In patients with HIV and tuberculosis (TB) coinfection, optimal timing of antiretroviral therapy is controversial. Although the World Health Organization guidelines recommend concurrent treatment of TB and HIV, antiretroviral therapy is sometimes delayed until the completion of tuberculosis treatment. Reasons given for delaying HIV treatment include potential drug interactions and the risk of immune reconstitution inflammatory syndrome. A recent unblinded randomized trial with 642 patients suggests that beginning antiretrovirals during TB treatment improves survival (level 2 [mid-level] evidence). Patients with HIV and TB infection were randomized to start antiretroviral therapy during TB therapy (in 2 integrated-therapy groups) vs. after completion of TB therapy (in 1 sequential-therapy group) and were followed for a median of 12 months. All patients received standard TB therapy and prophylaxis with trimethoprim/sulfamethoxazole. Antiretroviral treatment was a once-daily regimen of didanosine, lamivudine, and efavirenz. All-cause mortality was significantly lower for integrated therapy (5.8% vs. 12.7%, p = 0.003, NNT 14), with survival benefit observed in all patients regardless of CD4+ count. Integrated therapy was also associated with suppressed HIV RNA level at 12 months (90% vs. 77.8%, p = 0.006, NNT 8). Following an interim data analysis, it was recommended that patients in the sequential group initiate antiretroviral therapy as soon as possible (N Engl J Med 2010 Feb 25;362(8):697).
For more information, see the Tuberculosis prevention and treatment in HIV-infected persons topic in DynaMed.