Adjunctive Dexamethasone for Tuberculous Meningitis in HIV-Positive Adults

The ACT HIV trial was a double-blind, randomized, placebo-controlled study evaluating adjunctive dexamethasone in 520 HIV-positive adults with tuberculous meningitis across Vietnam and Indonesia. Participants received a 6–8-week tapering course of intravenous and oral dexamethasone or placebo alongside standard 12-month antituberculosis chemotherapy and antiretroviral therapy (ART). At 12-month follow-up, death occurred in 44.1% (dexamethasone) vs. 49.0% (placebo) (HR = 0.85; 95% CI: 0.66–1.10; P = 0.22)no, statistically significant survival benefit. Secondary outcomes (neurologic disability, IRIS, AIDS-defining events, open-label steroid use, serious adverse events) also showed no difference. Serious neurologic adverse events were fewer in the dexamethasone group, but overall serious adverse event rates were similar (~74%). Subgroup analyses (disease severity, CSF diagnosis, ART status, CD4 count) failed to identify a clearly benefiting population. Authors conclude that routine adjunctive dexamethasone offers no survival or secondary benefit in HIV-associated tuberculous meningitis

The ACT HIV trial was a double-blind, randomized, placebo-controlled study evaluating adjunctive dexamethasone in 520 HIV-positive adults with tuberculous meningitis across Vietnam and Indonesia. Participants received a 6–8-week tapering course of intravenous and oral dexamethasone or placebo alongside standard 12-month antituberculosis chemotherapy and antiretroviral therapy (ART). At 12-month follow-up, death occurred in 44.1% (dexamethasone) vs. 49.0% (placebo) (HR = 0.85; 95% CI: 0.66–1.10; P = 0.22)no, statistically significant survival benefit. Secondary outcomes (neurologic disability, IRIS, AIDS-defining events, open-label steroid use, serious adverse events) also showed no difference. Serious neurologic adverse events were fewer in the dexamethasone group, but overall serious adverse event rates were similar (~74%). Subgroup analyses (disease severity, CSF diagnosis, ART status, CD4 count) failed to identify a clearly benefiting population. Authors conclude that routine adjunctive dexamethasone offers no survival or secondary benefit in HIV-associated tuberculous meningitis