Reply to "at the crossroads between early or delayed antiretroviral therapy initiation during TB/HIV coinfection".

Dear Editor,

The THRio study was a cluster randomized trial evaluating the impact of training health care providers at 29 health clinics linked to the Rio the Janeiro City Health Secretariat to follow the Brazilian guidelines to treat latent TB infection among people living with HIV/AIDS (PLWHA). THRio included all current and new HIV/AIDS patients during a 4-year period independent of their CD4 cell counts, capturing data from medical charts. Our recent analysis published in the Brazilian Journal of Infectious Disease used data from the THRio cohort to compare simultaneous or deferred HAART in those diagnosed with TB and included all patients regardless of their CD4 count at the time of their TB episode. Our findings of a greater risk of death among patients with deferred HAART were consistent with clinical trials in Africa included predominantly patients with more advanced immune compromise.3, 4

Mfinanga et al. recently reported a non-significant difference between early and deferred HAART (waiting for completion of 6-month TB therapy course) with enrollment limited to those with CD4 counts over 220 cells/mm3 at time of TB diagnosis, suggesting that HAART can be delayed in PLWHA with relatively preserved immunity. However, all other trials and cohort data to date have shown benefit from early HAART, including ours, and have included patients with very low CD4 cell counts.

Mfinanga and colleagues proposed a change in the WHO guidelines, given their findings and their strength of evidence (placebo-controlled RCT), which should be better evaluated given other benefits derived from early HAART initiation, at both the individual and population level.

Conflicts of interest

The authors declare no conflicts of interest.