Wake R M, Poulikakos P, Groth J, Harrison T S, Macallan D C
Infection & Immunity Research Centre, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK.
Int J STD AIDS. 2013 Apr;24(4):263-8. doi: 10.1177/0956462412472431.
Management of tuberculosis (TB)-HIV co-infection is complicated by interactions between the diseases and their therapies. We developed and evaluated a strategy to (i) treat co-infected patients in a single co-infection clinic, (ii) maximize use of first-line drugs, (iii) delay antiretroviral therapy (ART) until two months post-TB treatment except in severe immunosuppression, (iv) commence efavirenz at 600 mg daily with therapeutic drug monitoring (TDM) and (v) target treatment completion. We conducted a prospective cohort review over 5.5 years in a UK tertiary referral center where 56 HIV-positive patients treated for TB were followed-up for a median 30 months. Main outcome measures were treatment completion, adverse events, immune reconstitution inflammatory syndrome, immunological and virological parameters, and TDM for efavirenz. Treatment completion rates were 88% (49/56); four patients were lost to local follow-up and three (5.4%) died during treatment; no deaths were TB-related. Adverse events were common (55%), but caused no treatment interruptions. Standard doses (600 mg daily) of efavirenz with rifampicin achieved or exceeded therapeutic levels in 25/28 (89%). This study supports combined management for TB-HIV co-infected patients. Delaying ART to two months post-TB treatment did not seem to result in poor clinical outcomes in this well-resourced context. Although efavirenz 600 mg daily usually achieved satisfactory levels, TDM is recommended.
结核病（TB）与人类免疫缺陷病毒（HIV）合并感染的管理因这两种疾病及其治疗方法之间的相互作用而变得复杂。我们制定并评估了一项策略，该策略包括：（i）在单一的合并感染诊所治疗合并感染的患者；（ii）最大限度地使用一线药物；（iii）在结核病治疗后两个月再开始抗逆转录病毒治疗（ART），严重免疫抑制患者除外；（iv）开始使用依非韦伦，每日600毫克，并进行治疗药物监测（TDM）；（v）以完成治疗为目标。我们在英国一家三级转诊中心进行了一项为期5.5年的前瞻性队列研究，对56名接受结核病治疗的HIV阳性患者进行了中位30个月的随访。主要结局指标包括治疗完成情况、不良事件、免疫重建炎症综合征、免疫学和病毒学参数以及依非韦伦的TDM。治疗完成率为88%（49/56）；4名患者失去当地随访，3名（5.4%）患者在治疗期间死亡；无死亡与结核病相关。不良事件很常见（55%），但未导致治疗中断。25/28（89%）的患者使用标准剂量（每日600毫克）的依非韦伦与利福平达到或超过治疗水平。本研究支持对TB-HIV合并感染患者进行联合管理。在这种资源充足的情况下，将ART推迟到结核病治疗后两个月似乎并未导致不良临床结局。虽然每日600毫克的依非韦伦通常能达到满意水平，但仍建议进行TDM。
