Tuberculosis screening and isoniazid preventive therapy implementation: a Brazilian experience

Abstract

Evaluation of: Durovni B, Saraceni V, Moulton LH, et al. Effect of improved tuberculosis screening and isoniazid preventive therapy on incidence of tuberculosis and death in patients with HIV in clinics in Rio de Janeiro, Brazil: a stepped wedge, cluster-randomised trial. Lancet Infect Dis 2013;13(10):852-8

Tuberculosis Preventive therapy has been used since the 1960s for both mass treatment of populations and for targeted therapy to high-risk groups such as children. The World Health Organization (WHO) recommends the use of Isoniazid preventive therapy (IPT) as one of the strategies to reduce the TB burden among people living with HIV infection. However, its uptake in countries with high TB burden has been poor. One of the main barriers to its widespread implementation is concerns around the ruling out of active TB. WHO, in its revised guidelines on IPT, recommends the use of a symptom-based algorithm for TB screening. The randomized clinical trial evaluated here explores the effect of an intervention, in the form of training the clinic staff to screen for TB, use of tuberculin skin test and IPT to treat latent TB infection, and assess its effect on rates of TB and death in HIV infected.

Keywords::

• barriers
• challenges
• implementation
• isoniazid preventive therapy
• PLHIV

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Screening for tuberculosis (TB) and preventive therapy implementation has a positive impact and needs scaling up, among people living with HIV, regardless of their antiretroviral therapy status.

• Training of healthcare personnel at antiretroviral treatment centers resulted in better implementation of the policy in Brazil and reduced TB incidence and mortality among people living with HIV.

• Regular and repeated counseling of patients about the importance of TB screening and adherence to isoniazid preventive therapy are important to improve effectiveness and avoid toxicity.

• The regimen to be used and duration needs to be decided at the country level, based on a number of factors including local TB epidemiology and drug resistance levels.

• National policies on Preventive therapy should address training needs for physicians and other healthcare workers, in addition to the logistical issues of drug supply and safety monitoring.