Carlos del Rio, MD reviewing Hosseinipour MC et al. Lancet 2016 Mar 19. Godfrey-Faussett P and Ayles H. Lancet 2016 Mar 19.

Among patients with advanced HIV disease in settings with high tuberculosis prevalence, starting empiric treatment for tuberculosis did not reduce mortality compared with isoniazid preventive therapy alone at ART initiation.

Tuberculosis (TB) is the most common cause of death in HIV-infected individuals initiating antiretroviral therapy (ART) in resource-limited settings. Therefore, empiric treatment for TB at the time of ART initiation in asymptomatic HIV-infected individuals living in settings with high TB prevalence has been suggested as an approach to reduce TB-associated mortality. The World Health Organization recommends that only isoniazid (preventive) therapy be initiated in this situation. To compare empiric TB treatment versus isoniazid therapy in people with advanced HIV initiating ART in settings where TB is common, researchers conducted the REMEMBER study. They enrolled 850 patients, primarily in sub-Saharan Africa, with CD4 count <50 cells/µL who screened negative for active TB using a symptom screen, and randomized participants 1:1 to empiric TB therapy or isoniazid. The primary endpoint was survival at 24 weeks.

Median CD4 count at enrollment was 18 cells/µL (interquartile range, 9–32). At week 24, there were 22 primary events (mostly deaths) in each group, and time to primary event did not differ between the two groups. Mortality was higher in those with CD4 <25 cells/µL. Adverse events were also similar between groups.

Citation(s):

Hosseinipour MC et al. Empirical tuberculosis therapy versus isoniazid in adult outpatients with advanced HIV initiating antiretroviral therapy (REMEMBER): A multicountry open-label randomised controlled trial. Lancet 2016 Mar 19; 387:1198.

Godfrey-Faussett P and Ayles H.Why are people living with HIV still dying of tuberculosis? Lancet 2016 Mar 19; 387:1141. 

JWatch