New research has brought into question the World Health Organisation’s recommendation that patients diagnosed with both HIV and tuberculosis be put onto antiretrovirals straight away.
South African patients qualify for HIV treatment if their CD4 count – a measure of a person’s immunity – is 350 or lower. But this threshold is waived in the case of patients “co-infected” with HIV and tuberculosis.
However, the study, conducted by the Desmond Tutu HIV Centre, the University of Cape Town, and City of Cape Town’s health directorate, found that although HIV treatment halved the mortality in co-infected patients with a CD4 count lower than 350, there was “no effect” on mortality for patients with higher counts.
The research, which involved studying almost 40?000 patients based in the Western Cape over three years, was published in the peer-reviewed Journal of Acquired Immune Deficiency Syndromes on Thursday.
In 2010 the World Health Organisation (WHO) recommended that all patients with HIV and tuberculosis be started on antiretroviral therapy immediately, regardless of their CD4 count. South Africa changed its HIV policy in 2012 to adopt these recommendations.
Should the policy be changed in under-resourced settings?Although the benefits of starting antiretroviral therapy in co-infected patients with low immunity has previously been proven, there is little research looking at whether there is a similar impact on mortality for patients with higher CD4 counts, said the researchers.
The study also found that 35.4% of co-infected patients with CD4 counts of lower than 350 did not receive antiretroviral therapy at all during the study period. The fact that over a third of patients infected with both HIV and tuberculosis did not receive antiretrovirals, the study authors noted, “confirms that poor antiretroviral therapy uptake among tuberculosis patients remains an urgent problem”.
This low uptake coupled with the fact that little benefit has been shown for starting relatively “healthy” patients onto treatment early has led the researchers to question South Africa’s implementation of the WHO recommendations.
“It is still unclear whether these [extended WHO and US] strategies will have a beneficial effect on individual patient outcomes and although they may be easily implemented in well-resourced countries, they may be particularly challenging for low-income countries with a high burden of disease,” noted the study authors.
However, whether early initiation of antiretroviral therapy will benefit the thousands of HIV patients infected with drug-resistant tuberculosis, which has much higher fatality rates than “normal” tuberculosis, is still unclear as the study excluded such patients.
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