Evaluation of a pro-active strategy for managing tuberculosis–HIV co-infection in a UK tertiary care setting

• Published in: International journal of STD & AIDS 2013-04, Vol.24 (4), p.263-268
• Main Authors: Wake, R M, Poulikakos, P, Groth, J, Harrison, T S, Macallan, D C
• Format: Article
• Language: English
• Subjects: Adult; AIDS/HIV; Anti-HIV Agents - therapeutic use; Antibiotics, Antitubercular - adverse effects; Antibiotics, Antitubercular - therapeutic use; Benzoxazines - therapeutic use; Coinfection - complications; Coinfection - drug therapy; Drug Monitoring - methods; HIV Infections - complications; HIV Infections - drug therapy; Human immunodeficiency virus; Humans; Middle Aged; Mycobacterium; Mycobacterium - isolation & purification; Prospective Studies; Rifampin - therapeutic use; Time Factors; Treatment Outcome; Tuberculosis - complications; Tuberculosis - drug therapy; United Kingdom; Viral Load
• ISSN: 0956-4624; 1758-1052
• DOI: 10.1177/0956462412472431

Summary Management of tuberculosis (TB)-HIV co-infection is complicated by interactions between the diseases and their therapies. We developed and evaluated a strategy to (i) treat co-infected patients in a single co-infection clinic, (ii) maximize use of first-line drugs, (iii) delay antiretroviral therapy (ART) until two months post-TB treatment except in severe immunosuppression, (iv) commence efavirenz at 600 mg daily with therapeutic drug monitoring (TDM) and (v) target treatment completion. We conducted a prospective cohort review over 5.5 years in a UK tertiary referral center where 56 HIV-positive patients treated for TB were followed-up for a median 30 months. Main outcome measures were treatment completion, adverse events, immune reconstitution inflammatory syndrome, immunological and virological parameters, and TDM for efavirenz. Treatment completion rates were 88% (49/56); four patients were lost to local follow-up and three (5.4%) died during treatment; no deaths were TB-related. Adverse events were common (55%), but caused no treatment interruptions. Standard doses (600 mg daily) of efavirenz with rifampicin achieved or exceeded therapeutic levels in 25/28 (89%). This study supports combined management for TB–HIV co-infected patients. Delaying ART to two months post-TB treatment did not seem to result in poor clinical outcomes in this well-resourced context. Although efavirenz 600 mg daily usually achieved satisfactory levels, TDM is recommended.