Transcript Feasibility of routine HIV testing for TB patients

Discussion group 1
TB preventive therapy for
PLWHA
Alasdair Reid for Fabio Scano
THD unit
Stop TB department WHO
What do we know?
What do we need to know?
What has to be done to fill the
knowledge gap?
What to do in the meantime?
What do we know?
Preventing first episode of TB
• 3 systematic reviews/meta-analyses
• IPT causes significant reduction of TB
incidence (50-60% reduction) in HIV+/PPD+
individuals
• 40% reduction in HIV+ PPD unknown
individuals
• Duration of effect - limited evidence but
likely to decline with time
What do we know?
Preventing first episode of TB (2)
• Short course Rifampicin containing
regimens as effective as IPT but higher SE
• No demonstrable effect on mortality
• Adherence – very variable and may
depend on length of treatment and
selection criteria
• Cost-effectiveness – limited data but
suggest cost-effective
• Feasibility - uncertain
What do we know?
Preventing first episode of TB (3)
• Simple symptom screening questionnaire
as effective as CXR in excluding active TB
• Use in pregnancy uncertain
• Use of IPT in settings with high
background INH resistance - unclear
• No evidence that drug resistance
increased by PT
• Breastfeeding infants of sm+ mothers and
household contacts <5 plus BCG
What do we know?
Preventive treatment aimed at
preventing recurrent TB
• Evidence of effect of IPT in preventing
recurrent TB in PLWHA
Ongoing research
CDC:
• 3/12 INH+RFP vs 9/12 INH
• 6/12 IPT vs lifelong IPT
CREATE:
• Lifelong IPT in SA mineworkers
• IPT and ART in Rio
• Impact of ICF and community
interventions including IPT in Zambia & SA
Ongoing research
South Africa 4 arm study
• 6/12 INH v lifelong INH v 3/12 RFP/INH v 3/12
RMP/INH
Botswana National IPT programme since
2003
• Evaluation in 2005 linked to DRS (1995/6, 1999,
2002)
USAID - India
• 6/12 EH vs 3yrs INH
NIAID
• INH to infants of HIV positive mothers
What do we need to know?
The research questions similar for primary or
secondary PT
Establish optimal regimens (drugs & duration) &
operational feasibility of PT in high HIV prevalence
settings
Role of PT in developing drug resistance and impact of
drug resistance on efficacy of PT
What is public health benefit (cost-effectiveness and
impact) of large scale PT in high HIV prevalence
settings.
Incident TB may be higher in HIV-infected patients with
a low CD4 count. Should this be a targeted group?
Efficacy & safety of routine IPT for HIV+ pregnant
women
Feasibility of PT programmes in the context of ART
scale-up national plans
What has to be done to fill the
knowledge gap?
RCT of ART +/- PT needed to answer the
question about added efficacy
• CREATE project in Brazil
Best way of delivering PT in routine setting
Development of a valid screening tool
Studies looking at the effect of PT
programmes on the emergence of anti-TB
drug resistance (to any drug)
A pilot phase study is needed in order to
determine the efficacy and safety of PT for
pregnant women
What to do in the meantime?
IPT should be offered as part of a minimum package of care
for PLWH on grounds of its efficacy at individual level.
Ongoing studies will show if mass PT will be an adjunctive
tool to control TB in high HIV prevalence settings (CREATE).
Emergence of drug resistance due to use of PT &
implementation of PT programmes in settings with high drug
resistance to any drug needs careful evaluation, eg
Botswana.
Not enough evidence to suggest that PT contributes to drug
resistance but high compliance should be encouraged.
CXR not necessary to exclude active TB in asymptomatic
subjects, symptom screening questionnaire imperative.
International guidelines need updating and programmes
should develop simple tools and train HCW in use of
screening tools.
Given limited data, PT cannot be recommended for eligible
pregnant women on a routine basis.