© 2008 American Thoracic Society
On Treatment Outcomes of Patients with HIV and TuberculosisFrom the Authors:Dr. Breen and colleagues underscore the important role highly active antiretroviral therapy (HAART) can play in the treatment of active tuberculosis in patients coinfected with HIV. In the study by Breen and coworkers conducted from 1997 through 2003, 71% of 156 coinfected patients received concurrent HAART with their tuberculosis treatment regimen (1), whereas in our study, conducted from 1990 through 2001, only 12% received HAART (2). Methodological differences aside, 1% of HIV-uninfected patients in both studies relapsed with tuberculosis. However, among HIV-infected tuberculosis patients, the study by Breen and coworkers, with higher rates of concurrent HAART, showed a lower relapse rate than our study. While the difference in relapse rate is likely due to the protective effect of HAART, also described in our study, the optimal timing of HAART after initiation of tuberculosis therapy remains to be determined. Breen and coworkers raise a concern about potential confounding of our finding that HIV-infected patients with tuberculosis receiving 6 months of treatment have higher relapse rates than those receiving more than 6 months (23 per 100 person-years vs. 7; RR, 4.33; 95% CI, 1.26–14.8; P = 0.02). Their suggestion that higher rates of previous opportunistic infections in the 6-month-duration group may reflect higher pill burdens and drug–drug interactions is intriguing, but not supported by the low rate of adverse events reported in this group relative to the group receiving more than 6 months of treatment (3 vs. 22%; RR, 0.14; 95% CI, 0.02–0.97; P = 0.01). Although the observational nature of our study limits our ability to control for confounding factors, we emphasize that those who completed tuberculosis treatment within a 6-month period had associated characteristics that identified them as being ideal candidates for a short-course regimen and of lower risk for relapse (i.e., they were adherent, they converted their cultures sooner, and they had few side effects), and yet this group had a four times higher rate of relapse as compared with those treated longer. As clinical trials are designed and subsequently pursued in the hopes of identifying a safer, faster-acting, and thus "shorter" regimen for tuberculosis, it is critical that we consider the unique complexities of HIV coinfection as well as the role HAART might play in such a regimen.
University of California, San Francisco
Medical Research Council Laboratories
National Jewish Medical and Research Center FOOTNOTES Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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