Preventive chemotherapy in TB-HIV and other co-infections: Cheap drugs, that work
While we wait for expanded antiretorivral (ARV) programmes to deliver life-saving treatments, preventive tuberculosis (TB) chemotherapy can also help people living with HIV/AIDS to live longer.
“There should definitely be emphasis on provision of [the drugs] cotrimoxazole, fluconazole and isoniazid for life-enhancement of people living with HIV and TB co-infection. Isoniazid is very helpful in preventing the onset of TB in the early stages of HIV infection” said Dr Peter Godfrey Faussett, specialist in infectious and tropical diseases at the London School of Hygiene & Tropical Medicine, in the UK.
While discussing the use of isoniazid (INH) therapy in treating HIV-TB co-infection, Faussett stressed that INH is not helpful when people have already developed active TB. But when their immunity is fairly good and TB is likely to still be ‘latent’, cotrimoxazole, fluconazole and INH can help them stay healthier and delay the progression of HIV-associated conditions such as TB.
These are simple and cost effective methods to help extend the lives of people living with HIV. Cotrimoxazole in India for instance, costs about US$0.01 (or one US cent) per day. INH therapy in early stages of HIV infection has shown positive results in countries like Botswana, and Malawi, delaying the progression of HIV-related conditions considerably.
Standard INH therapy lasts for 9 months, which kills latent TB bacteria, but in cases of TB-HIV co-infection, the therapy takes longer, and may be continued until HIV-associated conditions begin to appear.
INH therapy has been recommended by the World health Organization (WHO) since 1998. There are no reported side-effects and the only caution while managing TB-HIV co-infection is to remember that INH has to be stopped in the later stages of HIV infection.
Early in the AIDS epidemic, the administration of the antibacterial drug cotrimoxazole (CTX) was also an affordable treatment used to help save lives long before ARVs were available. As well as TB, cotrimoxazole has been shown to prevent and treat HIV-related infections such as pneumocystis pneumonia, toxoplasmosis (a parasitic infection of the intestines), and falciparum malaria when taken by people living with HIV. Side-effects of CTX appear limited to some people developing rash that can be avoided by following recommended dosage.
Numerous data analysis carried out by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO, as well as a full ‘Cochran review’, resulted in recommendations to administer cotrimoxazole prophylaxis as part of a package care for adults living with HIV/AIDS. The WHO, UNAIDS and United Nations Children’s Fund (UNICEF) also issued a joint statement (in November 2004) recommending CTX for all HIV-exposed children. More recently, British and South African researchers demonstrated that CTX reduces the risk of death in tuberculosis (TB) patients in a high HIV seroprevalence setting based on a study carried out in a rural area of South Africa.
However, studies have also yielded inconclusive results as to whether CTX is effective in people taking ARVs and in areas where bacterial resistance to CTX is common. Some public health physicians have expressed concerns with the theoretical potential of widespread use of CTX to increase drug resistance of malaria and pneumoccoccal pneumonia. Nevertheless, international health organisations still recommend CTX to be included in official national treatment guidelines based on the premise that it is known to save lives.
Why then is cotrimoxazole prophylaxis not more widely used in Asia?
Only a handful Asian countries with HIV/AIDS epidemic to date have included CTX in their official national HIV/AIDS treatment guidelines. The two WHO Asian regional offices – Southeast Asia and the Western Pacific – have yet to release any new regional CTX treatment guidelines in the wake of “3by5”. Regardless, official guidelines are useless unless recommendations are implemented. We already know that cotrimoxazole can save lives of people with HIV in Asia, so…what are we waiting for?
For those with active TB, a well-established and tested treatment is available, known as directly-observed treatment short-course, or DOTS,, although drug compliance continues to challenge service providers. In TB-HIV co-infection, motivating patients to be compliant to the drug regimen for TB treatment can be a big challenge. The defaulter rate in TB-HIV co-infection for TB treatment is much higher than treating TB in HIV sero-negative people. The death rate is also high, according to Dr Pacharee Kantipong, chief of the Department of Medicine, at Chiang Rai Regional Hospital in northern Thailand – an area of the country with high HIV-TB co-infection.
Dr Thandar Lwin, assistant director of the National Tuberculosis Programme in Myanmar, said that adherence is a persistent challenge while treating TB-HIV co-infection. She explained that we are not treating the virus or bacteria alone, rather human beings, so they need motivation and optimism to live and love their life. “Love can increase adherence”, she said.
Dr Lwin also said that she has a defaulter tracing mechanism in place to send out health workers to get the defaulters back to treatment within two months. This has improved the TB treatment compliance of people living with HIV substantially. She said that regular community or group education is a strong method of ensuring good TB treatment compliance from people living with HIV. She said multi-drug resistant TB (MDR TB) and HIV are the two mountainous challenges confronting public health in Myanmar. She said cases of MDR TB can be substantially reduced if proper TB treatment compliance is ensured as far as possible.
There is no doubt that TB prevention and treatment are essential life-extending interventions for people living with HIV/AIDS . While millions of people living with HIV wait for expanded ARV access programmes to deliver, raising awareness about TB prevention and cure (including treatment compliance) is clearly vital.
by: HDN Key Correspondnet Team
Email: correspondents@hdnet.org
(July 2005)
“There should definitely be emphasis on provision of [the drugs] cotrimoxazole, fluconazole and isoniazid for life-enhancement of people living with HIV and TB co-infection. Isoniazid is very helpful in preventing the onset of TB in the early stages of HIV infection” said Dr Peter Godfrey Faussett, specialist in infectious and tropical diseases at the London School of Hygiene & Tropical Medicine, in the UK.
While discussing the use of isoniazid (INH) therapy in treating HIV-TB co-infection, Faussett stressed that INH is not helpful when people have already developed active TB. But when their immunity is fairly good and TB is likely to still be ‘latent’, cotrimoxazole, fluconazole and INH can help them stay healthier and delay the progression of HIV-associated conditions such as TB.
These are simple and cost effective methods to help extend the lives of people living with HIV. Cotrimoxazole in India for instance, costs about US$0.01 (or one US cent) per day. INH therapy in early stages of HIV infection has shown positive results in countries like Botswana, and Malawi, delaying the progression of HIV-related conditions considerably.
Standard INH therapy lasts for 9 months, which kills latent TB bacteria, but in cases of TB-HIV co-infection, the therapy takes longer, and may be continued until HIV-associated conditions begin to appear.
INH therapy has been recommended by the World health Organization (WHO) since 1998. There are no reported side-effects and the only caution while managing TB-HIV co-infection is to remember that INH has to be stopped in the later stages of HIV infection.
Early in the AIDS epidemic, the administration of the antibacterial drug cotrimoxazole (CTX) was also an affordable treatment used to help save lives long before ARVs were available. As well as TB, cotrimoxazole has been shown to prevent and treat HIV-related infections such as pneumocystis pneumonia, toxoplasmosis (a parasitic infection of the intestines), and falciparum malaria when taken by people living with HIV. Side-effects of CTX appear limited to some people developing rash that can be avoided by following recommended dosage.
Numerous data analysis carried out by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO, as well as a full ‘Cochran review’, resulted in recommendations to administer cotrimoxazole prophylaxis as part of a package care for adults living with HIV/AIDS. The WHO, UNAIDS and United Nations Children’s Fund (UNICEF) also issued a joint statement (in November 2004) recommending CTX for all HIV-exposed children. More recently, British and South African researchers demonstrated that CTX reduces the risk of death in tuberculosis (TB) patients in a high HIV seroprevalence setting based on a study carried out in a rural area of South Africa.
However, studies have also yielded inconclusive results as to whether CTX is effective in people taking ARVs and in areas where bacterial resistance to CTX is common. Some public health physicians have expressed concerns with the theoretical potential of widespread use of CTX to increase drug resistance of malaria and pneumoccoccal pneumonia. Nevertheless, international health organisations still recommend CTX to be included in official national treatment guidelines based on the premise that it is known to save lives.
Why then is cotrimoxazole prophylaxis not more widely used in Asia?
Only a handful Asian countries with HIV/AIDS epidemic to date have included CTX in their official national HIV/AIDS treatment guidelines. The two WHO Asian regional offices – Southeast Asia and the Western Pacific – have yet to release any new regional CTX treatment guidelines in the wake of “3by5”. Regardless, official guidelines are useless unless recommendations are implemented. We already know that cotrimoxazole can save lives of people with HIV in Asia, so…what are we waiting for?
For those with active TB, a well-established and tested treatment is available, known as directly-observed treatment short-course, or DOTS,, although drug compliance continues to challenge service providers. In TB-HIV co-infection, motivating patients to be compliant to the drug regimen for TB treatment can be a big challenge. The defaulter rate in TB-HIV co-infection for TB treatment is much higher than treating TB in HIV sero-negative people. The death rate is also high, according to Dr Pacharee Kantipong, chief of the Department of Medicine, at Chiang Rai Regional Hospital in northern Thailand – an area of the country with high HIV-TB co-infection.
Dr Thandar Lwin, assistant director of the National Tuberculosis Programme in Myanmar, said that adherence is a persistent challenge while treating TB-HIV co-infection. She explained that we are not treating the virus or bacteria alone, rather human beings, so they need motivation and optimism to live and love their life. “Love can increase adherence”, she said.
Dr Lwin also said that she has a defaulter tracing mechanism in place to send out health workers to get the defaulters back to treatment within two months. This has improved the TB treatment compliance of people living with HIV substantially. She said that regular community or group education is a strong method of ensuring good TB treatment compliance from people living with HIV. She said multi-drug resistant TB (MDR TB) and HIV are the two mountainous challenges confronting public health in Myanmar. She said cases of MDR TB can be substantially reduced if proper TB treatment compliance is ensured as far as possible.
There is no doubt that TB prevention and treatment are essential life-extending interventions for people living with HIV/AIDS . While millions of people living with HIV wait for expanded ARV access programmes to deliver, raising awareness about TB prevention and cure (including treatment compliance) is clearly vital.
by: HDN Key Correspondnet Team
Email: correspondents@hdnet.org
(July 2005)
posted by AIDS-Care-Watch at 3:31 pm
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