High incidence of IRIS amongst HIV-positive TB patients starting HAART in India

A high incidence of immune reconstitution inflammatory syndrome (IRIS) amongst HIV-positive patients with tuberculosis (TB) in India who commenced HAART shortly after TB treatment has been reported in the December 15^th edition of the Journal of Acquired Immune Deficiency Syndromes. The investigators believe that their findings underscore the need for clinical trials in resource limited settings to better understand when to initiate HAART in the context of active opportunistic infections.

IRIS in individuals with TB during treatment with HAART has been well described in richer countries. As antiretroviral drugs become more widely available in resource limited settings, investigators in India wished to determine the incidence of IRIS amongst HIV-positive patients with high rates of tuberculosis commencing HAART.

A total of 333 adult HIV-positive patients who received generic HAART at the YRG CARE facility in Chennai, India, were included in the investigators analysis.

At the initiation of HAART, 144 individuals (44%) had active TB. The mean CD4 cell count of these patients at the time of HAART initiation was 122 cells/mm³, and after six months of anti-HIV therapy the mean increase in CD4 cell count was 130 cells/mm³.

Eleven patients developed IRIS during the course of the study. Their CD4 cell count at baseline (mean 124 cells/mm³) and their mean increase in CD4 cell count during anti-HIV therapy (124 cells/mm³) did not differ from patients who did not develop IRIS (p = 0.8).

IRIS developed a median of 42 days after starting HAART and the incidence of IRIS was 15 cases per 100 patient years. The median duration between the initiation of TB treatment and starting HAART was similar between patients regardless of whether or not they developed IRIS (p = 0.8).

Patients were treated with short-course cortico-steroids, aspiration and were counselled to continue their anti-HIV therapy.

“In this cohort from a resource-limited setting with a high background rate of TB, there is a high incidence of IRS”, write the investigators. They conclude by calling for clinical trials in resource limited settings “to help physicians better understand when to initiate antiretroviral therapy in the context of opportunistic infections” and also note that without adequate guidelines, doctors treating HIV in poorer countries “will face a new set of challenges to safe and effective therapy.”