speculate that initiating ART two weeks after the onset of TB treatment could
potentially save 150,000 of the 450,000 annual HIV-TB related deaths,” Dr Blanc
said in conclusion.
It’s not really clear that his calculation (a one-third reduction in
death) was appropriately applied here, as many of the annual TB deaths in people
with HIV probably occur in people not receiving treatment at all. But if
everyone received appropriate and timely diagnosis and received TB treatment
followed by ART two weeks afterwards, the survival benefit could be expected to
be even greater. However, this would require far better integration of TB/HIV
services than exists presently.
These data are
rather new, and some questions still remain unanswered. For example, was there a
faster time to TB culture conversion in people on early ART? Was there less
It is interesting that ART didn’t seem to change the risk of
early death and that the differences are powered by later events. It is also
curious that simply starting ART a mere six weeks earlier,
perhaps critically, while
– the body was under assault from a catastrophic
co-infection, produced a survival benefit that doesn’t seem to be explained by
differences in virological or CD4 cell responses.
Many of these deaths would
have occurred after the course of TB treatment was completed. Perhaps ART
protects the body from TB’s constitutional effects or perhaps having active TB
– even if it is successfully treated
– significantly weakens people, making
them more frail and susceptible to succumbing to other HIV-related conditions.
This may be a
particular danger in very advanced HIV disease. As a member of the audience
pointed out, it isn’t clear that you would see a similar survival benefit, or
IRIS frequency, in people with higher CD4 cells.
Dr Kevin de
Cock of the US Centers for Disease Control asked if would make more sense to treat both conditions at once? Dr Blanc pointed out that there are often very real operational challenges to
starting HIV treatment earlier
– such as the timing of getting a patient with TB tested for
HIV and giving them their results.
“I think it is
reasonable to have a two week delay: 72% of our patients did not know their
status a month before going into the study,” said Dr Blanc.
But the results
created quite a stir on the same day activists in a marched through the
conference centre in a 'cough-in', carrying coffins and signs that said “No
more people with HIV dying from TB”. In
the question period and during a later session on TB and HIV co-infection, various experts
discussed the implications of the findings.
“This is a
wonderful study that complements the results of the SAPIT study. I want to
point out that in the SAPIT study, the CD4 counts were substantially higher,
and the rate of IRIS was about 12% in those who started ART on TB drugs and
there was no mortality attributable to IRIS. So I think that the IRIS issue
not that it’s not important
– but it should not be a barrier to initiating
ART in people with HIV and TB,” said Jerry Friedland of Yale University
“It makes it
very compelling now more than ever, to do the testing as well as initiate ART,”
said Dr Wafaa El-Sadr of Columbia
University and ICAP in a
TB/HIV session just after the CAMELIA findings were presented. “I’m wondering
whether we should reconceptualise the treatment of TB in patients with HIV, and
frame it to them as 'ART is part of treating their TB' rather than presenting
it as treating two diseases. I think there’s compelling need to change the way
we are presenting ART to TB patients.”