Golub JE, Saraceni V, Cavalcante SC, Pacheco AG, Moulton LH, King BS, et al. The impact of antiretroviral therapy and isoniazid preventive therapy on tuberculosis incidence in HIV-infected patients in Rio de Janeiro, Brazil

Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland 21231, USA.
AIDS (Impact Factor: 5.55). 08/2007; 21(11):1441-8. DOI: 10.1097/QAD.0b013e328216f441
Source: PubMed


Tuberculosis is a common complication and leading cause of death in HIV infection. Antiretroviral therapy (ART) lowers the risk of tuberculosis, but may not be sufficient to control HIV-related tuberculosis. Isoniazid preventive therapy (IPT) reduces tuberculosis incidence significantly, but is not widely used.
We analysed tuberculosis incidence in 11 026 HIV-infected patients receiving medical care at 29 public clinics in Rio de Janeiro, Brazil, between 1 September 2003 and 1 September 2005. Data were collected through a retrospective medical record review. We determined rates of tuberculosis in patients who received neither ART nor IPT, only ART, only IPT, or both ART and IPT.
The overall tuberculosis incidence was 2.28 cases/100 person-years (PY) [95% confidence interval (CI) 2.06-2.52]. Among patients who received neither ART nor IPT, incidence was 4.01/100 PY. Patients who received ART had an incidence of 1.90/100 PY (95% CI 1.66-2.17) and those treated with IPT had a rate of 1.27/100 PY (95% CI 0.41-2.95). The incidence among patients who received ART and IPT was 0.80/100 PY (95% CI 0.38-1.47). Multivariate Cox proportional hazards modeling revealed a 76% reduction in tuberculosis risk among patients receiving both ART and IPT (adjusted relative hazard 0.24; P < 0.001) after adjusting for age, previous tuberculosis diagnosis, and CD4 cell counts at baseline.
The use of both IPT and ART in HIV-infected patients is associated with significantly reduced tuberculosis incidence. In conjunction with expanded access to ART, the wider use of IPT in patients with HIV will improve tuberculosis control in high burden areas.

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Available from: Valeria Saraceni,
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    • "IPT can dramatically reduce the risk of TB among PLWHA even among those receiving ART and living in areas with low TB rates [31-33]. The new WHO guideline strongly recommends IPT to HIV patients without active TB irrespective of immune status and whether or not a person is on ART [32]. "
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    • "IPT added to ART has been shown to further reduce TB rates by a supplementary factor of around 0.31–0.63 [23], [24], [26] but without a further large increment to life expectancy. The long-term durability of this effect is unknown, but sustained suppression was observed when IPT was given in combination with ART continuously over 3 years [25]. "
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    • "These findings are encouraging given the high rates of TB-associated mortality among HIV-infected PWID generally (Corbett et al., 2003; Kourbatova et al., 2006; McShane, 2005; Nunn et al., 2005; Sharma et al., 2005). Recent evidence has demonstrated that utilization of both IPT and ART in HIV-infected patients is associated with reduced TB incidence (Golub et al., 2007; Uyei et al., 2011), and IPT is currently recommended for all HIV-infected patients where TB is prevalent (World Health Organization, 2011). Although patients in the ICL and NCL groups were equally likely to have received recent TB screening, ICL participants were significantly more likely to receive IPT than NCL participants, suggesting that further reductions in morbidity among NCL participants may be achieved in ICL settings. "
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