The implementation of isoniazid preventive therapy in HIV clinics: the experience from the TB/HIV in Rio (THRio) Study

Abstract

Objective The TB/HIV in Rio (THRio) study was launched in September 2005 to assess the impact of integrated tuberculosis (TB) and HIV treatment strategies in 29 HIV clinics in Rio de Janeiro, Brazil. Design THRio is a cluster-randomized trial (CRT) to determine whether routine screening for and treatment of latent TB in HIV clinic patients with access to antiretroviral therapy will reduce TB incidence at the clinic level. THRio is part of the Consortium to Respond Effectively to AIDS/TB Epidemic that is implementing research studies to assess the impact of bold, new public health paradigms for controlling the AIDS/TB epidemic. Methods Twenty-nine public primary HIV clinics were randomly assigned a date to begin implementing TB screening procedures and provision of isoniazid preventive therapy (IPT) for TB/HIV coinfected patients. Final analysis of the CRT is expected in 2011. Results Starting at date of tuberculin skin test (TST)/IPT implementation at each clinic through August 2010, 1670 HIV-infected patients initiated IPT, of which 215 are still receiving treatment. Of the remaining 1455 patients, 1230 (85%) completed therapy and only 20 (1.2%) patients initiating IPT reported adverse reactions leading to discontinuation of therapy. IPT completion was higher among HIV-infected patients receiving HAART (87%) than those not yet receiving HAART (79%, P < 0.01). Times to TST and IPT have markedly decreased postintervention, but remain considerably long. The richness of the THRio database has resulted in several analyses of this expansive cohort of HIV-infected patients that are reviewed here. Conclusions The national implementation of TST and IPT for HIV-positive patients in Brazil has been invigorated partly due to THRio’s baseline results. Expanded use of IPT in HIV patients in Rio de Janeiro is achievable with high adherence and low adverse events, although this effort requires a package of activities including training, advocacy and reorganization of services.

High completion of isoniazid preventive therapy among HIV-infected children and adults in Kinshasa, Democratic Republic of Congo

“…Our observed high proportion of PLWH who completed six months of IPT is the same as that observed in a TB vaccine trial in Tanzania (87%) [12] and in public primary HIV clinics in Brazil (85%) [13]. A small study of IPT among pregnant women in Lesotho reported a lower proportion of IPT completion (64.5%) [14], probably due the high postpartum dropout that has been well documented among HIV-infected pregnant women [15].…”

Impact of Isoniazid Preventive Therapy for HIV-Infected Adults in Rio de Janeiro, Brazil

“…The model estimated that 16% of all HIV-infected individuals not previously treated for TB were infected with TB at baseline, compared to 15% of initial TST results positive in the primary study. 17 …”

“…16,17 Briefly, 29 public primary HIV clinics in Rio de Janeiro were assigned, in stepped-wedge fashion 18,19 to a random date of implementing TB screening and IPT over a 28-month period, then followed for an additional 20 months. During the time of this trial, Brazilian policy was to offer antiretroviral therapy (ART) to all HIV-infected adults with CD4 + T-cell counts ≤350 cells/mm 3 ; it is estimated that ART coverage among such individuals was 80%.…”

Tuberculosis prevention in HIV-infected pregnant women in South Africa

“…35 In a Brazilian study of HIV-infected patients receiving IPT (with or without ART), 1.2% of participants had adverse reactions leading to discontinuation of IPT. 36 In a study of 1 762 HIV-infected individuals receiving IPT in Botswana, 1.1% developed hepatitis, and one death was reported. 28 In Khayelitsha, a hepatitis risk of 2.9% was reported in patients receiving IPT and ART.…”