Halting Tuberculosis in Patients with HIV

Many physicians prescribe multi-drug tuberculosis regimens in patients with HIV as a precaution.

Individuals with HIV who are susceptible to tuberculosis (TB) see little benefit from TB drugs in the prevention of mortality, according to a recent study.

TB is the number 1 killer for HIV patients living in underdeveloped countries, including parts of Africa and India.

Since TB is hard to detect in patients with HIV and test results take time, many physicians will prescribe multi-drug TB treatments as a precaution.

A study published in the Lancet reported results from a multi-country, open-label, randomized clinical trial between 2011 and 2014 with 850 enrollees. The study, called REMEMBER, compared the efficacy of empirical TB therapy with isoniazid in HIV outpatients starting antiretroviral therapy (ART).

The results of the study showed that preventative therapy isoniazid had similar survival rates compared with the 4-drug TB treatment.

“We don't necessarily need to subject all these patients to multi-drug regimens," said co-lead study author, Gregory P. Bisson, MD, MSCE. “This new study shows that simple TB screening and isoniazid is a sufficient course of HIV care for this group, despite their very advanced HIV disease stage. Our participants were able to tolerate isoniazid very well, and we saw no evidence that they developed drug resistance more commonly, as is often feared.”

During the study, participants had a significantly low CD4 count, which is indicative of advanced HIV and a high risk for undiagnosed TB. All patients began ART, while 424 patients were given a multi-drug treatment for TB and 426 were given isoniazid alone.

Over the course of 24 weeks, about 1 in 20 patients from the study died. Those who were given empirical tuberculosis therapy saw no reduction in mortality at 24 weeks compared with isoniazid preventive therapy.

Additionally, by week 24, there was a higher rate of AIDS progression in the empirical group compared with the isoniazid group at 17% and 13%, respectively.

“The takeaway is that providers should screen HIV-positive patients for TB, as the WHO suggests, and patients who aren't diagnosed with TB should receive isoniazid,” Bisson said. “And furthermore, if these advanced HIV patients can tolerate the isoniazid, less advanced HIV patients very likely can do well under this paradigm, too.”

Currently, the World Health Organization’s (WHO) guidelines recommend that physicians screen HIV patients for TB and that isoniazid should be used as TB prevention for those who are not diagnosed with TB.

However, physicians have been hesitant in following these guidelines because of a lack of trust in the accuracy of TB screening and the concern for HIV patients without TB who receive isoniazid alone and potentially develop a resistance to the TB drug, according to the study.

This hesitation has led to a drop in screening and the utilization of isoniazid. Furthermore, providers are choosing to go with the more proactive multi-drug approach.

“Moving forward, we need to implement quality improvement projects and guideline-driven care, and start thinking about systematic TB screening and isoniazid as a crucial piece of HIV care in this population,” Bisson said.