Review editorial: Prevention of tuberculosis in resource-poor countries with increasing access to highly active antiretroviral treatment (original) (raw)
Related papers
The Indian Journal of Medical Research, 2020
Background & objectives: As India and other developing countries are scaling up isoniazid preventive therapy (IPT) for people living with HIV (PLHIV) in their national programmes, we studied the feasibility and performance of IPT in terms of treatment adherence, outcome and post-treatment effect when given under programmatic settings. Methods: A multicentre, prospective pilot study was initiated among adults living with HIV on isoniazid 300 mg with pyridoxine 50 mg after ruling out active tuberculosis (TB). Symptom review and counselling were done monthly during IPT and for six-month post-IPT. The TB incidence rate was calculated and risk factors were identified. Results: Among 4528 adults living with HIV who initiated IPT, 4015 (89%) successfully completed IPT. IPT was terminated in 121 adults (3%) due to grade 2 or above adverse events. Twenty five PLHIVs developed TB while on IPT. The incidence of TB while on IPT was 1.17/100 person-years (p-y) [95% confidence interval (CI) 0.8-1...
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2015
The duration of protection against tuberculosis provided by isoniazid preventive therapy is not known for human immunodeficiency virus (HIV)-infected individuals living in settings of medium tuberculosis incidence. We conducted an individual-level analysis of participants in a cluster-randomized, phased-implementation trial of isoniazid preventive therapy. HIV-infected patients who had positive tuberculin skin tests (TSTs) were followed until tuberculosis diagnosis, death, or administrative censoring. Nelson-Aalen cumulative hazard plots were generated and hazards were compared using the log-rank test. Cox proportional hazards models were fitted to investigate factors associated with tuberculosis diagnosis. Between 2003 and 2009, 1954 patients with a positive TST were studied. Among these, 1601 (82%) initiated isoniazid. Overall tuberculosis incidence was 1.39 per 100 person-years (PY); 0.53 per 100 PY in those who initiated isoniazid and 6.52 per 100 PY for those who did not (adjus...
The Lancet Infectious Diseases, 2010
Antiretroviral therapy and isoniazid preventive therapy (IPT) are both eff ective interventions to prevent HIV-associated tuberculosis, but work via diff erent mechanisms. We propose that these two interventions might best be used as complementary strategies at diff erent stages of HIV progression. At relatively high CD4-cell counts, IPT reduces tuberculosis risk by 64% (95% CI 39-78%) in patients with positive tuberculin skin tests, and is the key tuberculosis preventive intervention before patients are eligible for antiretroviral therapy. However, at low CD4-cell counts, reliable exclusion of active tuberculosis is diffi cult, fewer patients are eligible for IPT, and waning immune function might limit the durability of its eff ect. In such patients, antiretroviral therapy is the primary intervention needed, reducing tuberculosis incidence by 67% (95% CI 61-73%). However, tuberculosis risk during long-term antiretroviral therapy remains several times higher than background, especially in those with poor immune recovery. Patients might therefore derive additional benefi t from combined use of IPT and antiretroviral therapy to simultaneously treat mycobacterial infection and restore tuberculosis-specifi c immune function. For those fi rst presenting with advanced immunodefi ciency, we propose that concurrent IPT might best be delayed until completion of the fi rst few months of antiretroviral therapy, when active tuberculosis can be more reliably excluded. Data from randomised controlled trials are needed to underpin further development of public-health policy.
JAMA, 2005
Context Tuberculosis preventive therapy reduces tuberculosis incidence among human immunodeficiency virus (HIV)-infected individuals in clinical trials, but implementation has been limited and there are no data on effectiveness under routine conditions. Objective To determine the effect on tuberculosis incidence of a clinic providing isoniazid preventive therapy to HIV-infected adults under routine conditions. Design, Setting, and Participants Randomized intervention study with a novel incremental recruitment design. Between 1999 and 2001 (before antiretroviral therapy was available), 1655 HIV-infected male employees of a South African gold-mining company (median age, 37 years) were enrolled in the study. Median follow-up was 22.1 months. Intervention Employees were invited in random sequence to attend a workplace HIV clinic. Isoniazid, 300 mg/d, was self-administered for 6 months among attendees with no evidence of active tuberculosis. Main Outcome Measure Incidence of tuberculosis (including both first and recurrent episodes) during the periods before and after clinic enrollment. Results A total of 1016 of 1655 men included in the analysis attended the clinic at least once. Six hundred seventy-nine (97%) of 702 men eligible to start primary isoniazid preventive therapy did so. The tuberculosis incidence rate before vs after clinic enrollment was 11.9 vs 9.0 per 100 person-years, respectively (incidence rate ratio [IRR] after adjustment for calendar period, 0.68; 95% confidence interval [CI], 0.48-0.96). In a multivariable analysis adjusting for calendar period, age, and silicosis grade, the tuberculosis IRR for clinic enrollment was 0.62 (95% CI, 0.43-0.89). In a further analysis excluding individuals with a history of tuberculosis (and, hence, ineligible for isoniazid preventive therapy), the adjusted IRR for clinic enrollment was 0.54 (95% CI, 0.35-0.83). Conclusions Enrollment in a clinic offering primary isoniazid preventive therapy to HIV-infected adults reduced tuberculosis incidence by 38% overall and by 46% among individuals with no history of tuberculosis prior to the study. Tuberculosis incidence remained high despite isoniazid preventive therapy, and further work is needed to determine how to use additional interventions most effectively to reduce morbidity and mortality due to tuberculosis in HIV-infected persons.
PLOS ONE
Setting Four primary health care clinics providing tuberculosis (TB) and Human Immunodeficiency Virus care services in Bulawayo, Zimbabwe. Objectives To assess isoniazid preventive therapy (IPT) initiation and completion, factors associated with IPT uptake and incidence of TB, and TB and antiretroviral treatment (ART) outcomes among people living with HIV (PLHIV). Design This was a cohort study using routine data in the records for PLHIV initiated on ART from October 2013 to March 2014 with 31 December 2017 as the end of the follow-up period. Results A total of 408 PLHIV were eligible for IPT, 214 (52%) were initiated on IPT and 201 (94%) completed IPT. No person in the IPT-initiated group developed Tuberculosis (TB). Six persons with TB were reported among the non-IPT-initiated group leading to an incidence of 9 cases/1,000 person-years of follow-up. About 70% of those who developed and were treated for TB had a successful TB treatment outcome. The survival on ART at four years of follow-up was 88% among the IPT-initiated PLHIV that was significantly higher than the 75% survival in the group not-initiated on IPT. Conclusion The study revealed low IPT initiation among eligible PLHIV who, if started on IPT, completed the six month regimen. TB was reported only among the PLHIV not-initiated on IPT and the PLOS ONE |