Global guidelines for treatment of tuberculosis among persons living with HIV: unresolved issues [Perspectives]
Abstract:The Revised National Tuberculosis Control Programme (RNTCP) in India uses a fully intermittent thrice-weekly rifampicin-containing regimen for all tuberculosis (TB) patients, including those who are human immunodeficiency virus (HIV) infected, whereas the World Health Organization (WHO) recommends daily anti-tuberculosis treatment at least during the intensive phase. The WHO recommendation was based on the results of a meta-analysis demonstrating increased risk of recurrence and failure among HIV-infected TB patients receiving intermittent TB treatment compared to a daily regimen. Review of the primary evidence indicates limited, low-quality information on intermittency, mostly from observational studies in the pre-antiretroviral treatment (ART) era. Molecular epidemiology in India indicates that most of the recurrences and many of the failures result from exogenous re-infection, suggesting poor infection control and high transmission rather than poor regimen efficacy. Subsequently published studies have shown acceptable treatment outcomes among HIV-infected TB patients receiving intermittent anti-tuberculosis regimens with concomitant ART. Treatment outcomes among HIV-infected TB patients treated under programmatic conditions show low failure rates but high case fatality; death has been associated with lack of ART. The highest priority is therefore to reduce mortality by linking all HIV-infected TB patients to ART. While urgently seeking to reduce death rates among HIV-infected TB patients, given the poor evidence for change and operational advantages of an intermittent regimen, the RNTCP intends to collect the necessary evidence to inform national policy decisions through randomised clinical trials.
Document Type: Research Article
Affiliations: 1: Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India 2: Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India; Office of the World Health Organization Representative to India, New Delhi, India 3: National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India, New Delhi, India 4: International Union Against Tuberculosis and Lung Disease, South East Asia Regional Office, New Delhi, India 5: National AIDS Research Institute, Pune, India 6: Office of the World Health Organization Representative to India, New Delhi, India 7: National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Chennai, India
Publication date: May 1, 2012
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.
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