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Voice of America
Treating TB, HIV Together Decreases Mortality </b>
Rose Hoban Durham, North Carolina</i>
October 15, 2008

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In many parts of the world, patients with HIV arrive at a clinic not because they're sick with HIV, but because they are sick with tuberculosis. As VOA's Rose Hoban reports, some new research is revealing the best way to treat these patients.

Tuberculosis is epidemic in many poor countries that have high rates of HIV. But Dr. Salim Abdul Karim from the University of KwaZulu-Natal in South Africa says there has been no general agreement on how to treat the two diseases when a patient has them together.

"If you had to ask 10 medical practitioners how you would treat this patient, you would get 10 different answers," Karim says.

Anti-retroviral drugs used for treating HIV were created and tested in Western countries where there are few people with tuberculosis. As a result, researchers never studied the best way to treat HIV and TB together and the possible interactions among different drugs.

Treatments for HIV, TB Interact

But in places such as southern Africa, patients frequently do have both diseases simultaneously. Doctors struggle to treat them and manage the many problems associated with treating TB and HIV together. To begin with, Karim says, medications for tuberculosis and HIV frequently interact with one another.

"The TB drugs induce some key enzymes in the liver that result in the anti-retroviral drugs being metabolized more quickly," Karim says. He explains this has the result of making the anti-retrovirals less effective.

In particular, the TB drug called rifampicin causes this liver reaction.

"Rifampicin is a key drug in TB, so you cannot exclude it from TB treatment," Karim says.

Another problem is that some patients actually get sicker once they start taking TB drugs. Karim explains this occurs because the body's immune system goes into overdrive once it gets some help from medication. This kind of immune reaction can be so serious that patients need to be hospitalized.

The third problem is that patients getting treated for TB and HIV simultaneously end up taking a lot of pills - up to 30 per day - each with its own side effects.

"So we have a lot of concern that when you put patients on anti-retrovirals that they might then stop taking their TB drugs because of side effects they're getting from the anti-retroviral drugs," Karim says. "It's just the process of having to take seven drugs... I mean, handfuls of medication."

Patients Who Delay Treatment More Likely to Die

Karim and colleagues from Columbia University in the United States started a study to determine the best way to treat these patients. They recruited more than 600 people to try different ways of taking the drugs. Some would complete six months of TB treatment, then get HIV medications; some would take the first two months of TB medications and then start HIV drugs while completing TB treatment. A third group would get the two kinds of medications together. The trial is still going on.

In August, Karim and his colleagues reviewed the preliminary data. They found that patients waiting to complete TB treatment before getting HIV drugs were 50 percent more likely to die than patients being treated for both diseases simultaneously. Immediately, they altered the study so that all patients were getting some TB treatment.

"We should encourage all patients who have both tuberculosis and HIV to receive both therapies, both sets of drugs, at the same time," Karim says.

"TB therapy... they have to start because they won't die from HIV. They'll die from the TB," he warns. "Don't wait for them to finish their TB treatment. Start the antiretroviral drugs."

The study results were announced in a press release, rather than the usual publication in a medical journal. Karim says in the time it would take to publish these results, 10 thousand people in South Africa alone could die from being treated for TB before getting any anti-retroviral drugs. So he says they're urging doctors who see these patients to get them started on anti-retrovirals before completing the six-month course of TB medications.



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