At the crossroads between early or delayed antiretroviral therapy initiation during tuberculosis/human immunodeficiency virus coinfection.

Dear Editor,

Saraceni et al. report the results of the THRio observational cohort, which showed an 89% increased risk of mortality when antiretroviral therapy (ART) was delayed (more than 60 days and less 365 days after tuberculosis (TB) treatment) during HIV-associated TB. However, the median CD4 count at TB diagnosis in this cohort was 150 cells/μL, a fact that may compromise the generalization and interpretation of the study results. On the other hand, the investigators provide further support to WHO guidelines, which recommend that all HIV-infected individuals with active TB (regardless of CD4 cell count) should receive ART as soon as possible, generally within 2–8 weeks. Recently, Mfinanga et al. showed that delaying ART prescription for at least six months (TB treatment) was not inferior in terms of TB treatment outcome and overall survival, when compared to early ART within two weeks of starting TB treatment in patients with CD4 cell counts more than 220 cells/μL. Additionally, the early ART arm was associated with a non-significant increase in TB recurrences.

The treatment of HIV-associated TB remains a daunting and challenging task; challenges include excessive pill burden, patient compliance, drug interactions, overlapping treatment toxicities, and emergence of immune reconstitution disease. Moreover, it is estimated that severe drug adverse events occurred more often among HIV-infected TB patients compared with uninfected subjects. Conversely, obviating the concomitant TB/HIV therapy, especially in individuals with preserved immune function, might simplify TB management cases, increasing adherence as well as maintaining the same overall survival outcome, as seen in early ART strategy. Therefore, the time is ripe for policy makers and scientists to harmonize approach regarding when to start ART during TB coinfection.

Conflicts of interest

The author declares no conflicts of interest.