Initiating antitretroviral therapy (ART) within two weeks of tuberculosis (TB) diagnosis improved survival among patients with HIV, TB, and moderately to severely compromised immune systems in research published in the Annals of Internal Medicine. However, delaying ART initiation until the end of TB treatment could be feasible for patients with higher immune cell counts.

Current recommendations from the World Health Organization (WHO) advise initiation of TB treatment first, followed by ART within 2–8 weeks for patients with moderately to severely compromised immune systems. Jean B. Nachega, MD, PhD, MPH, of the University of Pittsburgh Medical Center, and colleagues sought to investigate the optimal timing of ART initiation in patients with HIV and TB based on immune cell counts. Data from eight randomized clinical trials of over 4,500 patients comparing early and delayed ART initiation (1–4 weeks vs. 8–12 weeks after initiation of TB treatment) or deferred ART initiation (after the end of TB treatment).

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Early ART reduced mortality vs. delayed ART among patients with baseline CD4+ T-cell counts<0.050 × 10^9 cells/L (RR, 0.71 [CI, 0.54– 0.93];  I2=0%). A mortality benefit was not observed with early ART for those with CD4+ T-cell counts > 0.050 × 10^9 cells/L (RR, 1.05 [CI, 0.68–1.61]; I2=56%). Early ART was associated with a greater incidence of TB-associated immune reconstitution inflammatory syndrome (TB-IRIS) than delayed ART (RR, 2.31 [CI, 1.87–2.86]; I2=19%).

While the study does not support early ART for patients with higher immune cell counts, other research has found clinical and public health benefits with early ART such as decreasing comorbidities due to ongoing inflammation caused by HIV and lowering the risk of HIV transmission. Clinicians should weigh the risks and benefits against the burden of co-administration of TB and HIV treatment for each patient, Dr. Machega added.

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