Increase TB preventive therapy for HIV patients

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Tuberculosis and HIV are the leading infectious causes of death worldwide.  Three million people have TB. Most of it is latent. But that huge reservoir is one of the main challenges TB control programs face—how do we get rid of a disease that more than 1/3 of the world’s population has?

About 36.9 million people have HIV, according to the WHO. The HIV epidemic has the been a major cause of the TB resurgence. In South Africa, for example, 60% of TB patients are co-infected with HIV. Isoniazid is one the top drugs that fights TB disease. Several studies through the Consortium to Respond Effectively to the AIDS TB Epidemic (CREATE) have shown that isoniazid can be used prophylactically to reduce TB disease and death, especially in settings where the TB is endemic and the HIV risk is high. This is particularly important among HIV+ patients who are more likely to die from TB than HIV- TB patients. The WHO and the South African Department of Health recommend giving isoniazid preventive therapy (IPT) according to the following table:

IPT chart

TST stands for TB skin test (the Mantoux or PPD as it is often known). HIV+ patients do not often have positive skin tests since it requires the immune system to mount a response. So in resource-constrained settings where getting skin test materials may be difficult, the WHO recommends giving IPT to any HIV+ patient to help reduce the risk of him or her developing TB.

This of course poses new problems—how do we get the isoniazid supply to those resource-constrained areas where the HIV burden is high? Increasing funding toward TB programs is essential to reduce the TB burden in high prevalence HIV populations. Part of the PEPFAR HIV strategy in South Africa is to reduce the TB infections and deaths by 50%. Yet the PEPFAR funding toward HIV programs in South Africa will be reduced after 2017. Cutting the TB rates in half is ambitious but may be possible if part of the strategy is to ensure IPT is given to all HIV+ patients who live in TB endemic areas, like much of South Africa. But without steady funding this goal becomes unrealistic. It must be renewed if we want to stop TB.

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3 Responses to “Increase TB preventive therapy for HIV patients”

  1. sbfphc Says:

    This posting raises the important debate between desirable scientifically sound interventions and affordable interventions. Even when the drugs in question are relatively “cheap”, the sheer volume of medicines needed would be daunting in high prevalence settings like South Africa. In addition there is the issue of using contrimoxazole as a preventive measure for some opportunistic infections. Not only are there cost issues with this, but one would wonder if there would there be any drug interaction issues, too. As HIV becomes more of a ‘chronic’ condition, we begin to realize that lifelong compliance with a number of medicines, just like people with hypertension, presents a financial and adherence challenge.

  2. jodeleonmph Says:

    Although the IPT drug sounds promising, there are several questions I have that potential sponsors of the IPT program may also have:

    How do IPT program workers expect to identify all HIV+ individuals in the affected area? Of course there are existing medical records of confirmed HIV+ individuals, but what about the numerous amounts of incident cases that occur? Screening alone may pose some sort of financial burden that can dip into costs of IPT drug supply.

    How has the social reception and adherence to the IPT program fared? Is there a social stigma associated with the program at all since it targets HIV+ individuals (and will that prevent susceptible individuals from participation)? Since the IPT program is designed to last at least 6 months, how well are ‘patients’ adhering to their scheduled administrations? Sponsors are not likely to continue funding of a program that essentially isn’t well received.

    What are the recommendations for infants and pregnant women? Presumably, these are two very susceptible populations–have any adverse short term or long term effects been observed?

  3. asangua1 Says:

    This is an interesting topic. In Thailand, there is also high prevalence of TB among HIV patients. However, many physicians do not test for TB skin test or prescribe isoniazid for HIV patients. I believe this is also true in many other countries than South African countries. As this policy form WHO is not universal, I think it will be difficult to request fund from organizations outside African or WHO.
    If this policy is proven benefits not only in Africa, but also other countries that have high prevalence of TB in HIV, may be PEPFAR can get fund to support their program from major organizations.

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