liu J, Harypursat V, Chen Y. HIV-associated talaromycosis: does timing of antiretroviral therapy matter༟. J Infect 2021; 84:410-417. [PMID: 34963636 DOI: 10.1016/j.jinf.2021.12.032] [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: 09/17/2021] [Revised: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES No current academic data is available with respect to the optimal timing to initiate antiretroviral therapy (ART) in HIV-positive patients with talaromycosis. Our study aimed to evaluate the optimal timing of ART initiation for patients presenting with AIDS-related talaromycosis. METHODS In this prospective, randomized, open-label multicenter trial, 228 patients from 15 hospitals in China were randomly assigned to an early ART group (initiation of ART within 2 weeks after randomization) and a deferred ART group (initiation of ART 2 weeks after randomization). The primary endpoint was all-cause mortality during the 48 weeks after randomization. RESULTS We observed a significant difference in mortality between the early ART group and the deferred ART group (2.2% vs. 8.9%, 95%CI: -0.15 to 14.05, p=0.049). The composite outcome of AIDS-defining events or death in the early ART group was found to be lower than that in the deferred ART group (3.3% vs. 14.9%; 95%CI: 2.93 to 19.23, p=0.008). CONCLUSIONS The prognosis of HIV-infected patients with talaromycosis in the early ART group was more favorable than that of patients in the deferred ART group. These results demonstrate that early ART initiation should be considered in HIV-infected patients with talaromycosis .
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Affiliation(s)
- Yuanyuan Qin
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yihong Zhou
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Songtao Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yanqiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing Yuan
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jingmin Nie
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing Ouyang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Hao Wu
- Department of Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yingmei Qin
- Department of Infectious Diseases, the Fourth People's Hospital of Nanning, Guangxi, China
| | - Zhongsheng Jiang
- Department of Infectious Diseases, Liuzhou General Hospital, Guangxi, China
| | - Guoqiang Zhou
- Department of Infectious Diseases, the First Hospital of Changsha, Hunan, China
| | - Qun Tian
- Department of Infectious Diseases, the Third People's Hospital of Guilin, Guangxi, China
| | - Ke Lan
- Department of Infectious Disease, Longtan Hospital of Guangxi Zhuang Autonomous Region, Guangxi, China
| | - Yang Zhou
- Department of Infectious Diseases, the Third People's Hospital of Shenzhen, Guangdong, China
| | - Xinping Yang
- Department of Infectious Diseases, Yunnan Provincial Infectious Disease Hospital, Yunnan, China
| | - Kaiyin He
- Department of Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangdong, China
| | - Jun Liu
- Department of Infectious Diseases, Kunming Third People's Hospital, Yunnan, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China.
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Sharan R, Ganatra SR, Bucsan AN, Cole J, Singh DK, Alvarez X, Gough M, Alvarez C, Blakley A, Ferdin J, Thippeshappa R, Singh B, Escobedo R, Shivanna V, Dick EJ, Hall-Ursone S, Khader SA, Mehra S, Rengarajan J, Kaushal D. Antiretroviral therapy timing impacts latent tuberculosis infection reactivation in a tuberculosis/simian immunodeficiency virus coinfection model. J Clin Invest 2021; 132:153090. [PMID: 34855621 PMCID: PMC8803324 DOI: 10.1172/jci153090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
Studies using the nonhuman primate model of Mycobacteriumtuberculosis/simian immunodeficiency virus coinfection have revealed protective CD4+ T cell–independent immune responses that suppress latent tuberculosis infection (LTBI) reactivation. In particular, chronic immune activation rather than the mere depletion of CD4+ T cells correlates with reactivation due to SIV coinfection. Here, we administered combinatorial antiretroviral therapy (cART) 2 weeks after SIV coinfection to study whether restoration of CD4+ T cell immunity occurred more broadly, and whether this prevented reactivation of LTBI compared to cART initiated 4 weeks after SIV. Earlier initiation of cART enhanced survival, led to better control of viral replication, and reduced immune activation in the periphery and lung vasculature, thereby reducing the rate of SIV-induced reactivation. We observed robust CD8+ T effector memory responses and significantly reduced macrophage turnover in the lung tissue. However, skewed CD4+ T effector memory responses persisted and new TB lesions formed after SIV coinfection. Thus, reactivation of LTBI is governed by very early events of SIV infection. Timing of cART is critical in mitigating chronic immune activation. The potential novelty of these findings mainly relates to the development of a robust animal model of human M. tuberculosis/HIV coinfection that allows the testing of underlying mechanisms.
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Affiliation(s)
- Riti Sharan
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Shashank R Ganatra
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Allison N Bucsan
- Department of Molecular Microbiology, Washington University, St. Louis, St. Louis, United States of America
| | - Journey Cole
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Dhiraj K Singh
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Xavier Alvarez
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Maya Gough
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Cynthia Alvarez
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Alyssa Blakley
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Justin Ferdin
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Rajesh Thippeshappa
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Bindu Singh
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Ruby Escobedo
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Vinay Shivanna
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Edward J Dick
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Shannan Hall-Ursone
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
| | - Shabaana A Khader
- Department of Molecular Microbiology, Washington University, St. Louis, St. Louis, United States of America
| | - Smriti Mehra
- Divisions of Bacteriology and Parasitology, Tulane National Primate Research Center, Covington, United States of America
| | - Jyothi Rengarajan
- Emory Vaccine Center and Yerkes National Primate Research Center, Emory University School of Medicine, Atlanta, United States of America
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, United States of America
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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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Abstract
PURPOSE OF REVIEW People living with HIV (PLWH) are commonly coinfected with Mycobacterium tuberculosis, particularly in high-transmission resource-limited regions. Despite expanded access to antiretroviral therapy and tuberculosis (TB) treatment, TB remains the leading cause of death among PLWH. This review discusses recent advances in the management of TB in PLWH and examines emerging therapeutic approaches to improve outcomes of HIV-associated TB. RECENT FINDINGS Three recent key developments have transformed the management of HIV-associated TB. First, the scaling-up of rapid point-of-care urine-based tests for screening and diagnosis of TB in PLWH has facilitated early case detection and treatment. Second, increasing the availability of potent new and repurposed drugs to treat drug-resistant TB has generated optimism about the treatment and outcome of multidrug-resistant and extensively drug-resistant TB. Third, expanded access to the integrase inhibitor dolutegravir to treat HIV in resource-limited regions has simplified the management of TB/HIV coinfected patients and minimized serious adverse events. SUMMARY While it is unequivocal that substantial progress has been made in early detection and treatment of HIV-associated TB, significant therapeutic challenges persist. To optimize the management and outcomes of TB in HIV, therapeutic approaches that target the pathogen as well as enhance the host response should be explored.
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Adoption of evidence-informed guidelines in prescribing protease inhibitors for HIV-Tuberculosis co-infected patients on rifampicin and effects on HIV treatment outcomes in Uganda. BMC Infect Dis 2021; 21:822. [PMID: 34399706 PMCID: PMC8369708 DOI: 10.1186/s12879-021-06533-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to determine how emerging evidence over the past decade informed how Ugandan HIV clinicians prescribed protease inhibitors (PIs) in HIV patients on rifampicin-based tuberculosis (TB) treatment and how this affected HIV treatment outcomes. METHODS We reviewed clinical records of HIV patients aged 13 years and above, treated with rifampicin-based TB treatment while on PIs between1st-January -2013 and 30th-September-2018 from twelve public HIV clinics in Uganda. Appropriate PI prescription during rifampicin-based TB treatment was defined as; prescribing doubled dose lopinavir/ritonavir- (LPV/r 800/200 mg twice daily) and inappropriate PI prescription as prescribing standard dose LPV/r or atazanavir/ritonavir (ATV/r). RESULTS Of the 602 patients who were on both PIs and rifampicin, 103 patients (17.1% (95% CI: 14.3-20.34)) received an appropriate PI prescription. There were no significant differences in the two-year mortality (4.8 vs. 5.7%, P = 0.318), loss to follow up (23.8 vs. 18.9%, P = 0.318) and one-year post TB treatment virologic failure rates (31.6 vs. 30.7%, P = 0.471) between patients that had an appropriate PI prescription and those that did not. However, more patients on double dose LPV/r had missed anti-retroviral therapy (ART) days (35.9 vs 21%, P = 0.001). CONCLUSION We conclude that despite availability of clinical evidence, double dosing LPV/r in patients receiving rifampicin-based TB treatment is low in Uganda's public HIV clinics but this does not seem to affect patient survival and viral suppression.
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Kendall MA, Lalloo U, Fletcher CV, Wu X, Podany AT, Cardoso SW, Ive P, Benson CA. Safety and Pharmacokinetics of Double-Dose Lopinavir/Ritonavir + Rifampin Versus Lopinavir/Ritonavir + Daily Rifabutin for Treatment of Human Immunodeficiency Virus-Tuberculosis Coinfection. Clin Infect Dis 2021; 73:706-715. [PMID: 34398956 PMCID: PMC8366816 DOI: 10.1093/cid/ciab097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/02/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Protease inhibitor-based antiretroviral therapy may be used in resource-limited settings in persons with human immunodeficiency virus and tuberculosis (HIV-TB). Data on safety, pharmacokinetics/pharmacodynamics (PK/PD), and HIV-TB outcomes for lopinavir/ritonavir (LPV/r) used with rifampin (RIF) or rifabutin (RBT) are limited. METHODS We randomized adults with HIV-TB from July 2013 to February 2016 to arm A, LPV/r 400 mg/100 mg twice daily + RBT 150 mg/day; arm B, LPV/r 800 mg/200 mg twice daily + RIF 600 mg/day; or arm C, LPV/r 400 mg/100 mg twice daily + raltegravir (RAL) 400 mg twice daily + RBT 150 mg/day. All received two nucleoside reverse transcriptase inhibitors and other TB drugs. PK visits occurred on day 12 ± 2. Within-arm HIV-TB outcomes were summarized using proportions and 95% CIs; PK were compared using Wilcoxon tests. RESULTS Among 71 participants, 52% were women; 72% Black; 46% Hispanic; median age, 37 years; median CD4+ count, 130 cells/mm3; median HIV-1 RNA, 4.6 log10 copies/mL; 46% had confirmed TB. LPV concentrations were similar across arms. Pooled LPV AUC12 (157 203 hours × ng/mL) and Ctrough (9876 ng/mL) were similar to historical controls; RBT AUC24 (7374 hours × ng/mL) and Ctrough (208 ng/mL) were higher, although 3 participants in arm C had RBT Cmax <250 ng/mL. Proportions with week 48 HIV-1 RNA <400 copies/mL were 58%, 67%, and 61%, respectively, in arms A, B, and C. CONCLUSIONS Double-dose LPV/r+RIF and LPV/r+RBT 150mg/day had acceptable safety, PK and TB outcomes; HIV suppression was suboptimal but unrelated to PK. Faster RBT clearance and low Cmax in 3 participants on RBT+RAL requires further study.
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Affiliation(s)
- Michelle A Kendall
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Umesh Lalloo
- Enhancing Care Foundation, Durban International Clinical Research Site (CRS), Durban, South Africa
| | - Courtney V Fletcher
- UNMC Center for Drug Discovery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Xingye Wu
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anthony T Podany
- UNMC Center for Drug Discovery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sandra W Cardoso
- Instituto de Pesquisa Clinica Evandro Chagas (IPEC) CRS, Rio de Janeiro, Brazil
| | - Prudence Ive
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Constance A Benson
- Antiviral Research Center, University of California, San Diego, San Diego, California, USA
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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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Li L, Li J, Chai C, Liu T, Li P, Qu M, Zhao H. Association of CD4 T cell count and optimal timing of antiretroviral therapy initiation with immune reconstitution inflammatory syndrome and all-cause mortality for HIV-infected adults with newly diagnosed pulmonary tuberculosis: a systematic review and meta-analysis. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2021; 14:670-679. [PMID: 34239668 PMCID: PMC8255206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/07/2021] [Indexed: 06/13/2023]
Abstract
AIMS CD4 T cell count and optimal timing of antiretroviral therapy (ART) during tuberculosis (TB) treatment are challenging. We conducted a meta-analysis to assess the association of CD4 T cell count and timing of ART initiation with immune reconstitution inflammatory syndrome (IRIS) and all-cause mortality of patients co-infected with HIV/TB. METHODS We conducted an electronic search of clinical studies dated from January 1980 to December 2019 in PubMed and EMBASE. Randomized, controlled trials evaluating low-base CD4 T cell count (< 50 cells/μL) versus high-base CD4 T cell count (≥ 50 cells/μL), and/or early ART initiation (1 to 28 days after starting TB treatment) versus delayed ART initiation (≥ 28 days after starting TB treatment) were included. The primary endpoints were all-cause mortality and TB-related immune reconstitution inflammatory syndrome (IRIS-TB). The risk ratio (RR) was calculated as a measure of intervention effect. Mantel-Haenszel method was used to estimate the RR. RESULTS Ten trials (n = 5226) were conducted in North America, Africa, and Asia. We found that low-baseline CD4 T cell count increased the incidence of TB-associated IRIS (RR, 1.47; 95% CI, 1.24-1.75; I2 = 58%) and all-cause mortality (RR, 2.42; 95% CI, 1.71-3.42; I2 = 41%) compared with high baseline CD4 T cell count, and early ART initiation increased the incidence of TB-associated IRIS compared with delayed ART initiation (RR, 1.80; 95% CI, 1.57-2.07; I2 = 74%). However, early ART initiation did not reduce all-cause mortality (RR, 0.91; 95% CI, 0.74-1.12; I2 = 49%) compared with delayed ART initiation. CONCLUSIONS The present study demonstrates that low-baseline CD4 T cell count (< 50 cells/μL) in patients co-infected with TB-HIV increases the incidence of TB-associated IRIS and all-cause mortality. Early ART initiation (≤ 28 days) in patients co-infected with TB-HIV increases the incidence of TB-associated IRIS. However, evidence is insufficient to refute or support a survival benefit conferred by the comparison between early ART initiation (≤ 28 days) and delayed ART initiation.
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Affiliation(s)
- Lifang Li
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Jianqiang Li
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Chunwei Chai
- Department of Internal Medicine, The Fourth People’s Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Tanzhen Liu
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Pingping Li
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Mengrui Qu
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Hui Zhao
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
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Davis AG, Wasserman S, Maxebengula M, Stek C, Bremer M, Daroowala R, Aziz S, Goliath R, Stegmann S, Koekemoer S, Jackson A, Lai Sai L, Kadernani Y, Sihoyiya T, Liang CJ, Dodd L, Denti P, Crede T, Naude J, Szymanski P, Vallie Y, Banderker I, Moosa S, Raubenheimer P, Lai RPJ, Joska J, Nightingale S, Dreyer A, Wahl G, Offiah C, Vorster I, Candy S, Robertson F, Meintjes E, Maartens G, Black J, Meintjes G, Wilkinson RJ. Study protocol for a phase 2A trial of the safety and tolerability of increased dose rifampicin and adjunctive linezolid, with or without aspirin, for HIV-associated tuberculous meningitis [LASER-TBM]. Wellcome Open Res 2021; 6:136. [PMID: 34286103 PMCID: PMC8283551 DOI: 10.12688/wellcomeopenres.16783.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Tuberculous meningitis (TBM) is the most lethal form of tuberculosis with a mortality of ~50% in those co-infected with HIV-1. Current antibiotic regimens are based on those known to be effective in pulmonary TB and do not account for the differing ability of the drugs to penetrate the central nervous system (CNS). The host immune response drives pathology in TBM, yet effective host-directed therapies are scarce. There is sufficient data to suggest that higher doses of rifampicin (RIF), additional linezolid (LZD) and adjunctive aspirin (ASA) will be beneficial in TBM yet rigorous investigation of the safety of these interventions in the context of HIV associated TBM is required. We hypothesise that increased dose RIF, LZD and ASA used in combination and in addition to standard of care for the first 56 days of treatment with be safe and tolerated in HIV-1 infected people with TBM. Methods: In an open-label randomised parallel study, up to 100 participants will receive either; i) standard of care (n=40, control arm), ii) standard of care plus increased dose RIF (35mg/kg) and LZD (1200mg OD for 28 days, 600mg OD for 28 days) (n=30, experimental arm 1), or iii) as per experimental arm 1 plus additional ASA 1000mg OD (n=30, experimental arm 2). After 56 days participants will continue standard treatment as per national guidelines. The primary endpoint is death and the occurrence of solicited treatment-related adverse events at 56 days. In a planned pharmacokinetic (PK) sub-study we aim to assess PK/pharmacodynamic (PD) of oral vs IV rifampicin, describe LZD and RIF PK and cerebrospinal fluid concentrations, explore PK/PD relationships, and investigate drug-drug interactions between LZD and RIF. Safety and pharmacokinetic data from this study will inform a planned phase III study of intensified therapy in TBM. Clinicaltrials.gov registration: NCT03927313 (25/04/2019)
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Affiliation(s)
- Angharad G Davis
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Faculty of Life Sciences, University College London, London, WC1E 6BT, UK.,Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Mpumi Maxebengula
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Cari Stek
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - Marise Bremer
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Remy Daroowala
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - Saalikha Aziz
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Rene Goliath
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Stephani Stegmann
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Sonya Koekemoer
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Louise Lai Sai
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Yakub Kadernani
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Thandi Sihoyiya
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - C Jason Liang
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Lori Dodd
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Maryland, USA
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Thomas Crede
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Jonathan Naude
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Patryk Szymanski
- Mitchells Plain Hospital, 8 A Z Berman Drive, Lentegeur, Cape Town, 7785, South Africa
| | - Yakoob Vallie
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Ismail Banderker
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Shiraz Moosa
- New Somerset Hospital, Portswood Rd, Green Point, Cape Town, 8051, South Africa
| | - Peter Raubenheimer
- Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Rachel P J Lai
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
| | - John Joska
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Sam Nightingale
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Anna Dreyer
- Department of Psychiatry and Mental Health, HIV Mental Health Research Unit, Neuroscience Institute, University of Cape Town, Observatory, 7925, South Africa
| | - Gerda Wahl
- Department of Medicine, Water Sisulu University, Mthatha, 5117, South Africa
| | - Curtis Offiah
- Department of Neuroradiology, Imaging Department, Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, UK
| | - Isak Vorster
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory, 7925, South Africa
| | - Sally Candy
- Division of Diagnostic Radiology, University of Cape Town, Groote Schuur Hospital, Observatory, 7925, South Africa
| | - Frances Robertson
- MRC/UCT Medical Imaging Research Unit Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, South Africa
| | - Ernesta Meintjes
- MRC/UCT Medical Imaging Research Unit Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - John Black
- Department of Medicine, Water Sisulu University, Mthatha, 5117, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, Midland Rd, London, NW1 1AT, UK.,Faculty of Life Sciences, University College London, London, WC1E 6BT, UK.,Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa.,Department of Infectious Diseases, Imperial College London, London, W12 0NN, UK
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Bentzon AK, Panteleev A, Mitsura V, Borodulina E, Skrahina A, Denisova E, Tetradov S, Podlasin R, Riekstina V, Kancauskiene Z, Paduto D, Mocroft A, Trofimova T, Miller R, Post F, Grezesczuk A, Lundgren JD, Inglot M, Podlekareva D, Bolokadze N, Kirk O. Healthcare delivery for HIV-positive people with tuberculosis in Europe. HIV Med 2021; 22:283-293. [PMID: 33215809 PMCID: PMC9801686 DOI: 10.1111/hiv.13016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND In a 2013 survey, we reported distinct discrepancies in delivery of tuberculosis (TB) and HIV services in eastern Europe (EE) vs. western Europe (WE). OBJECTIVES To verify the differences in TB and HIV services in EE vs. WE. METHODS Twenty-three sites completed a survey in 2018 (EE, 14; WE, nine; 88% response rate). Results were compared across as well as within the two regions. When possible, results were compared with the 2013 survey. RESULTS Delivery of healthcare was significantly less integrated in EE: provision of TB and HIV services at one site (36% in EE vs. 89% in WE; P = 0.034), and continued TB follow-up in one location (42% vs. 100%; P = 0.007). Although access to TB diagnostics, standard TB and HIV drugs was generally good, fewer sites in EE reported unlimited access to rifabutin/multi-drug-resistant TB (MDR-TB) drugs, HIV integrase inhibitors and opioid substitution therapy (OST). Compared with 2013, routine usage of GeneXpert was more common in EE in 2018 (54% vs. 92%; P = 0.073), as was access to moxifloxacin (46% vs. 91%; P = 0.033), linezolid (31% vs. 64%; P = 0.217), and bedaquiline (0% vs. 25%; P = 0.217). Integration of TB and HIV services (46% vs. 39%; P = 1.000) and provision of OST to patients with opioid dependency (54% vs. 46%; P = 0.695) remained unchanged. CONCLUSION Delivery of TB and HIV healthcare, including integration of TB and HIV care and access to MDR-TB drugs, still differs between WE and EE, as well as between individual EE sites.
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Affiliation(s)
- A K Bentzon
- CHIP (Centre of Excellence for Health, Immunity and Infections), Department of Infectious Disease, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - A Panteleev
- Department of HIV/TB, TB Hospital 2, St Petersburg, Russia
| | - V Mitsura
- Gomel State Medical University, Gomel, Belarus
| | - E Borodulina
- Department of Phthisiology and Pulmonology, Samara State Medical University of Minzdrav of Russia, Samara, Russia
| | - A Skrahina
- Republican Research and Practical Clinic for Pulmonology, Minsk, Belarus
| | - E Denisova
- Botkin Hospital of Infectious Disease, St Petersburg, Russia
| | - S Tetradov
- Dr. Victor Babes Hospital, Bucharest, Romania
| | - R Podlasin
- Wojewodski Szpital Zakanzy/Medical University of Warsaw, Warsaw, Poland
| | - V Riekstina
- Clinic of TB and Lung Diseases, Riga, Latvia
| | - Z Kancauskiene
- Clinic for Communicable Diseases and AIDS, Vilnius, Lithuania
| | - D Paduto
- Gomel Region Clinic for Hygiene, Svetlogorsk, Belarus
| | - A Mocroft
- Department of Infection and Population Health, University College London, London, UK
| | - T Trofimova
- Clinic for Prevention and Control of AIDS, Novgorod, Russia
| | - R Miller
- Mortimer Market Clinic, London, UK
| | - F Post
- King's College Hospital, London, UK
| | - A Grezesczuk
- Medical University Teaching Hospital, Bialystok, Poland
| | - J D Lundgren
- CHIP (Centre of Excellence for Health, Immunity and Infections), Department of Infectious Disease, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - M Inglot
- Wroclaw University School of Medicine, Wroclaw, Poland
| | - D Podlekareva
- CHIP (Centre of Excellence for Health, Immunity and Infections), Department of Infectious Disease, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - N Bolokadze
- Infectious Diseases, AIDS and Clinical Immunology Research Clinic, Tbilisi, Georgia
| | - O Kirk
- CHIP (Centre of Excellence for Health, Immunity and Infections), Department of Infectious Disease, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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38
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Seddiki N, French M. COVID-19 and HIV-Associated Immune Reconstitution Inflammatory Syndrome: Emergence of Pathogen-Specific Immune Responses Adding Fuel to the Fire. Front Immunol 2021; 12:649567. [PMID: 33841434 PMCID: PMC8024517 DOI: 10.3389/fimmu.2021.649567] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/08/2021] [Indexed: 12/15/2022] Open
Abstract
Both coronavirus disease 2019 (COVID-19) and mycobacterial immune reconstitution inflammatory syndrome (IRIS) in patients with HIV-1 infection result from immunopathology that is characterized by increased production of multiple pro-inflammatory chemokines and cytokines associated with activation of myeloid cells (monocytes, macrophages and neutrophils). We propose that both conditions arise because innate immune responses generated in the absence of effective adaptive immune responses lead to monocyte/macrophage activation that is amplified by the emergence of a pathogen-specific adaptive immune response skewed towards monocyte/macrophage activating activity by the immunomodulatory effects of cytokines produced during the innate response, particularly interleukin-18. In mycobacterial IRIS, that disease-enhancing immune response is dominated by a Th1 CD4+ T cell response against mycobacterial antigens. By analogy, it is proposed that in severe COVID-19, amplification of monocyte/macrophage activation results from the effects of a SARS-CoV-2 spike protein antibody response with pro-inflammatory characteristics, including high proportions of IgG3 and IgA2 antibodies and afucosylation of IgG1 antibodies, that arises from B cell differentiation in an extra-follicular pathway promoted by activation of mucosa-associated invariant T cells. We suggest that therapy for the hyperinflammation underlying both COVID-19 and mycobacterial IRIS might be improved by targeting the immunomodulatory as well as the pro-inflammatory effects of the ‘cytokine storm’.
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Affiliation(s)
- Nabila Seddiki
- Inserm, U955, Equipe 16, Créteil, 94000, France, Université Paris Est, Faculté de Médecine, Créteil, France.,Vaccine Research Institute (VRI), Créteil, France
| | - Martyn French
- School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia.,Division of Immunology, PathWest Laboratory Medicine, Perth, WA, Australia
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Abstract
Care of patients with human immunodeficiency virus (HIV) infection in the intensive care unit (ICU) has changed dramatically since the infection was first recognized in the United States in 1981. The purpose of this review is to describe the current important aspects of care of patients with HIV infection in the ICU, with a primary focus on the United States and developed countries. The epidemiology and initial approach to diagnosis and treatment of HIV (including the newest antiretroviral guidelines), common syndromes and their management in the ICU, and typical comorbidities and opportunistic infections of patients with HIV infection are discussed.
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40
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De Castro N, Marcy O, Chazallon C, Messou E, Eholié S, N'takpe JB, Bhatt N, Khosa C, Timana Massango I, Laureillard D, Chau GD, Domergue A, Veloso V, Escada R, Wagner Cardoso S, Delaugerre C, Anglaret X, Molina JM, Grinsztejn B. Standard dose raltegravir or efavirenz-based antiretroviral treatment for patients co-infected with HIV and tuberculosis (ANRS 12 300 Reflate TB 2): an open-label, non-inferiority, randomised, phase 3 trial. THE LANCET. INFECTIOUS DISEASES 2021; 21:813-822. [PMID: 33667406 DOI: 10.1016/s1473-3099(20)30869-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/16/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients co-infected with HIV and tuberculosis, antiretroviral therapy options are limited due to drug-drug interactions with rifampicin. A previous phase 2 trial indicated that raltegravir 400 mg twice a day or efavirenz 600 mg once a day might have similar virological efficacy in patients given rifampicin. In this phase 3 trial, we assessed the non-inferiority of raltegravir to efavirenz. METHODS We did a multicentre, open-label, non-inferiority, randomised, phase 3 trial at six sites in Côte d'Ivoire, Brazil, France, Mozambique, and Vietnam. We included antiretroviral therapy (ART)-naive adults (aged ≥18 years) with confirmed HIV-1 infection and bacteriologically confirmed or clinically diagnosed tuberculosis who had initiated rifampicin-containing tuberculosis treatment within the past 8 weeks. Using computerised random numbers, we randomly assigned participants (1:1; stratified by country) to receive raltegravir 400 mg twice daily or efavirenz 600 mg once daily, both in combination with tenofovir and lamivudine. The primary outcome was the proportion of patients with virological suppression at week 48 (defined as plasma HIV RNA concentration <50 copies per mL). The prespecified non-inferiority margin was 12%. The primary outcome was assessed in the intention-to-treat population, which included all randomly assigned patients (excluding two patients with HIV-2 infection and one patient with HIV-1 RNA concentration of <50 copies per mL at inclusion), and the on-treatment population, which included all patients in the intention-to-treat population who initiated treatment and were continuing allocated treatment at week 48, and patients who had discontinued allocated treatment due to death or virological failure. Safety was assessed in all patients who received at least one dose of the assigned treatment regimen. This study is registered with ClinicalTrials.gov, NCT02273765. FINDINGS Between Sept 28, 2015, and Jan 5, 2018, 460 participants were randomly assigned to raltegravir (n=230) or efavirenz (n=230), of whom 457 patients (230 patients in the raltegravir group; 227 patients in the efavirenz group) were included in the intention-to-treat analysis and 410 (206 patients in the raltegravir group; 204 patients in the efavirenz group) in the on-treatment analysis. At baseline, the median CD4 count was 103 cells per μL and median plasma HIV RNA concentration was 5·5 log10 copies per mL (IQR 5·0-5·8). 310 (68%) of 457 participants had bacteriologically-confirmed tuberculosis. In the intention-to-treat population, at week 48, 140 (61%) of 230 participants in the raltegravir group and 150 (66%) of 227 patients in the efavirenz had achieved virological suppression (between-group difference -5·2% [95% CI -14·0 to 3·6]), thus raltegravir did not meet the predefined criterion for non-inferiority. The most frequent adverse events were HIV-associated non-AIDS illnesses (eight [3%] of 229 patients in the raltegravir group; 21 [9%] of 230 patients in the efavirenz group) and AIDS-defining illnesses (ten [4%] patients in the raltegravir group; 13 [6%] patients in the efavirenz group). 58 (25%) of 229 patients in raltegravir group and 66 (29%) of 230 patients in the efavirenz group had grade 3 or 4 adverse events. 26 (6%) of 457 patients died during follow-up: 14 in the efavirenz group and 12 in the raltegravir group. INTERPRETATION In patients with HIV given tuberculosis treatment, non-inferiority of raltegravir compared with efavirenz was not shown. Raltegravir was well tolerated and could be considered as an option, but only in selected patients. FUNDING National French Agency for AIDS Research, Ministry of Health in Brazil, Merck. TRANSLATIONS For the Portuguese and French translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nathalie De Castro
- Department of Infectious Diseases, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France; Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France.
| | - Olivier Marcy
- Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France
| | - Corine Chazallon
- Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France
| | - Eugène Messou
- Centre de Prise en charge de Recherche et de Formation, Abidjan, Côte d'Ivoire; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire; Département de Dermatologie et d'Infectiologie, Unite de Formation et de Recherche des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | - Serge Eholié
- Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire; Département de Dermatologie et d'Infectiologie, Unite de Formation et de Recherche des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | | | - Nilesh Bhatt
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Celso Khosa
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | | | - Didier Laureillard
- Research Unit 1058 Pathogenesis and Control Chronical Infections, INSERM, French Blood Center, University of Montpellier, Montpellier, France; Department of Infectious and Tropical Diseases, Nimes University Hospital, Nimes, France
| | - Giang Do Chau
- General Planning Department, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Anaïs Domergue
- National Agency for Research on AIDS and Viral Hepatitis Research Site, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Valdilea Veloso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Rodrigo Escada
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Constance Delaugerre
- Department of Virology, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U944, Université de Paris, Paris, France
| | - Xavier Anglaret
- Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France; Centre de Prise en charge de Recherche et de Formation, Abidjan, Côte d'Ivoire
| | - Jean-Michel Molina
- Department of Infectious Diseases, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U944, Université de Paris, Paris, France
| | - Beatriz Grinsztejn
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Ravimohan S, Auld SC, Maenetje P, Ratsela N, Mlotshwa M, Ncube I, Smith JP, Vangu MDT, Sebe M, Kossenkov A, Weissman D, Wallis RS, Churchyard G, Kornfeld H, Bisson GP. Lung Injury on Antiretroviral Therapy in Adults With Human Immunodeficiency Virus/Tuberculosis. Clin Infect Dis 2021; 70:1845-1854. [PMID: 31242296 DOI: 10.1093/cid/ciz560] [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: 03/14/2019] [Accepted: 06/24/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Immune restoration on antiretroviral therapy (ART) can drive inflammation in people living with human immunodeficiency virus (HIV) who have pulmonary tuberculosis (TB), but its effects on the lungs have not been assessed. We evaluated associations between pulmonary inflammation, recovery of pathogen-specific CD4 T-cell function, and lung injury prior to and after ART initiation in adults with HIV and pulmonary TB. METHODS This was a prospective cohort study in South Africa, following adults with HIV and pulmonary TB prior to and up to 48 weeks after ART initiation. Pulmonary-specific inflammation was defined as total glycolytic activity (TGA) on [18]F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) at baseline and 4 weeks after ART initiation. Spirometry, respiratory symptom tests, and flow cytometry were performed at the same times to assess lung involvement and the frequency of mycobacteria-specific CD4 T-cells. In addition, we evaluated lung function longitudinally up to 48 weeks after ART initiation. RESULTS Greater lung TGA on FDG PET-CT was associated with worse lung function and respiratory symptoms prior to ART initiation, and nearly half of subjects experienced worsening lung inflammation and lung function at Week 4 of ART. Worsening Week 4 lung inflammation and pulmonary function were both associated with greater increases in pathogen-specific functional CD4 T-cell responses on ART, and early decreases in lung function were independently associated with persistently lower lung function months after TB treatment completion. CONCLUSIONS Increases in pulmonary inflammation and decreases in lung function are common on ART, relate to greater ART-mediated CD4 T-cell restoration, and are associated with the persistent impairment of lung function in individuals with HIV/TB.
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Affiliation(s)
- Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Sara C Auld
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Jonathan P Smith
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Mboyo-Di-Tamba Vangu
- Nuclear Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, South Africa
| | | | | | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Gavin Churchyard
- The Aurum Institute, Johannesburg.,Advancing Care and Treatment for Tuberculosis/Human Immuondeficiency Virus, A Collaborating Centre of The South African Medical Research Council.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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42
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Dooley KE, Kaplan R, Mwelase N, Grinsztejn B, Ticona E, Lacerda M, Sued O, Belonosova E, Ait-Khaled M, Angelis K, Brown D, Singh R, Talarico CL, Tenorio AR, Keegan MR, Aboud M. Dolutegravir-based Antiretroviral Therapy for Patients Coinfected With Tuberculosis and Human Immunodeficiency Virus: A Multicenter, Noncomparative, Open-label, Randomized Trial. Clin Infect Dis 2021; 70:549-556. [PMID: 30918967 DOI: 10.1093/cid/ciz256] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The concurrent treatment of tuberculosis and human immunodeficiency virus (HIV) is challenging, owing to drug interactions, overlapping toxicities, and immune reconstitution inflammatory syndrome (IRIS). The efficacy and safety of dolutegravir (DTG) were assessed in adults with HIV and drug-susceptible tuberculosis. METHODS International Study of Patients with HIV on Rifampicin ING is a noncomparative, active-control, randomized, open-label study in HIV-1-infected antiretroviral therapy-naive adults (CD4+ ≥50 cells/mm3). Participants on rifampicin-based tuberculosis treatment ≤8 weeks were randomized (3:2) to receive DTG (50 mg twice daily both during and 2 weeks after tuberculosis therapy, then 50 mg once daily) or efavirenz (EFV; 600 mg daily) with 2 nucleoside reverse transcriptase inhibitors for 52 weeks. The primary endpoint was the proportion of DTG-arm participants with plasma HIV-1-RNA <50 copies/mL (responders) by the Food and Drug Administration Snapshot algorithm (intent-to-treat exposed population) at Week 48. The study was not powered to compare arms. RESULTS For DTG (n = 69), the baseline HIV-1 RNA was >100 000 copies/mL in 64% of participants, with a median CD4+ count of 208 cells/mm3; for EFV (n = 44), 55% of participants had HIV-1 RNA >100 000 copies/mL, with a median CD4+ count of 202 cells/mm3. The Week 48 response rates were 75% (52/69, 95% confidence interval [CI] 65-86%) for DTG and 82% (36/44, 95% CI 70-93%) for EFV. The DTG nonresponses were driven by non-treatment related discontinuations (n = 10 lost to follow-up). There were no deaths or study drug switches. There were 2 discontinuations for toxicity (EFV). There were 3 protocol-defined virological failures (2 DTG, no acquired resistance; 1 EFV, emergent resistance to nucleoside reverse transcriptase inhibitors and nonnucleoside reverse transcriptase inhibitors). The tuberculosis treatment success rate was high. Tuberculosis-associated IRIS was uncommon (4/arm), with no discontinuations for IRIS. CONCLUSIONS Among adults with HIV receiving rifampicin-based tuberculosis treatment, twice-daily DTG was effective and well tolerated. CLINICAL TRIALS REGISTRATION NCT02178592.
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Affiliation(s)
- Kelly E Dooley
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard Kaplan
- Desmond Tutu Human Immunodeficiency Virus (HIV) Foundation, Cape Town
| | | | - Beatriz Grinsztejn
- Instituto de Pesquisa Clínica Evandro Chagas Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil
| | - Eduardo Ticona
- Hospital Nacional Dos de Mayo, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Marcus Lacerda
- Instituto Leônidas & Maria Deane (Fiocruz)/Tropical Medicine Foundation Dr Heitor Vieira Dourado, Manaus, Brazil
| | - Omar Sued
- Fundación Huésped, Buenos Aires, Argentina
| | - Elena Belonosova
- Regional Center For Prevention and Treatment of Acquired Immunodeficiency Syndrome and Infectious Diseases, Orel, Russia
| | | | | | - Dannae Brown
- ViiV Healthcare Ltd., Melbourne, Victoria, Australia
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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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44
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Wong K, Nguyen J, Blair L, Banjanin M, Grewal B, Bowman S, Boyd H, Gerstner G, Cho HJ, Panfilov D, Tam CK, Aguilar D, Venketaraman V. Pathogenesis of Human Immunodeficiency Virus- Mycobacterium tuberculosis Co-Infection. J Clin Med 2020; 9:E3575. [PMID: 33172001 PMCID: PMC7694603 DOI: 10.3390/jcm9113575] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023] Open
Abstract
Given that infection with Mycobacterium tuberculosis (Mtb) is the leading cause of death amongst individuals living with HIV, understanding the complex mechanisms by which Mtb exacerbates HIV infection may lead to improved treatment options or adjuvant therapies. While it is well-understood how HIV compromises the immune system and leaves the host vulnerable to opportunistic infections such as Mtb, less is known about the interplay of disease once active Mtb is established. This review explores how glutathione (GSH) depletion, T cell exhaustion, granuloma formation, and TNF-α upregulation, as a result of Mtb infection, leads to an increase in HIV disease severity. This review also examines the difficulties of treating coinfected patients and suggests further research on the clinical use of GSH supplementation.
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Affiliation(s)
- Kevin Wong
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - James Nguyen
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Lillie Blair
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Marina Banjanin
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Bunraj Grewal
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Shane Bowman
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Hailey Boyd
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Grant Gerstner
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Hyun Jun Cho
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - David Panfilov
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Cho Ki Tam
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Delaney Aguilar
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
| | - Vishwanath Venketaraman
- College of Osteopathic Medicine of the Pacific-NorthWest, Western University of Health Sciences, Lebanon, OR 97355, USA; (K.W.); (J.N.); (L.B.); (M.B.); (B.G.); (S.B.); (H.B.); (G.G.); (H.J.C.); (D.P.); (C.K.T.); (D.A.)
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
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45
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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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46
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Mshweshwe-Pakela N, Hansoti B, Mabuto T, Kerrigan D, Kubeka G, Hahn E, Charalambous S, Hoffmann CJ. Feasibility of implementing same-day antiretroviral therapy initiation during routine care in Ekurhuleni District, South Africa: Retention and viral load suppression. South Afr J HIV Med 2020; 21:1085. [PMID: 32934830 PMCID: PMC7479383 DOI: 10.4102/sajhivmed.v21i1.1085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
Background Same-day initiation (SDI) of antiretroviral therapy (ART) has been advocated as an approach to increase linkage to care and overall ART initiation. Clinical trials have demonstrated impressive benefits. However, questions regarding patient preparedness and retention in care remain for routine implementation of this approach. Objectives In this study, we sought to describe SDI of ART during routine care delivery and compare time to ART initiation on longitudinal care outcomes. Method We performed a retrospective chart review of 100 consecutive individuals, newly diagnosed with HIV, from 10 health facilities across Ekurhuleni, from January to July 2017. Records were reviewed for a period of 1 year post-diagnosis. Abstracted data included demographics, time to ART initiation, clinic visits and laboratory test results (including viral load testing). Results A total of 993 patient records were reviewed, of which 826 were included in the analysis. The majority of patients (752, 91%) had ART initiation recorded, of which 654 (79%) had ART initiated within 30 days, and 224 (27%) had SDI. Uptake of SDI of ART was higher among women (36% vs. 10.4%; p < 0.001) and in younger patients (33.7% in those < 29 years; p < 0.01). Retention in care at 6 months was achieved in 477 (58%) patients. Of those with 6-month viral loads, 350/430 (73%) had a viral load < 400 c/m. Retention in care and viral suppression were similar among those with SDI of ART and later ART initiation. Conclusion Same-day initiation of ART was successfully delivered with similar retention and viral load outcomes as subsequent initiation, providing re-assurance for scale-up of this strategy in routine care.
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Affiliation(s)
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, United States of America.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tonderai Mabuto
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Deanna Kerrigan
- Department of Sociology, American University, Washington, United States of America
| | - Griffiths Kubeka
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Elizabeth Hahn
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J Hoffmann
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America.,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
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47
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Bisson GP, Bastos M, Campbell JR, Bang D, Brust JC, Isaakidis P, Lange C, Menzies D, Migliori GB, Pape JW, Palmero D, Baghaei P, Tabarsi P, Viiklepp P, Vilbrun S, Walsh J, Marks SM. Mortality in adults with multidrug-resistant tuberculosis and HIV by antiretroviral therapy and tuberculosis drug use: an individual patient data meta-analysis. Lancet 2020; 396:402-411. [PMID: 32771107 PMCID: PMC8094110 DOI: 10.1016/s0140-6736(20)31316-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/14/2020] [Accepted: 05/21/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND HIV-infection is associated with increased mortality during multidrug-resistant tuberculosis treatment, but the extent to which the use of antiretroviral therapy (ART) and anti-tuberculosis medications modify this risk are unclear. Our objective was to evaluate how use of these treatments altered mortality risk in HIV-positive adults with multidrug-resistant tuberculosis. METHODS We did an individual patient data meta-analysis of adults 18 years or older with confirmed or presumed multidrug-resistant tuberculosis initiating tuberculosis treatment between 1993 and 2016. Data included ART use and anti-tuberculosis medications grouped according to WHO effectiveness categories. The primary analysis compared HIV-positive with HIV-negative patients in terms of death during multidrug-resistant tuberculosis treatment, excluding those lost to follow up, and was stratified by ART use. Analyses used logistic regression after exact matching on country World Bank income classification and drug resistance and propensity-score matching on age, sex, geographic site, year of multidrug-resistant tuberculosis treatment initiation, previous tuberculosis treatment, directly observed therapy, and acid-fast-bacilli smear-positivity to obtain adjusted odds ratios (aORs) and 95% CIs. Secondary analyses were conducted among those with HIV-infection. FINDINGS We included 11 920 multidrug-resistant tuberculosis patients. 2997 (25%) were HIV-positive and on ART, 886 (7%) were HIV-positive and not on ART, and 1749 (15%) had extensively drug-resistant tuberculosis. By use of HIV-negative patients as reference, the aOR of death was 2·4 (95% CI 2·0-2·9) for all patients with HIV-infection, 1·8 (1·5-2·2) for HIV-positive patients on ART, and 4·2 (3·0-5·9) for HIV-positive patients with no or unknown ART. Among patients with HIV, use of at least one WHO Group A drug and specific use of moxifloxacin, levofloxacin, bedaquiline, or linezolid were associated with significantly decreased odds of death. INTERPRETATION Use of ART and more effective anti-tuberculosis drugs is associated with lower odds of death among HIV-positive patients with multidrug-resistant tuberculosis. Access to these therapies should be urgently pursued. FUNDING American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.
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Affiliation(s)
- Gregory P Bisson
- Department of Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Mayara Bastos
- Social Medicine Institute, State University of Rio de Janeiro, Rio de Janeiro, Brazil; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Jonathon R Campbell
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Didi Bang
- Virus & Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | - James C Brust
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | | | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
| | - Dick Menzies
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Giovanni B Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Maugeri Care and Research Institute, Tradate, Italy
| | | | - Domingo Palmero
- División Neumotisiología, Hospital Muñiz, Buenos Aires, Argentina
| | - Parvaneh Baghaei
- Clinical Tuberculosis and Epidemiology Research Center National Research Institute for Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Tabarsi
- Clinical Tuberculosis and Epidemiology Research Center National Research Institute for Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Piret Viiklepp
- National Institute of Health Development, Tallinn, Estonia
| | - Stalz Vilbrun
- Groupe Haitien d'Étude du Sarcome de Kaposi et des infections Opportunistes, Port-au-Prince, Haiti
| | - Jonathan Walsh
- Department of Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Suzanne M Marks
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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48
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Sharan R, Bucşan AN, Ganatra S, Paiardini M, Mohan M, Mehra S, Khader SA, Kaushal D. Chronic Immune Activation in TB/HIV Co-infection. Trends Microbiol 2020; 28:619-632. [PMID: 32417227 PMCID: PMC7390597 DOI: 10.1016/j.tim.2020.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/03/2020] [Accepted: 03/25/2020] [Indexed: 12/27/2022]
Abstract
HIV co-infection is the most critical risk factor for the reactivation of latent tuberculosis (TB) infection (LTBI). While CD4+ T cell depletion has been considered the major cause of HIV-induced reactivation of LTBI, recent work in macaques co-infected with Mycobacterium tuberculosis (Mtb)/simian immunodeficiency virus (SIV) suggests that cytopathic effects of SIV resulting in chronic immune activation and dysregulation of T cell homeostasis correlate with reactivation of LTBI. This review builds on compelling data that the reactivation of LTBI during HIV co-infection is likely to be driven by the events of HIV replication and therefore highlights the need to have optimum translational interventions directed at reactivation due to co-infection.
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Affiliation(s)
- Riti Sharan
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Allison N Bucşan
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Shashank Ganatra
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Mirko Paiardini
- Yerkes National Primate Research Center, Emory University School of Medicine, Atlanta, GA 30329, USA
| | - Mahesh Mohan
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Smriti Mehra
- Tulane National Primate Research Center, Tulane University School of Medicine, Covington, LA 70433, USA
| | - Shabaana A Khader
- Department of Molecular Microbiology, Washington University in St Louis School of Medicine, St Louis, MO 63110, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA.
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Caminero JA, García-García JM, Caylà JA, García-Pérez FJ, Palacios JJ, Ruiz-Manzano J. Update of SEPAR guideline «Diagnosis and Treatment of Drug-Resistant Tuberculosis». Arch Bronconeumol 2020; 56:514-521. [PMID: 32446667 DOI: 10.1016/j.arbres.2020.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 01/30/2023]
Abstract
New evidence and knowledge about the clinical management of drug-resistant tuberculosis (TB) in the last 3 years, makes it necessary to update the recent guideline published by SEPAR in 2017, mainly in relation to new diagnostic methods, drug classification, and regimens of treatment recommended to treat patients with isoniazid-resistance TB, rifampicin resistance TB and multidrug-resistant TB. With respect to tuberculosis diagnosis, we recommend the use of rapid molecular assays that also help to detect mutations associated with resistance. In relation to the treatment of multidrug-resistant TB we prioritize effective all-oral shorter treatment regimens including bedaquiline, a fluoroquinolone (levofloxacin or moxifloxacin), bedaquiline and linezolid, instead of the previously recommended short-course treatment with aminoglycosides and other less effective and more toxic drugs. The design of these regimens (initial schedule and changes in the regimen if necessary) should be made in accordance with drug-resistant TB experts; the treatment should be the responsibility of personnel with experience in the treatment of TB and in TB units guaranteeing the follow-up of the treatment and the management of drugs adverse effects.
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Affiliation(s)
- José A Caminero
- Servicio de Neumología, Hospital General de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España; Unión Internacional contra la Tuberculosis y Enfermedades Respiratorias (La Unión), París, Francia; Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, España
| | - José-María García-García
- Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, España; Unidad de Gestión Clínica de Neumología, Hospital Universitario San Agustín, Avilés, Asturias, España.
| | - Joan A Caylà
- Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, España; Fundación de la Unidad de Investigación en Tuberculosis (fuiTB) de Barcelona, España
| | - Francisco J García-Pérez
- Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, España; Servicio de Neumología, Hospital Universitario de La Princesa, Madrid, España
| | - Juan J Palacios
- Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, España; Unidad de Referencia Regional de Micobacterias, Servicio de Microbiología, Hospital Universitario Central de Asturias, Oviedo, España
| | - Juan Ruiz-Manzano
- Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, España; Centro Médico Teknon, Barcelona, España
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50
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Girum T, Yasin F, Dessu S, Zeleke B, Geremew M. "Universal test and treat" program reduced TB incidence by 75% among a cohort of adults taking antiretroviral therapy (ART) in Gurage zone, South Ethiopia. Trop Dis Travel Med Vaccines 2020; 6:12. [PMID: 32864154 PMCID: PMC7393880 DOI: 10.1186/s40794-020-00113-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains the leading cause of morbidity and mortality in peoples living with HIV and at least 25% of deaths are attributed to TB. Many countries implement the Universal Test and Treat (UTT) program for HIV, which is believed to reduce the incidence of TB. However, there are limited studies that evaluate the impact of UTT on TB incidence. Therefore, by recruiting a cohort of ART users in the "UTT" and "differed treatment" programs, we aim to measure the effect of the UTT program on TB incidence. OBJECTIVE To measure the effect of "UTT" program on TB incidence among a cohort of adults taking antiretroviral therapy (ART) in Gurage Zone, South Ethiopia. METHODS A retrospective cohort study was conducted through record review over 5 years (2014-2019) in public health facilities in Gurage Zone. Three hundred eighty-four records were randomly selected and reviewed using a standardized structured checklist. Data was entered using Epi Info™ Version 7 and analyzed by STATA. A generalized linear model with binomial link function was fitted to measure the adjusted incidence density/incidence rate ratio and to identify predictors of incidence difference between the two programs. RESULTS During the follow up period, 39 incident TB cases were identified with an overall incidence rate of 4.79/100 person-year (PY). TB incidence was significantly lower in the UTT cohort (IR = 2.10/100 PY) in comparison to the differed program cohort (IR = 6.23/100 PY). The adjusted incidence rate ratio (AIRR) of TB among patients enrolled in the UTT program was; 0.25 (95% CI = 0.08-0.70). Thus, there was a reduction of TB incidence by 75% in the UTT program compared to differed program. In addition, IPT (isoniazid preventive therapy) use (AIRR = 0.35 (95% CI = 0.22-0.48)), WHO Stage I and II (AIRR = 0.70 (95% CI = 0.61-0.94)) and higher base line CD4 count (AIRR = 0.96 (95% CI = .94-0.99)) significantly reduced the incidence of TB. However, treatment failure increase the incidence (AIRR = 5.8 (95% CI = 1.93-8.46)). CONCLUSION TB incidence was significantly reduced by 75% after UTT. Therefore, intervention to further reduce the incidence has to focus on strengthening UTT program and IPT.
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Affiliation(s)
- Tadele Girum
- Department of Public health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Fedila Yasin
- Department of Public health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Samuel Dessu
- Department of Public health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Bereket Zeleke
- Department of Pharmacy, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Mulugeta Geremew
- Department of Statistics, College of Computing and informatics, Wolkite University, Wolkite, Ethiopia
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