442. Early Versus Delayed Initiation of Antiretroviral Therapy (ART) in Patients with HIV Infection and Concurrent Cryptococcal Meningitis: A Systematic Review of Randomized Controlled Trials
Session: Poster Abstract Session: HIV Challenges and Complications
Friday, October 21, 2011
Room: Poster Hall B1
Handouts
  • Early Versus Delayed Initiation of ART in HIV Patients with Cryptococcal Meningitis.pdf (174.0 kB)
  • Background: Currently, initiation of HIV therapy is based on CD4 cell count. However, the point during the course of HIV infection at which ART is best initiated in patients with concomitant Cryptococcal meningitis remains unclear. Guidelines issued by various agencies provide different initiation recommendations according to resource availability. The aim of this systematic review was to provide an evidence base from which health care providers can make effective decisions in treating patients.

    Methods: We searched the following databases from January 1980 to February 2011: PUBMED, EMBASE, and WHO International Clinical Trials Registry Platform, AEGIS database for conference abstracts, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. A total of 35 full text articles were identified and supplemented by a bibliographic search. Two review authors independently assessed study eligibility, extracted data, and graded methodological quality and bias.

    Results: Two eligible randomized controlled trials were included (N = 691). In our pooled analysis, we combined the clinical data for both trials comparing early initiation ART (less than four weeks after starting antifungal treatment) versus delayed initiation of ART (four weeks or more after starting antifungal treatment). There was a 40% increase in death (RR=1.40, 95% CI [0.42, 4.68]) in the group with early initiation of ART compared to the group with delayed initiation of ART. We equally observed that there was a 63% increased risk of non-fatal AIDS progression (RR=1.63, 95% CI [0.84-3.16]) for early initiation of ART compared to delayed initiation of ART. However these results were not statistically significant (all CI’s include a RR of 1, p=0.58 for mortality outcome and p=0.15 for the AIDS progression outcome). There was no evidence of heterogeneity or publication bias.

     Conclusion: This systematic review shows that there is insufficient evidence in support of either early or late initiation of ART in HIV patients with concurrent Cryptoccocal meningitis. As such large studies with appropriate comparison groups, and adequate follow-up are warranted to provide the evidence base for effective decision making.


    Subject Category: H. HIV/AIDS and other retroviruses

    Basile Njei, MD, MSPH, Medicine, University of Connecticut School of Medicine, Farmington, CT, Emmanuel kenta-Bibi, MD, MPH, MSMed, Family Medicine, Middlesex Hospital , Middletown, CT, Alain Lekoubou, MD, H˘pital Neurologique et neurochirurgical Pierre Wertheimer, Lyon, France, Nelvis Njei, PharmDs, University of Maryland School of Pharmacy, Baltimore, MD and Eugene-Justine Kongnyuy, MD, MPH, PhD, Liverpool School of Tropical Medicine, Liverpool, United Kingdom

    Disclosures:

    B. Njei, None

    E. kenta-Bibi, None

    A. Lekoubou, None

    N. Njei, None

    E. J. Kongnyuy, None

    Findings in the abstracts are embargoed until 12:01 a.m. EST Thursday, Oct. 20 with the exception of research findings presented at IDSA press conferences.