00:45 | Earlier versus Later Start of Antiretroviral Therapy in HIV-Infected Adults with TuberculosisNEJM BLOGGERS
02:29 | Timing of Antiretroviral Therapy for HIV-1 Infection and Tuberculosis
04:08 | Integration of Antiretroviral Therapy with Tuberculosis Treatment
05:41 | When to Start Antiretroviral Therapy in HIV-Associated Tuberculosis
06:15 | Brief Report: Inflammatory Skin and Bowel Disease Linked to ADAM17 Deletion
07:29 | Neighborhoods, Obesity, and Diabetes — A Randomized Social Experiment
08:54 | Panretinal Photocoagulation for Proliferative Diabetic Retinopathy
10:42 | Case 32-2011 — A 19-Year-Old Man with Recurrent Pancreatitis
12:31 | Stalking Influenza Diversity with a Universal Antibody
14:20 | Defining Essential Health Benefits — The View from the IOM Committee
16:07 | Medical Device Innovation — Is “Better” Good Enough?
17:58 | The Supply-Side Economics of Abortion
19:50 | Multiple Intracranial Tuberculomas
20:52 | Jejunal Diverticular Bleeding
EXCERPTED SCRIPTS
00:45 | "Earlier versus Later Start of Antiretroviral Therapy in HIV-Infected Adults with Tuberculosis" by François-Xavier Blanc from CHU Bicêtre, Le Kremlin-Bicêtre, France. When to initiate antiretroviral therapy in patients with newly diagnosed HIV infection and tuberculosis has been debated. This study from Cambodia determine whether the earlier initiation of ART (2 weeks after the onset of tuberculosis treatment), as compared with later initiation (8 weeks afterward), could reduce mortality among patients with advanced immunodeficiency. The risk of death was significantly reduced in the group that received ART earlier, with 59 deaths among 332 patients (18%), as compared with 90 deaths among 329 patients (27%) in the later-ART group. The risk of tuberculosis-associated immune reconstitution inflammatory syndrome was significantly increased in the earlier-ART group. Irrespective of the study group, the median gain in the CD4+ T-cell count was 114 per cubic millimeter, and the viral load was undetectable at week 50 in 96.5% of the patients. Initiating ART 2 weeks after the start of tuberculosis treatment significantly improved survival among HIV-infected adults with CD4+ T-cell counts of 200 per cubic millimeter or lower.
02:29 | "Timing of Antiretroviral Therapy for HIV-1 Infection and Tuberculosis" by Diane Havlir, from University of Califonia, San Francisco. This international study involving 809 patients with HIV and TB coinfection compared earlier therapy for both infections with waiting 8 to 12 weeks to initiate antiretrovirals after anti-TB therapy.In the earlier-ART group, 12.9% of patients had a new AIDS-defining illness or died by 48 weeks, as compared with 16.1% in the later-ART group. Among patients with screening CD4+ T-cell counts of less than 50 per cubic millimeter, 15.5% of patients in the earlier-ART group versus 26.6% in the later-ART group had a new AIDS-defining illness or died. Tuberculosis-associated immune reconstitution inflammatory syndrome was more common with earlier ART than with later ART (11% vs. 5%). The rate of viral suppression at 48 weeks was 74% and did not differ between the groups.
Overall, earlier ART did not reduce the rate of new AIDS-defining illness and death, as compared with later ART. In persons with CD4+ T-cell counts of less than 50 per cubic millimeter, earlier ART was associated with a lower rate of new AIDS-defining illnesses and death.
04:08 | "Antiretroviral Therapy Initiation during Tuberculosis Treatment" by Salim Abdool Karim from the Centre for the AIDS Programme of Research in South Africa, Durban. This study from South Africa determined the optimal time for initiation of ART in patients with HIV infection and tuberculosis. The incidence rate of the acquired immunodeficiency syndrome (AIDS) or death was 6.9 cases per 100 person-years in the earlier-ART group (18 cases) as compared with 7.8 per 100 person-years in the later-ART group (19 cases) . However, among patients with CD4+ T-cell counts of less than 50 per cubic millimeter, the incidence rates of AIDS or death were 8.5 and 26.3 cases per 100 person-years, respectively. The incidence rates of the immune reconstitution inflammatory syndrome (IRIS) were 20.1 and 7.7 cases per 100 person-years, respectively. Early initiation of ART in patients with CD4+ T-cell counts of less than 50 per cubic millimeter increased AIDS-free survival. Deferral of the initiation of ART to the first 4 weeks of the continuation phase of tuberculosis therapy in those with higher CD4+ T-cell counts reduced the risks of IRIS and other adverse events related to ART without increasing the risk of AIDS or death.
05:41 | In Editorial M. Estée Török from Addenbrooke's Hospital, Cambridge, UK, writes that the results of these three trials provide important evidence to guide clinicians who are treating patients with HIV-associated tuberculosis. The evidence, including the study results provides support for the earlier initiation of ART in patients coinfected with HIV and tuberculosis who have advanced immunosuppression, apart from those who present with tuberculous meningitis.
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