The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
Curr Opin Infect Dis. 2011 Feb;24(1):34-42. doi: 10.1097/QCO.0b013e3283420f76.
We review recently published literature concerning the optimum time to start antiretroviral therapy (ART) in patients with HIV-associated opportunistic infections.
In addition to data from observational studies, results from six randomized controlled clinical trials were available by July 2010. The collective findings of these trials were that patients with CD4 cell counts less than 200 cells/μl who start ART within the first 2 weeks of treatment for opportunistic infections including Pneumocystis jirovecii pneumonia, serious bacterial infections or pulmonary tuberculosis have lower mortality when compared to patients starting ART at later time-points. Moreover, patients with pulmonary tuberculosis and CD4 counts of 200-500 cells/μl who started ART during tuberculosis (TB) treatment had improved survival compared to those who deferred ART until after the end of treatment. In contrast, in two separate studies, immediate ART conferred no survival benefit in patients with TB meningitis and was associated with substantially higher mortality risk in patients with cryptococcal meningitis.
Initiation of ART during the first 2 weeks of treatment for serious opportunistic infections has been shown to be associated with improved survival with the exception of patients with tuberculous meningitis and cryptococcal meningitis. Further clinical trials are ongoing.
我们对近期发表的有关 HIV 相关机会性感染患者开始抗逆转录病毒治疗（ART）的最佳时机的文献进行了回顾。
除了观察性研究的数据外，截至 2010 年 7 月，还有 6 项随机对照临床试验的结果可用。这些试验的综合结果表明，对于 CD4 细胞计数小于 200 个/μl 的患者，在开始治疗后的前 2 周内开始接受 ART 治疗，包括卡氏肺孢子虫肺炎、严重细菌感染或肺结核，其死亡率低于在以后的时间点开始 ART 的患者。此外，对于 CD4 计数为 200-500 个/μl 的肺结核患者，在结核病（TB）治疗期间开始 ART 可改善生存，而延迟 ART 至治疗结束后则会降低生存率。相比之下，在两项单独的研究中，急性 ART 对结核性脑膜炎患者没有生存获益，反而与隐球菌性脑膜炎患者的死亡率显著增加相关。
在严重机会性感染的最初 2 周内开始 ART 已被证明与生存改善相关，但结核性脑膜炎和隐球菌性脑膜炎患者除外。目前正在进行进一步的临床试验。
