Abstract
BackgroundIPT with or without concomitant administration of ART is a proven intervention to prevent tuberculosis among PLHIV. However, there are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources.ObjectivesTo measure the level of uptake and effectiveness of IPT in reducing tuberculosis incidence in a cohort of PLHIV enrolled into HIV care between 2007 and 2010 in five hospitals in southern Ethiopia.MethodsA retrospective cohort analysis of electronic patient database was done. The independent effects of no intervention, “IPT-only,” “IPT-before-ART,” “IPT-and-ART started simultaneously,” “ART-only,” and “IPT-after-ART” on TB incidence were measured. Cox-proportional hazards regression was used to assess association of treatment categories with TB incidence.ResultsOf 7,097 patients, 867 were excluded because they were transferred-in; a further 823 (12%) were excluded from the study because they were either identified to have TB through screening (292 patients) or were on TB treatment (531). Among the remaining 5,407 patients observed, IPT had been initiated for 39% of eligible patients. Children, male sex, advanced disease, and those in Pre-ART were less likely to be initiated on IPT. The overall TB incidence was 2.6 per 100 person-years. As compared to those with no intervention, use of “IPT-only” (aHR = 0.36, 95% CI = 0.19–0.66) and “ART-only” (aHR = 0.32, 95% CI = 0.24–0.43) were associated with significant reduction in TB incidence rate. Combining ART and IPT had a more profound effect. Starting IPT-before-ART (aHR = 0.18, 95% CI = 0.08–0.42) or simultaneously with ART (aHR = 0.20, 95% CI = 0.10–0.42) provided further reduction of TB at ∼80%.ConclusionsIPT was found to be effective in reducing TB incidence, independently and with concomitant ART, under programme conditions in resource-limited settings. The level of IPT provision and effectiveness in reducing TB was encouraging in the study setting. Scaling up and strengthening IPT service in addition to ART can have beneficial effect in reducing TB burden among PLHIV in settings with high TB/HIV burden.
Highlights
The TB/HIV syndemic is a global public health challenge accounting for nearly 25% of all HIV-associated deaths [1]
Isoniazid Preventive Therapy (IPT) was found to be effective in reducing TB incidence, independently and with concomitant antiretroviral therapy (ART), under programme conditions in resource-limited settings
TB incidence was much higher during the first six months of ART suggesting a possibility of TB immune reconstitution inflammatory syndrome (IRIS) which occurs in the face of very low CD4 count [13]
Summary
The TB/HIV syndemic is a global public health challenge accounting for nearly 25% of all HIV-associated deaths [1]. Of 8.7 million estimated incident tuberculosis (TB) cases in 2011, about 13% were among people living with HIV (PLHIV) [1]. 277 TB cases per 100,000 people per year [2] as well as a high HIV burden country with adult (15–49) HIV prevalence of 1.5% [3]. To reduce the burden of TB among PLHIV, the World Health Organization (WHO) recommends Intensified Case Finding (ICF), Isoniazid Preventive Therapy (IPT), Infection control, and early initiation of antiretroviral therapy (ART) [4]. The uptake of IPT has been limited due to difficulties in excluding active TB, added pill burden for patients, side effects, poor adherence to IPT, and concerns about development of drug resistance. There are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources
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