Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries

Authors from The Union have published a paper in The International Journal of Tuberculosis and Lung Disease, entitled: Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries.

People living with HIV (PLHIV) are at a high risk of developing tuberculosis (TB), and preventing TB is therefore critical. Preventive therapies have been seen to be extremely effective, yet in most low-income countries with high-burdens of HIV-associated TB these interventions are not happening. This recent paper explores these challenges and provides practical and up-to-date information on key interventions that can be implemented by programme managers to prevent TB among PLHIV in low-income countries.

The paper has been developed by Union TB-HIV consultants after a meeting at the 48th Union World Conference on Lung Health in Guadalajara, Mexico, where potential interventions were discussed. The paper specifically reviews the most important therapeutic interventions - antiretroviral therapy (ART) and isoniazid preventive therapy (IPT), focusing on the programmatic challenges and opportunities around their implementation and putting them in the context of other preventive interventions.

The World Health Organization (WHO) now recommends that all PLHIV, regardless of their CD4 cell count or the clinical stage of disease, should initiate ART, and that this early initiation amongst asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. The paper highlights that whilst data on ART in preventing TB are encouraging, ART in isolation does not do the job adequately and optimisation of TB prevention therefore requires additional interventions.

It is now established that IPT, combined with ART among PLHIV, significantly reduces the risk of TB and mortality compared with ART alone, and therefore has great potential benefits. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB.

The authors urge that to reduce TB in PLHIV in low-income countries measures need to include ensuring that all persons at risk know their HIV status, and that for those diagnosed with HIV infection, there is the immediate initiation and sustained use of ART. The implementation and scale-up of IPT combined with early ART should be considered, addressing issues such as: treatment duration, use of diagnostic tools to exclude active TB, robust supply of drugs, patient-centred support and follow-up, TB detection among close contacts, and infection control. Strong commitment and collaboration between HIV and TB programmes are required.  

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