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Open Access Highly Accessed Research article

The impact of HAART initiation timing on HIV-TB co-infected patients, a retrospective cohort study

Chin-Hui Yang12, Kuan-Jung Chen3, Jih-Jin Tsai456, Yu-Hui Lin7, Shu-Hsing Cheng8, Kwei-Feng Wang1 and Hung-Yi Chiou9*

Author Affiliations

1 Centers for Disease Control, Ministry of Health and Welfare, 5F, No.6, Linsen S. Rd., Taipei City 100, Taiwan

2 Ph. D. program in School of Public Health, Taipei Medical University, No. 250, 469 Wu-Hsing Street, Taipei, Taiwan

3 Department of Chest Medicine, RenAi branch of Taipei City Hospital, No. 10, Section 4, Ran-Ai Road, Taipei, Taiwan

4 School of Medicine, College of Medicine, Kaohsiung Medical University, No.100, Shih-Chuan 1st Road, Kaohsiung, Taiwan

5 Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, , No.100, Tzyou 1st Road, Kaohsiung, Taiwan

6 Tropical Medicine Center, Kaohsiung Medical University Hospital, School of Medicine, College of Medicine, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, Taiwan

7 Section of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, No.1650, Sec. 4, Taiwan Boulevard, Taichung, Taiwan

8 Section of Infectious Diseases, Department of Internal Medicine, Taoyuan General Hospital, No. 1492, Chung-Shan Road, Taoyuan, Taiwan

9 School of Public Health, Taipei Medical University, No. 250, Wu-Hsing Street, Taipei, Taiwan

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BMC Infectious Diseases 2014, 14:304  doi:10.1186/1471-2334-14-304

Published: 4 June 2014

Abstract

Background

Optimal timing for initiating highly active antiretroviral therapy (HAART) in HIV-TB coinfected patients is challenging for clinicians. We aim to evaluate the impact of different timing of HAART initiation on TB outcome of HIV-infected adults in Taiwan.

Methods

A population-based retrospective cohort study was conducted through linking the HIV and TB registries of Taiwan Centers for Disease Control (CDC) during 1997 to 2006. Clinical data of HIV-TB co-infected patients, including the presence of immune reconstitution inflammatory syndrome (IRIS), was collected through medical records review. The outcome of interest was all-cause mortality within 1 year following TB diagnosis. The Cox proportional hazard model was used to explore the probability of death and IRIS after TB diagnosis by adjusting for confounding factors and factors of interest. The probability of survival and TB IRIS were calculated by the Kaplan-Meier method and compared between different HAART initiation timing groups by the log-rank test.

Results

There were 229 HIV-TB co-infected patients included for analysis and 60 cases (26.2%) died within one year. Besides decreasing age and increasing CD4 lymphocyte count, having started HAART during TB treatment was significantly associated with better survival (adjusted Hazard Ratio was 0.11, 95% CI 0.06–0.21). As to the timing of HAART initiation, there was only non-significant benefit on survival among cases initiating HAART within 15 days, at 16–30 days and at 31–60 days of TB treatment than initiating after 60 days. Cases with HAART initiated after 30 days had lower risk in developing IRIS than cases with HAART initiated earlier. Cases with IRIS had significantly higher rate of re-hospitalization (49% vs. 4%, p < 0.001) and prolonged hospitalization (28 days vs. 18.5 days, p < 0.01).

Conclusion

The present study found that starting HAART during TB treatment is associated with better one-year survival, although earlier initiation within 60 days of TB treatment did not show statistical differences in survival than later initiation. Initiation of HAART within 30 days appeared to increase the risk of IRIS. Deferring HAART to 31–60 days of TB treatment might be optimal after considering the risks and benefits.

Keywords:
Tuberculosis; HIV; Mortality; HAART