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TB Prophylaxis in HIV infected individuals

TB Prophylaxis in HIV infected individuals. A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 Ernest Barbot, Patrice Joseph, Patrick Paul, Patrice Sévère, Paul D. Leger, Daniel W, Fitzgerald and Jean W Pape. Global TB Epidemiology.

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TB Prophylaxis in HIV infected individuals

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  1. TB Prophylaxis in HIV infected individuals A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 Ernest Barbot, Patrice Joseph, Patrick Paul, Patrice Sévère, Paul D. Leger, Daniel W, Fitzgerald and Jean W Pape

  2. Global TB Epidemiology • One third of the world population is infected with Mycobacterium tuberculosis • Each year 8.4 million of new TB cases and 1.9 million of death • 95% of cases and 98% of death occurs in developing countries • In Haiti, the incidence of tuberculosis is one of the highest : 180 per 100,000

  3. Global TB/HIV • HIV fuels the tuberculosis epidemic • HIV is the most powerful known risk factor for reactivation of latent tuberculosis infection to active disease

  4. Global TB/HIV • The annual risk of developing tuberculosis in PLWA who is co-infected with tuberculosis ranges from 5-15% • HIV increases the rate of recurrent tuberculosis which may be due to either endogenous reactivation (true relapse) or exogenous re-infection

  5. HIV and Tuberculosis in Haiti • The most affected country in the Americas • 50 % of adult patients in sanatoria were HIV+ (1988) • About 10%/year of HIV+ PPD+ are developing active TB • Estimated that at least 30% of new TB cases are due to HIV

  6. Studies Two important studies have been conducted by GHESKIO to verify the importance of the use of INH as prophylaxis in HIV-infected patients: • To assess the efficacy of INH in preventing active TB in symptom-free HIV infected individuals • To determine whether post-treatment INH prophylaxis decreases the risk of recurrent TB

  7. Incidence of active tuberculosis in PPD positive subjects Pape JW et al: The Lancet 342: 1993

  8. Tuberculosis Preventionin HIV and PPD Positive Persons Rate of active tuberculosis cases per 100 person-years Placebo Intervention Author/Place/Date Pape et al/Haiti/1993 INH, X 1 year 10 1.7 Markowitz et al/USA/1997 INH, X 6 mo 4.7 1.6 Whalen et al/Uganda/1997 INH, X 6 mo 3.41 1.08 INH+RIF, X 3 mo 3.41 1.32 INH+RIF+PZA, X 3 mo 3.41 1.73 Halsey et al/Haiti INH, 2X/week, X 6 mo - 1.0 RIF +PZA , X 8 weeks - 3.7 INH = Isoniazid; RIF = Rifampin; PZA = Pyrazinamide

  9. Effect of Preventive INH on the Incidenceof Active TB and Progression of HIV Infection Pape JW et al: The Lancet 342: 1993

  10. PPD Positive Individual PPD Negative Individual Pape JW et al: The Lancet 342: 1993

  11. 233 patients treated for TB Randomised HIV+ (142) HIV- (91) Placebo (74) Isoniazid (68) Placebo (40) Isoniazid (51) • Recurrent TB 12 2 0 1 • Recurrence rate per 100 persons-years (95% CI) 7.8 (4.1-13.3) 1.4 (0.0-3.4) 0.0 (0.0-4.0) 0.7 (0.0-3.9) Fitzgerald D, Desvarieux M, Sévère P, Joseph P, Johnson WD Jr, Pape J.W. The Lancet 2000 356 : 1470-74 Effect of Post-treatment Isoniazid on Prevention of TB in HIV-infected Individuals

  12. Effect of Post Treatment Isoniazid Prophylaxis on TB Recurrence Among Hiv+ Patients Proportion free of recurrent tuberculosis Population free of recurrent tuberculosis Time from completion of TB therapy (months) Fitzgerald D, Desvarieux M, Sévère P, Joseph P, Johnson WD Jr, Pape J.W. The Lancet 2000 356 : 1470-74

  13. Post-treatment INH for the prevention of recurrent TB in HIV-infected individuals • High rate of recurrent TB in HIV-1-positive individuals • Ten-fold greater risk of recurrent TB than HIV-1-negative

  14. Duration of Isoniazid prophylaxis and time of recurrence of Tuberculosis Fitzgerald D, Morse MM, Pape JW, Johnson WD Jr CID 2000; 311495-1497

  15. Summary • HIV and TB co-infection are common in HIV-infected individuals • INH prophylaxis should be considered for HIV+, PPD+ patients and may also be appropriate for PPD-patients in areas where TB is highly endemic • HIV+ patients with class B/C of CDC with TB should receive post treatment INH prophylaxis

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