Glucocorticoids reduce excessive inflammation in pleural tuberculosis and have been shown to hasten resolution in HIV negative patients. Active tuberculosis can speed progression of HIV infection since HIV replicates more rapidly in activated lymphocytes. Given that prednisolone therapy is associated with reduced immune activation in HIV positive subjects, the authors hypothesised that adjunct therapy with prednisolone in HIV positive patients with pleural tuberculosis would decrease viral replication and improve survival.

In this study, 197 Ugandan HIV infected patients with pleural tuberculosis were randomised to receive treatment for 8 weeks with either a reducing dose of prednisolone or placebo, together with 6 months of treatment with a four-drug antituberculous regime. The median follow up periods were 1.65 and 1.48 years in the prednisolone and placebo groups, respectively. Prednisolone had no effect on either survival or HIV viral load. The mortality rate ratio for prednisolone compared with placebo, after adjusting for confounding factors, was 0.99 (95% CI 0.62 to 1.56, p = 0.95). Use of prednisolone was associated with significantly more rapid improvements in anorexia, weight loss, cough, and radiological resolution of pleural effusion. However, use of prednisolone was also associated with a significantly increased risk of adverse effects (9%) compared with placebo (2%; p = 0.03), and a significantly higher incidence of Kaposi’s sarcoma (prednisolone 4.2 cases/100 person-years; placebo 0 cases/100 person-years, p = 0.02).

In light of the lack of survival benefit and the increased risk of Kaposi’s sarcoma, the authors recommend that prednisolone should not be used in HIV associated tuberculous pleurisy.