Numbers of HIV-positive people who started antiretroviral therapy (ART) during treatment for tuberculosis rose 4- to 5-fold from 2006 to 2012 at two Uganda HIV clinic, reflecting new data and evolving guidelines. But many HIV-positive people with higher CD4 counts still did not start ART if they have TB, despite World Health Organization advice.
In the early and mid-2000s, clinicians typically did not start ART in HIV/TB-coinfected people until they completed their course of TB therapy. But research began to show better survival with earlier ART initiation during TB therapy. The World Health Organization now recommends starting ART in all HIV-positive adults with active TB regardless of CD4 count.
To assess the impact of new findings and guidelines on clinical practice, researchers measured trends in ART initiation among adults starting TB therapy at two Uganda clinics between 26 August 2006 and 29 September 2012. They divided time into four calendar periods reflecting “publication of seminal clinical studies” or guideline revisions.
The proportion of people with a CD4 count at or below 50 cells/µL who started ART within 14 days of starting TB therapy rose from 7% to 14% over the entire observation period, and the proportion starting ART within 30 days jumped from 14% to 86%. The fraction of patients with a CD4 count above 50 cells/µL who started ART within 60 days of starting TB therapy rose from 16% to 28%.
After statistical adjustment for sociodemographic factors, the ART initiation rate rose 4.57-fold (95% confidence interval 1.76 to 11.86) over the study period among people with a CD4 count at or below 50 cells/µL. Over the same period the ART-start rate rose 5.43-fold (95% confidence interval 3.16 to 9.31) in people with a CD4 count above 50 cells/µL.
Despite these large changes in ART initiation for people receiving TB therapy, the researchers note that “a significant proportion of individuals with higher CD4 cell counts do not start ART within recommended time frames.” They call for “targeted dissemination and implementation efforts... to achieve target levels in practice.”
Source: Tara Vijayan, Fred C. Semitala, Nicholas Matsiko, Patrick Elyanu, Jennifer Namusobya, Diane V. Havlir, Moses Kamya, Elvin H. Geng. Changes in the timing of antiretroviral therapy initiation in HIV-infected patients with tuberculosis in Uganda: a study of the diffusion of evidence into practice in the global response to HIV/AIDS. Clinical Infectious Diseases. 2013; 57: 1766-1772.
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For World Health Organization antiretroviral guidelines