Changing Clinical Presentation and Survival in HIV-Associated Tuberculosis After Highly Active Antiretroviral Therapy:

High Rates of Drug-induced Liver Injury in People Living With HIV Coinfected With Tuberculosis (TB) Irrespective of Antiretroviral Therapy Timing During Antituberculosis Treatment: Results From the Starting Antiretroviral Therapy at Three Points in TB Trial

BACKGROUND

New onset or worsening drug-induced liver injury challenges coinfected patients on antiretroviral therapy (ART) initiation during antituberculosis (TB) treatment.

METHODS

Post hoc analysis within a randomized trial, the Starting Antiretroviral Therapy at Three Points in Tuberculosis trial, was conducted. Patients were randomized to initiate ART either early or late during TB treatment or after TB treatment completion. Liver enzymes were measured at baseline, 6-month intervals, and when clinically indicated.

RESULTS

Among 642 patients enrolled, the median age was 34 years (standard deviation, 28-40), and 17.6% had baseline CD4+ cell counts <50 cells/mm3. Overall, 146/472 patients (52, 47, and 47: early, late, and sequential arms) developed new-onset liver injury following TB treatment initiation. The incidence of liver injury post-ART initiation in patients with CD4+ cell counts <200 cells/mm3 and ≥200 cells/ mm3 was 27.4 (95% confidence interval [CI], 18.0-39.8), 19.0 (95% CI, 10.9-30.9), and 18.4 (95% CI, 8.8-33.8) per 100 person-years, and 32.1 (95% CI, 20.1-48.5), 11.8 (95% CI, 4.3-25.7), and 28.2 (95% CI, 13.5-51.9) per 100 person-years in the early, late integrated, and sequential treatment arms, respectively. Severe and life-threatening liver injury occurred in 2, 7, and 3 early, late, and sequential treatment arm patients, respectively. Older age and hepatitis B positivity predicted liver injury.

CONCLUSIONS

High incidence rates of liver injury among cotreated human immunodeficiency virus (HIV)-TB coinfected patients were observed. Clinical guidelines and policies must provide guidance on frequency of liver function monitoring for HIV-TB coinfected patients.

Pulmonary Infections in Immunocompromised Hosts: Clinical

Pulmonary infections in immunocompromised patients remain a significant contributor to mortality, morbidity, and health care-associated costs in such a vulnerable patient population. Their epidemiology is changing, set forth by new trends in immunosuppressive regimens and also prophylaxis. The host characteristics, presenting clinical symptomatology, along with radiographic patterns, have also evolved. The microbiology diagnostics are now enriched with nonculture methods for better identification of the causative pathogens. Chest imaging remains the cornerstone of the initial workup. Our article will examine the new trends in epidemiology, clinical findings, and diagnostics for immunocompromised patients with pulmonary infections (transplant recipients, neutropenic hosts, HIV-infected patients, and patients with autoimmune conditions). We will also review the differential diagnosis that most of the times includes malignancies and drug or radiation-related toxicities.

Patient characteristics and perceived health status of individuals with HIV and tuberculosis coinfection in Guangxi, China

To explore demographics, clinical and medication profiles, patients' social support, and perceived health status in HIV/TB coinfected patients in Guangxi, China.We performed a cross-sectional study in the HIV clinic of the Guigang City People's Hospital (N = 150). Health professionals conducted face-to-face interviews and collected data from patients' electronic medical records regarding patients' demographic, clinical, and medication information, as well as their social support and perceived health status. We classified all HIV/AIDS patients into HIV monoinfected and TB coinfected, at a ratio of 2:1.Compared with the HIV monoinfected, patients with HIV/TB coinfection were more likely to be older, male, less educated, unemployed, carrying health insurance, having advanced stage of HIV infection, longer history with HIV, and other opportunistic infections. Patients coinfected with TB were also more likely to hold a negative belief that their HIV treatment could prevent exacerbations, and reported significantly worse emotional/informational support, social interaction, and perceived health status. Better social support and better self-efficacy to the HIV treatment adherence was significantly associated with better perceived health status among patients with HIV and TB coinfection.Having HIV/TB coinfection was associated with poorer perceived general well-being and mental health, particularly in those undergoing TB therapy. Our findings suggest the need for mental health referrals and medication management for coinfected individuals, as well as further efforts and policies to improve coordinated care.

Human CD8(+) T cells transduced with an additional receptor bispecific for both Mycobacterium tuberculosis and HIV-1 recognize both epitopes

Tuberculosis (TB) and human immunodeficiency virus type 1 (HIV-1) infection are closely intertwined, with one-quarter of TB/HIV coinfected deaths among people died of TB. Effector CD8(+) T cells play a crucial role in the control of Mycobacterium tuberculosis (MTB) and HIV-1 infection in coinfected patients. Adoptive transfer of a multitude of effector CD8(+) T cells is an appealing strategy to impose improved anti-MTB/HIV-1 activity onto coinfected individuals. Due to extensive existence of heterologous immunity, that is, T cells cross-reactive with peptides encoded by related or even very dissimilar pathogens, it is reasonable to find a single T cell receptor (TCR) recognizing both MTB and HIV-1 antigenic peptides. In this study, a single TCR specific for both MTB Ag85B199-207 peptide and HIV-1 Env120-128 peptide was screened out from peripheral blood mononuclear cells of a HLA-A*0201(+) healthy individual using complementarity determining region 3 spectratype analysis and transferred to primary CD8(+) T cells using a recombinant retroviral vector. The bispecificity of the TCR gene-modified CD8(+) T cells was demonstrated by elevated secretion of interferon-γ, tumour necrosis factor-α, granzyme B and specific cytolytic activity after antigen presentation of either Ag85B199-207 or Env120-128 by autologous dendritic cells. To the best of our knowledge, this study is the first report proposing to produce responses against two dissimilar antigenic peptides of MTB and HIV-1 simultaneously by transfecting CD8(+) T cells with a single TCR. Taken together, T cells transduced with the additional bispecific TCR might be a useful strategy in immunotherapy for MTB/HIV-1 coinfected individuals.

When to start antiretroviral therapy during tuberculosis treatment?

PURPOSE OF REVIEW

Effective treatment exists for tuberculosis (TB) and for HIV, but treating both diseases simultaneously presents several challenges. This review assesses the evidence for the timing of antiretroviral therapy (ART) initiation in patients coinfected with TB.

RECENT FINDINGS

Published evidence clearly demonstrates that TB-HIV integration is essential for improved survival, but the question of when to start ART during TB treatment is more complex. Five randomized controlled trials assessed this question: four trials showed no difference in the incidence rates of AIDS or death between TB patients initiating ART within 2 months compared to later during TB therapy, while one trial showed a significant survival gain with ART initiation within 2 weeks of TB therapy start. All five studies found improved AIDS-free survival with earlier ART initiation in TB patients with low CD4 T-cell counts, except among patients with TB meningitis. The survival benefit was, however, accompanied by increased immune reconstitution inflammatory syndrome events.

SUMMARY

The trial data support the World Health Organization recommendations on when to start ART in TB-HIV coinfected patients including earlier ART initiation in severely immune-compromised patients. However, several challenges remain in integrating TB and HIV treatment in public healthcare services. Additional research on timing of ART is needed for patients with drug-resistant and extrapulmonary TB, notably TB meningitis.

Integration of antiretroviral therapy with tuberculosis treatment

BACKGROUND

We previously reported that integrating antiretroviral therapy (ART) with tuberculosis treatment reduces mortality. However, the timing for the initiation of ART during tuberculosis treatment remains unresolved.

METHODS

We conducted a three-group, open-label, randomized, controlled trial in South Africa involving 642 ambulatory patients, all with tuberculosis (confirmed by a positive sputum smear for acid-fast bacilli), human immunodeficiency virus infection, and a CD4+ T-cell count of less than 500 per cubic millimeter. Findings in the earlier-ART group (ART initiated within 4 weeks after the start of tuberculosis treatment, 214 patients) and later-ART group (ART initiated during the first 4 weeks of the continuation phase of tuberculosis treatment, 215 patients) are presented here.

RESULTS

At baseline, the median CD4+ T-cell count was 150 per cubic millimeter, and the median viral load was 161,000 copies per milliliter, with no significant differences between the two groups. The incidence rate of the acquired immunodeficiency syndrome (AIDS) or death was 6.9 cases per 100 person-years in the earlier-ART group (18 cases) as compared with 7.8 per 100 person-years in the later-ART group (19 cases) (incidence-rate ratio, 0.89; 95% confidence interval [CI], 0.44 to 1.79; P=0.73). However, among patients with CD4+ T-cell counts of less than 50 per cubic millimeter, the incidence rates of AIDS or death were 8.5 and 26.3 cases per 100 person-years, respectively (incidence-rate ratio, 0.32; 95% CI, 0.07 to 1.13; P=0.06). The incidence rates of the immune reconstitution inflammatory syndrome (IRIS) were 20.1 and 7.7 cases per 100 person-years, respectively (incidence-rate ratio, 2.62; 95% CI, 1.48 to 4.82; P<0.001). Adverse events requiring a switching of antiretroviral drugs occurred in 10 patients in the earlier-ART group and 1 patient in the later-ART group (P=0.006).

CONCLUSIONS

Early initiation of ART in patients with CD4+ T-cell counts of less than 50 per cubic millimeter increased AIDS-free survival. Deferral of the initiation of ART to the first 4 weeks of the continuation phase of tuberculosis therapy in those with higher CD4+ T-cell counts reduced the risks of IRIS and other adverse events related to ART without increasing the risk of AIDS or death. (Funded by the U.S. President's Emergency Plan for AIDS Relief and others; SAPIT ClinicalTrials.gov number, NCT00398996.).

A randomized trial of punctuated antiretroviral therapy in Ugandan HIV-seropositive adults with pulmonary tuberculosis and CD4⁺ T-cell counts of ≥ 350 cells/μL

BACKGROUND

Optimal treatment of human immunodeficiency virus (HIV)-associated tuberculosis in patients with high CD4⁺ T-cell counts is unknown. Suppression of viral replication during therapy for tuberculosis may block effects of immune activation on T cells and slow HIV disease progression.

METHODS

We conducted a randomized trial in 214 HIV-infected patients with active tuberculosis and CD4⁺ T-cell counts of ≥ 350 cells/μL to determine whether 6 months of antiretroviral therapy given during tuberculosis treatment would improve clinical outcomes. Subjects were randomized to receive 6 months of abacavir-lamivudine-zidovudine concurrent with tuberculosis therapy or delayed antiretroviral therapy. Endpoints were CD4⁺ T-cell counts of < 250 cells/μL, AIDS, or death.

RESULTS

Intervention and comparison arms had similar median CD4⁺ counts (517 and 534 cells/μL, respectively) and HIV RNA levels (4.6 and 4.7 log₁₀ copies/μL, respectively). Viral suppression was achieved in 86% of patients allocated to intervention. Seventeen subjects (15.6%) in the intervention arm developed study outcome compared to 25 subjects (22.8%) in the comparison arm (P = .17). Grade 3 or 4 adverse events were less frequent in the intervention arm. By 2 months, 90% of subjects in both arms were culture-negative for tuberculosis.

CONCLUSIONS

Short-term antiretroviral therapy during tuberculosis treatment in patients with CD4⁺T-cell counts of >350 cells/μL was safe and associated with clinical benefits.

British HIV Association national audit on the management of patients co-infected with tuberculosis and HIV

This audit aims to compare UK management of tuberculosis (TB)/HIV co-infection with recommended practice and to describe local care arrangements. Services providing HIV care were invited to complete a survey of care arrangements and to review case notes of HIV positive patients aged over 16 who started therapy for active TB between October 2007 and April 2008. Corresponding TB services, if separate, were invited to complete a similar survey. Responses were received from 124 of 170 HIV services, and 18 corresponding TB services. Data were obtained for 236 coinfected patients. Despite some incomplete data, this audit yielded useful findings. Many positive smear results were unacceptably delayed. The TB therapy completion rate fell short of the chief medical officer's (CMO's) 85% target. Culture confirmation of pulmonary TB met the CMO's 65% target. A high number of patients were diagnosed with HIV during investigation of TB. Contrary to current guidelines, many services do not routinely test TB patients for HIV.

Human immunodeficiency virus and tuberculosis coinfection in children: challenges in diagnosis and treatment

The burden of childhood tuberculosis (TB) is influenced by the human immunodeficiency virus (HIV) epidemic and this dangerous synergy affects various aspects of both diseases; from pathogenesis and the epidemiologic profile to clinical presentation, diagnosis, treatment, and prevention. HIV-infected infants and children are at increased risk of developing severe forms of TB. The TB diagnosis is complicated by diminished sensitivity and specificity of clinical features and diagnostic tools like the tuberculin skin test and chest x-ray. Although alternative ways of pulmonary sampling and the development of interferon-γ assays have shown to lead to some improvement of TB diagnosis in HIV-infected children, new diagnostic tools are urgently needed. Coadministration of anti-TB treatment and antiretroviral drugs induces severe complications, and this highlights the need to define optimal treatment regimens. Practical implementation of these regimens in TB control programs should be combined with isoniazid preventive therapy in TB-exposed HIV-infected children. The risk of severe complications after Bacille Calmette-Guérin vaccination of HIV-infected children emphasizes the need for new nonviable vaccines. This article reviews the current status of pediatric HIV-TB coinfection with specific emphasis on the diagnosis and treatment.

Timing of initiation of antiretroviral drugs during tuberculosis therapy

BACKGROUND

The rates of death are high among patients with coinfection with tuberculosis and the human immunodeficiency virus (HIV). The optimal timing for the initiation of antiretroviral therapy in relation to tuberculosis therapy remains controversial.

METHODS

In an open-label, randomized, controlled trial in Durban, South Africa, we assigned 642 patients with both tuberculosis and HIV infection to start antiretroviral therapy either during tuberculosis therapy (in two integrated-therapy groups) or after the completion of such treatment (in one sequential-therapy group). The diagnosis of tuberculosis was based on a positive sputum smear for acid-fast bacilli. Only patients with HIV infection and a CD4+ cell count of less than 500 per cubic millimeter were included. All patients received standard tuberculosis therapy, prophylaxis with trimethoprim-sulfamethoxazole, and a once-daily antiretroviral regimen of didanosine, lamivudine, and efavirenz. The primary end point was death from any cause.

RESULTS

This analysis compares data from the sequential-therapy group and the combined integrated-therapy groups up to September 1, 2008, when the data and safety monitoring committee recommended that all patients receive integrated antiretroviral therapy. There was a reduction in the rate of death among the 429 patients in the combined integrated-therapy groups (5.4 deaths per 100 person-years, or 25 deaths), as compared with the 213 patients in the sequential-therapy group (12.1 per 100 person-years, or 27 deaths); a relative reduction of 56% (hazard ratio in the combined integrated-therapy groups, 0.44; 95% confidence interval, 0.25 to 0.79; P=0.003). Mortality was lower in the combined integrated-therapy groups in all CD4+ count strata. Rates of adverse events during follow-up were similar in the two study groups.

CONCLUSIONS

The initiation of antiretroviral therapy during tuberculosis therapy significantly improved survival and provides further impetus for the integration of tuberculosis and HIV services. (ClinicalTrials.gov number, NCT00398996.)

Influence of HIV infection on mortality in a cohort of patients treated for tuberculosis in the context of wide access to HAART, in Rio de Janeiro, Brazil

OBJECTIVE

To analyze the influence of HIV serostatus on mortality related to tuberculosis (TB) in the context of wide access to highly active antiretroviral therapy (HAART) in a middle-income country.

METHODS

Prospective cohort study including patients who started antituberculous therapy between April 2000 and July 2005 at a referral center in Rio de Janeiro, Brazil.

RESULTS

Two hundred seven patients were enrolled, 106 were seropositive for HIV. There were 21 TB-related deaths in HIV-positive subjects (24.7 deaths per 100 patient-years) and 2 (2.5 deaths per 100 patient-years) among HIV-negative patients (rate ratio = 9.76, P < 0.001). Among HIV-infected subjects, TB-related mortality tended to be lower in patients treated with HAART [hazard ratio (HR) = 0.58, P = 0.06]. However, mortality among patients treated with HAART was still significantly increased as compared with HIV-negative patients (HR = 6.6, P = 0.014). In a Cox regression model adjusted for disseminated TB (P = 0.04), and treatment with antituberculous regimens not containing rifampicin (P = 0.11), mortality was significantly higher among seropositive patients not on HAART compared with HIV-negative subjects (HR = 6.30, P = 0.024). Among subjects treated with HAART, there was a nonsignificant increase in mortality (rate ratio = 3.48, P = 0.14).

CONCLUSIONS

HIV infection still has a substantial impact on TB-related mortality in the context of wide access to HAART in a middle-income country.

Effect of free treatment and surveillance on HIV-infected persons who have tuberculosis, Taiwan, 1993-2006

In 1997, Taiwan made highly active antiretroviral therapy (HAART) available without cost to HIV-infected persons; in 2001, a national web-based surveillance system was implemented. Healthcare workers use the system to monitor patients' conditions and can intervene when necessary. Free HAART, coupled with the surveillance system, appears to have increased survival rates of HIV-infected persons with tuberculosis in Taiwan.

Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: An institutional urban clinic experience

BACKGROUND

Widespread introduction of highly active antiretroviral therapy (HAART) in the mid 1990s has altered the presentation of the cutaneous manifestations associated with HIV infection.

OBJECTIVE

Our purpose was to evaluate the use of HAART on the prevalence and spectrum of cutaneous manifestations in HIV-infected patients.

METHODS

A study of the initial visits of 897 HIV-infected patients at an urban dermatology clinic between 1996 and 2002 was performed.

RESULTS

Folliculitis was the most common cutaneous disorder identified. Patients with CD4-positive cell counts less than 200 cells/mm3 had an increased prevalence of folliculitis and prurigo nodularis, whereas those with HIV viral loads higher than 55,000 copies/mL had a higher prevalence of idiopathic pruritus and candidiasis. Patients not receiving HAART had increased rates of folliculitis and prurigo nodularis. Patients receiving HAART had increased rates of photosensitivity and molluscum contagiosum.

LIMITATIONS

This was a cross-sectional study in which temporality was unable to be determined.

CONCLUSION

With ongoing therapeutic advancements, the cutaneous manifestations associated with HIV infection will continue to evolve.

Does immune reconstitution syndrome promote active tuberculosis in patients receiving highly active antiretroviral therapy?

OBJECTIVES

To assess whether highly active anti-retroviral therapy (HAART) contributes to the presentation of active tuberculosis (TB).

DESIGN

Retrospective single-centre cohort study.

METHODS

A total of 111 HIV-infected individuals with active TB were identified at an urban teaching hospital between February 1997 and April 2004. Those receiving HAART at the time of TB diagnosis were assessed.

RESULTS

Nineteen of 111 (17%) were receiving HAART when TB developed. Within this group there appeared to be two distinct populations. Thirteen of 19, 12 from ethnic or social groups with high background rates of TB, developed disease a median of 41 days (range, 7-109) after starting HAART ('early TB' group). In six of 19 ('late TB' group), TB occurred a median of 358 days after HAART initiation (range, 258-598). The 'early TB' group had lower CD4 cell counts when starting HAART in comparison with the 'late TB' group (median; 87 versus 218 x 10 cells/l; P = 0.04); however no difference was observed in the rate of change of CD4 cell count (P = 0.5) or HIV load. Paradoxical reaction rate in the 'early TB' group was significantly greater than in the 'late-TB' group (62 versus 0%, P = 0.02) and greater than in a similar control population who started HAART while taking anti-TB therapy (62 versus 30%, P = 0.05).

CONCLUSIONS

These data suggest anti-HIV treatment may amplify the presentation of active TB. This has implications for antiretroviral programmes in countries with high TB rates and warrants prospective investigation of a larger cohort.

How effectively does HAART restore immune responses to Mycobacterium tuberculosis? Implications for tuberculosis control

Use of highly active antiretroviral treatment (HAART) has had a major impact on HIV-associated morbidity and mortality in industrialized countries. Access to HAART is now expanding in low-income countries where tuberculosis (TB) is the most important opportunistic disease. The incidence of TB has been fueled by the HIV epidemic and in many countries with high HIV prevalence current TB control measures are failing. HAART reduces the incidence of TB in treated cohorts by approximately 80% and therefore potentially has an important role in TB control in such countries. However, despite the huge beneficial effect of HAART, rates of TB among treated patients nevertheless remain persistently higher than among HIV-negative individuals. This observation raises the important question as to whether immune responses to Mycobacterium tuberculosis (MTB) are completely or only partially restored during HAART. Current data suggest that full restoration of circulating CD4 cell numbers occurs only among a minority of patients and that, even among these, phenotypic abnormalities and functional defects in lymphocyte subsets often persist. Suboptimal restoration of MTB-specific immune responses may greatly reduce the extent to which HAART is able to contribute to TB control at the community level because patients receiving HAART live much longer and yet would maintain a chronically heightened risk of TB.

Utility of Tuberculosis Directly Observed Therapy Programs as Sites for Access to and Provision of Antiretroviral Therapy in Resource-Limited Countries

The overwhelming share of the global human immunodeficiency virus (HIV) infection and disease burden is borne by resource-limited countries. The explosive spread of HIV infection and growing burden of disease in these countries has intensified the need to find solutions to improved access to treatment for HIV infection. The epidemic of HIV infection and acquired immune deficiency syndrome (AIDS) has been accompanied by a severe epidemic of tuberculosis. Tuberculosis has become the major cause of morbidity and mortality in patients with HIV disease worldwide. Among the various models of provision of HIV/AIDS care, one logical but unexplored strategy is to integrate HIV/AIDS and tuberculosis care and treatment, including highly active antiretroviral therapy, through existing tuberculosis directly observed therapy programs. This strategy could address the related issues of inadequate access and infrastructure and need for enhanced adherence to medication and thereby potentially improve the outcome for both diseases.

Tuberculosis and HIV: a partnership against the most vulnerable

Tuberculosis (TB) is a major cause of morbidity and mortality worldwide. Each year, there are eight million new Mycobacterium tuberculosis complex (MTB) infections and three million TB-related deaths. The catastrophic effects of TB are borne disproportionately among the most vulnerable. The HIV pandemic has further increased the burden so that the risk of TB reactivation from latency is 5 to 15 percent in HIV/TB coinfection. Tuberculosis reactivation fuels further primary infections, creating a vicious cycle of increasing infection, disease, and deaths. In addition, drug-resistant TB exacerbates this increasingly common problem. The clinical presentations of TB in relation to HIV and HIV-associated immune deficiency are discussed from the perspective of clinical diagnosis and treatment in patient care. Tuberculosis prophylaxis, concurrent drug treatment of TB and HIV, drug interactions, and overlapping toxicities are detailed for the practitioner. Immune reconstitution inflammatory reactions are now a common phenomenon in HIV treatment, where similar reactions have been less commonly described in TB treatment in the past. Global distributive injustices in wealth, the burden of disease, and the provision of healthcare are obvious in TB, and clearly show us that the needs of the most vulnerable populations must be met in order to address the problems.

The changing picture of the HIV/AIDS epidemic

Twenty years after it was first recognized, the HIV/AIDS epidemic continues to expand, but its impact varies greatly in different parts of the World. The worst of the epidemic is now centered in developing countries, especially sub-Saharan Africa, and areas such as Eastern Europe, which was only marginally involved a few years ago but has recently experienced the largest growth in the epidemic. In industrialized countries Highly Active Antiretroviral Therapy (HAART) has changed the natural history of HIV/AIDS, causing a reduction in mortality and morbidity due to HIV/AIDS and related diseases. Many interlocking factors determine the impact of HAART at the population level, including reduction of morbidity and mortality, changes in the natural history of HIV/AIDS and associated illnesses, and the effects of HAART on HIV transmission. To fully appreciate the potential benefits of HAART, the epidemic should continue to be monitored in the future, and the effects of HAART on reducing HIV transmission should also be evaluated. Interventions addressed to encourage the adoption of safer sex practices are badly needed, since a "rebound" in risky sexual behaviors was recently reported among high risk groups, which is, at least in part, attributable to the optimism about new treatments.