Yang Chin-Hui, Chen Kuan-Jung, Tsai Jih-Jin, Lin Yu-Hui, Cheng Shu-Hsing, Wang Kwei-Feng, Chiou Hung-Yi
School of Public Health, Taipei Medical University, No, 250, Wu-Hsing Street, Taipei, Taiwan.
BMC Infect Dis. 2014 Jun 4;14:304. doi: 10.1186/1471-2334-14-304.
Optimal timing for initiating highly active antiretroviral therapy (HAART) in HIV-TB coinfected patients is challenging for clinicians. We aim to evaluate the impact of different timing of HAART initiation on TB outcome of HIV-infected adults in Taiwan.
A population-based retrospective cohort study was conducted through linking the HIV and TB registries of Taiwan Centers for Disease Control (CDC) during 1997 to 2006. Clinical data of HIV-TB co-infected patients, including the presence of immune reconstitution inflammatory syndrome (IRIS), was collected through medical records review. The outcome of interest was all-cause mortality within 1 year following TB diagnosis. The Cox proportional hazard model was used to explore the probability of death and IRIS after TB diagnosis by adjusting for confounding factors and factors of interest. The probability of survival and TB IRIS were calculated by the Kaplan-Meier method and compared between different HAART initiation timing groups by the log-rank test.
There were 229 HIV-TB co-infected patients included for analysis and 60 cases (26.2%) died within one year. Besides decreasing age and increasing CD4 lymphocyte count, having started HAART during TB treatment was significantly associated with better survival (adjusted Hazard Ratio was 0.11, 95% CI 0.06-0.21). As to the timing of HAART initiation, there was only non-significant benefit on survival among cases initiating HAART within 15 days, at 16-30 days and at 31-60 days of TB treatment than initiating after 60 days. Cases with HAART initiated after 30 days had lower risk in developing IRIS than cases with HAART initiated earlier. Cases with IRIS had significantly higher rate of re-hospitalization (49% vs. 4%, p < 0.001) and prolonged hospitalization (28 days vs. 18.5 days, p < 0.01).
The present study found that starting HAART during TB treatment is associated with better one-year survival, although earlier initiation within 60 days of TB treatment did not show statistical differences in survival than later initiation. Initiation of HAART within 30 days appeared to increase the risk of IRIS. Deferring HAART to 31-60 days of TB treatment might be optimal after considering the risks and benefits.
对于临床医生而言，确定人类免疫缺陷病毒（HIV）合并结核病（TB）感染患者开始高效抗逆转录病毒治疗（HAART）的最佳时机具有挑战性。我们旨在评估台湾地区不同HAART启动时机对HIV感染成人结核病结局的影响。
通过关联台湾疾病控制中心（CDC）1997年至2006年的HIV和TB登记信息，开展了一项基于人群的回顾性队列研究。通过病历审查收集HIV-TB合并感染患者的临床数据，包括免疫重建炎症综合征（IRIS）的发生情况。感兴趣的结局是结核病诊断后1年内的全因死亡率。采用Cox比例风险模型，通过调整混杂因素和感兴趣的因素，探讨结核病诊断后死亡和IRIS的概率。采用Kaplan-Meier法计算生存率和TB IRIS概率，并通过对数秩检验比较不同HAART启动时机组之间的差异。
共纳入229例HIV-TB合并感染患者进行分析，其中60例（26.2%）在1年内死亡。除年龄降低和CD4淋巴细胞计数增加外，在结核病治疗期间开始HAART与更好的生存率显著相关（调整后的风险比为0.11，95%可信区间为0.06-0.21）。关于HAART启动时机，在结核病治疗的15天内、16-30天和31-60天开始HAART的患者与60天后开始的患者相比，在生存率方面仅有不显著的益处。HAART在30天后开始的患者发生IRIS的风险低于HAART更早开始的患者。发生IRIS的患者再次住院率显著更高（49%对4%，p<0.001），住院时间更长（28天对18.5天，p<0.01）。
本研究发现，在结核病治疗期间开始HAART与更好的1年生存率相关，尽管在结核病治疗60天内更早开始HAART与更晚开始相比，在生存率方面未显示出统计学差异。在30天内开始HAART似乎会增加IRIS的风险。综合考虑风险和益处后，将HAART推迟至结核病治疗的31-60天可能是最佳选择。
