n Southern African Journal of HIV Medicine - HIV / TB : when is it safe to start HAART? : debate




South Africa has the fourth highest burden of tuberculosis (TB) worldwide after China, India and Indonesia and has the highest TB notification rate of any country. The World Health Organization (WHO) estimated that in 2006 South Africa had 303 114 incident TB cases; of these patients, 32% were tested for HIV and 53% were found to be HIV infected. HIV testing of TB cases has been encouraged by the WHO and testing has resulted in identification of increasing numbers of HIV-infected individuals in the TB control programme. The success of this policy has been demonstrated in the Cape Town Gugulethu antiretroviral clinic, where referrals directly from the local TB clinics have increased from 15% to 30% within the past 2 years. The national TB control programme has therefore become an increasingly important pathway to HIV care and access to highly active antiretroviral therapy (HAART). An additional 15 - 20% of patients in the Gugulethu programme have a diagnosis of TB made during the HAART screening period, further increasing the number of individuals on TB medication who require HAART. Mortality after referral is very high. The HIV / TB case mortality has been reported to be as high as 16 - 35% prior to the introduction of HAART, with both HIV and TB contributing to this mortality. Optimal timing of HAART is currently unknown and there is an urgent need for development of evidence-based protocols for HAART initiation and immune reconstitution disease (IRD) management.


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