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Open Access Highly Accessed Research article

HIV care and treatment factors associated with improved survival during TB treatment in Thailand: an observational study

Jay K Varma12*, Sriprapa Nateniyom3, Somsak Akksilp4, Wiroj Mankatittham5, Chawin Sirinak6, Wanchai Sattayawuthipong7, Channawong Burapat2, Wanitchaya Kittikraisak2, Patama Monkongdee2, Kevin P Cain1, Charles D Wells1 and Jordan W Tappero12

Author Affiliations

1 U.S. Centers for Disease Control and Prevention, Atlanta, USA

2 Thailand Ministry of Public Health – U.S. CDC Collaboration, Nonthaburi, Thailand

3 Thailand Ministry of Public Health, Nonthaburi, Thailand

4 Office of Disease Prevention and Control 7, Ubon Ratchathani, Thailand

5 Bamrasnaradura Institute, Nonthaburi, Thailand

6 Bangkok Metropolitan Administration, Bangkok, Thailand

7 Phuket Provincial Health Office, Phuket, Thailand

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BMC Infectious Diseases 2009, 9:42  doi:10.1186/1471-2334-9-42

Published: 13 April 2009

Abstract

Background

In Southeast Asia, HIV-infected patients frequently die during TB treatment. Many physicians are reluctant to treat HIV-infected TB patients with anti-retroviral therapy (ART) and have questions about the added value of opportunistic infection prophylaxis to ART, the optimum ART regimen, and the benefit of initiating ART early during TB treatment.

Methods

We conducted a multi-center observational study of HIV-infected patients newly diagnosed with TB in Thailand. Clinical data was collected from the beginning to the end of TB treatment. We conducted multivariable proportional hazards analysis to identify factors associated with death.

Results

Of 667 HIV-infected TB patients enrolled, 450 (68%) were smear and/or culture positive. Death during TB treatment occurred in 112 (17%). In proportional hazards analysis, factors strongly associated with reduced risk of death were ART use (Hazard Ratio [HR] 0.16; 95% confidence interval [CI] 0.07–0.36), fluconazole use (HR 0.34; CI 0.18–0.64), and co-trimoxazole use (HR 0.41; CI 0.20–0.83). Among 126 patients that initiated ART after TB diagnosis, the risk of death increased the longer that ART was delayed during TB treatment. Efavirenz- and nevirapine-containing ART regimens were associated with similar rates of adverse events and death.

Conclusion

Among HIV-infected patients living in Thailand, the single most important determinant of survival during TB treatment was use of ART. Controlled clinical trials are needed to confirm our findings that early ART initiation improves survival and that the choice of non-nucleoside reverse transcriptase inhibitor does not.