Introduction: Interaction between HAART and TB Treatment TB and HIV: A Deadly Partnership

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Introduction Interaction between HAART and TB
TreatmentTB and HIV A Deadly Partnership

• Jean William Pape MD
• Professor of Medicine
• Division of International Medicine and Infectious
  Diseases
• Weill Cornell Medical College, New York, NY
• Director, Centres GHESKIO, Port-au-Prince, Haiti
• AIDS 2008 Poster Discussion
• Skills Building Room 10
• August 4, 2008
• 100-200PM

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TB Prevention in HIV-infected/AIDS and
concomitant HAART and TB treatment

• TB Prevention
• INH preventive therapy (IPT) reduces risk of TB
  by 62 in PPD and by 36 overall (Woldehanna and
  Volmink, Cochrane Review 2006)
• HAART reduces the risk of TB (Jones JL et al Int
  J Tuberc lung Dis 4 (11) 1026-1031)
• What about if provided together?
• TB Therapy and HAART
• Duration of TB treatment in patients on HAART
• Side effects
• Immune Reconstitution Syndrome
• Timing of HAART initiation in patients on TB
  treatment

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Prevention of TB in HIV-infected patients
TB Rates in 11,026 HIV Patients with Access to
ART and IPT in Rio de Janeiro Golub et al.,
AIDS 2007, 211441-1448
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Concomitant TB Treatment and HAART

• Duration of TB therapy in patients on HAART
  unknown
• 6 months versus 9-12 months (WHO (206)
  Antiretroviral therapy for HIV infection in
  adults in resources constrained settings
  Perriens JH et al N Engl J Med 1995 332 (12)
  779-784)
• 6 months INH (Fitzgerald DW et al Lancet
  20003561470-74).
• Toxicity
• PIs and NNRTI and rifamycins
• Risk of development of the immune reconstitution
  syndrome (IRS)
• Administration of HAART within the first 2 months
  of starting anti TB treatment is an independent
  predictor of IRIS. (Navas E et al Arch.Int Med
  2002 16297-9)
• Led to the delay in initiation of HAART in
  patients started on anti-TB treatment
• Optimal timing of HAART initiation unknown Many
  on-going studies to determine whether early
  initiation of ART improves survival as compared
  with delayed ART
• GHESKIO CIPRA study Completed enrollment of 816
  AIDS patients randomized to early HAART
  initiation (US/European guidelines) versus
  deferred HAART initiation based on WHO criteria
  
• ACTG 5221 Immediate Versus Deferred Initiation
  of HAART for AIDS patients treated for TB
  Tuberculosis with CD4 lt200 Cells/mm 3

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Survival of 201 Patients with AIDS and TB on
anti-TB treatment and HAART according to timing
of TB

• Mortality ()
• TB at HAART initiation11
• TB gt 3 months after HAART2
• TB lt3 months after HAART 27

Koenig S, Fitzgerald D, Pape JW, Centres GHESKIO,
Haiti
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HAART and TB therapy Summary

• The use of both IPT and HAART in HIV-infected
  patients reduces the incidence of TB and is
  recommended
• Concomitant administration of HAART and anti-TB
  meds is associated with
• High pills burden
• Higher rate of side effects (PIs and NNRTI and
  rifamycins),
• Immune reconstitution Syndrome (IRS)
• Unknown
• Optimal duration of TB therapy in AIDS patients
  on HAART
• Best timing for starting HAART in AIDS patients
  with TB
• TB mortality in Haiti found higher during first 3
  months of HAART and could be associated with
  early high mortality seen in resources
  constrained settings
• MDRTB and XDRTB when associated with HIV
  increased considerably the mortality rate