Free Content Potential utility of empirical tuberculosis treatment for HIV-infected patients with advanced immunodeficiency in high TB-HIV burden settings [Unresolved issues]

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Abstract:

The human immunodeficiency virus (HIV) and HIV-associated tuberculosis (TB-HIV) epidemics remain uncontrolled in many resource-limited regions, especially in sub-Saharan Africa. The scale of these epidemics requires the consideration of innovative bold interventions and ‘out-of-the-box’ thinking. To this end, a symposium entitled ‘Controversies in HIV’ was held at the 40th Union World Conference on Lung Health in Cancun, Mexico, in December 2009. The first topic debated, entitled ‘Annual HIV testing and immediate start of antiretroviral therapy for all HIV-infected persons’, received much attention at international conferences and in the literature in 2009. The second topic forms the subject of this article. The rationale for the use of empirical TB treatment is premised on the hypothesis that in settings worst affected by the TB-HIV epidemic, a subset of HIV-infected patients have such a high risk of undiagnosed TB and of associated mortality that their prognosis may be improved by immediate initiation of empirical TB treatment used in conjunction with antiretroviral therapy. In addition to morbidity and mortality reduction, additional benefits may include prevention of nosocomial TB transmission and TB preventive effect. Potential adverse consequences, however, may include failure to consider other non-TB diagnoses, drug co-toxicity, compromised treatment adherence, and logistical and resource challenges. There may also be general reluctance among national TB programmes to endorse such a strategy. Following fruitful debate, the conclusion that this strategy should be carefully evaluated in randomised controlled trials was strongly supported. This paper provides an in-depth consideration of this proposed intervention.

Keywords: Africa; HIV; empirical treatment; mortality; tuberculosis

Document Type: Invited Paper

Affiliations: 1: Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; and Zambia AIDS Related Tuberculosis Project, University of Zambia Ridgeway Campus, Lusaka, Zambia 2: National Tuberculosis Programme, Dar Es Salaam, Tanzania 3: South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch, South Africa 4: Family Health International, Washington, DC, USA 5: Grupo Pela VIDDA–Rio de Janeiro, Parceria Brasileira Contra a Tuberculose (Stop TB Brazil), Rio de Janeiro, Rio de Janeiro, Brazil 6: Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK 7: Department of HIV/AIDS, World Health Organization, Geneva, Switzerland 8: Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; and International Union Against Tuberculosis and Lung Disease, Paris, France

Publication date: March 1, 2011

More about this publication?
  • The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research. The IJTLD is dedicated to the continuing education of physicians and health personnel and the dissemination of information on tuberculosis and lung health world-wide.

    Certain IJTLD articles are selected for translation into French, Spanish, Chinese or Russian. They are available on the Union website

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