Tuberculosis Preventive Therapy in the Era of HIV Infection: Overview and Research Priorities

Abstract

The recognition of tuberculosis (TB) as a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected persons has led to renewed interest in TB preventive therapy and its incorporation into the essential package of health care for these individuals. Despite convincing data regarding its efficacy, TB preventive therapy has not been widely implemented. Further work is needed to determine how to overcome the barriers to the implementation of such therapy, including how best to exclude the presence of active TB before providing preventive therapy. Such issues as the optimal duration of preventive therapy for and the role of TB preventive therapy in the treatment of individuals receiving antiretroviral therapy remain to be defined. Ongoing research will help to determine how best to use this intervention in the care of HIV-infected persons and in the control of TB on a wider basis.

Tuberculosis preventive therapy: An underutilised strategy to reduce individual risk of TB and contribute to TB control

“…[26] IPT, given for 6 -12 months after TB treatment, is effective in reducing the risk of recurrent TB disease and is recommended by the WHO. [21,27] IPT with ART IPT combined with ART reduced the risk of TB disease by 80 -97% and death by up to 50% in HIV-infected persons. [28][29][30][31] A recent individually randomised, pragmatic, controlled trial demonstrated that IPT, taken for 12 months with ART, decreased TB incidence by 37% (hazard ratio (HR) 0.63; 95% CI 0.41 -0.94) overall compared with ART alone.…”

III Diretrizes para Tuberculose da Sociedade Brasileira de Pneumologia e Tisiologia

“…(59), (85), (86[1A]), (88) TST induration ≥ 5 mm being infected with HIV having been in contact with a case of pulmonary TB within the last 2 years and having been vaccinated with BCG more than 2 years prior not having been treated for TB and having sequelae of lesions on chest X-ray being a transplant candidate or a transplant recipient being immunocompromised due to other reasons (use of ≥ 15 mg/day of prednisone or equivalent for more than 1 month or being a candidate for the use of TNF-α inhibitors) TST conversion being a worker in the prison system or an elderly care worker being a mycobacteriology laboratory staff member being a health care professional having had contact with a case of pulmonary TB recently regardless of one's age TST induration ≥ 10 mm having been in contact with a case of pulmonary TB within the last 2 years and having been vaccinated with BCG 2 or less than 2 years prior being an intravenous drug user being immunocompromised due to insulin-dependent diabetes mellitus, silicosis, lymphoma, or neoplasms in the head, neck, and lungs; or due to procedures such as gastrectomy, hemodialysis, and gastrointestinal bypass being indigenous Regardless of the TST result being HIV positive and having been in contact with a case of infectious pulmonary TB within the last 2 years or having sequelae of lesions from pulmonary TB on chest X-ray without a history of treatment for TB, regardless of the TST result (even with an induration < 5 mm) The need for repeating treatment of LTB should be considered under two conditions:…”

“…The regimens recommended are the same as those for HIV-negative patients (see "Treatment of TB"), with the possibility of replacing R with rifabutin in patients on ARV therapy incompatible with R. (88,89) The best option for the composition of the ARV regimen is efavirenz combined with two NRTIs, and no dosage change is required when it is administered together with R. (89,90) The occurrence of IRIS is not an indication for discontinuing any of the treatments. The management of IRIS includes the use of corticosteroids in more severe cases.…”

“…(97,98) Reintroduction of the RHZE regimen (1,88,93,94) • ALT/AST < 2 times ULN: reinitiate R, H, and Z one at a time. First R (with or without E); 3-7 days after the reintroduction, request tests; if there is no increase in ALT/AST levels, reintroduce H; if, 1 week after the • uncontrolled or recurrent hemoptysis • complications, including empyema, pneumothorax, and bronchopleural fistula • differentiation between TB and lung cancer…”

The HIV-associated tuberculosis epidemic—when will we act?

“…14,39 Isoniazid preventive therapy treats latent tuberculosis infection, thereby reducing progression to active disease, and simultaneously prevents new infections from becoming established. 40 Major barriers to eff ective implementation of tuberculosis screening and preventive therapy include the diffi culty of diagnosis of both tuberculosis infection and disease, and the length and toxic eff ects of available antituberculosis treatment regimens. Such barriers result in underdiagnosis and undertreatment of both infection and disease in the community and in specialist facilities.…”