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Potential Utility of Empirical Tuberculosis Treatment for HIV-Infected patients with Advanced Immunodeficiency in High TB-HIV Burden Settings

Publication year: 
Author (s): 
Lawn, S.D. [et al.]
Publication details: 
Paris, International Union Against Tuberculosis and Lung Disease, 2011
Publication in: 
Int J Tuberc Lung Dis 15(3), 2011: pp. 287–295

The human immunodefi ciency virus (HIV) and HIV associated tuberculosis (TB-HIV) epidemics remain uncontrolled in many resource-limited regions, especially in
sub-Saharan Africa. The scale of these epidemics requires the consideration of innovative bold interventions and ‘out-of-the-box’ thinking. To this end, a symposium entitled ‘Controversies in HIV’ was held at the 40th Union World Conference on Lung Health in Cancun, Mex ico, in December 2009. The fi rst topic debated, entitled ‘Annual HIV testing and immediate start of antiretroviral
therapy for all HIV-infected persons’, received much attention at international conferences and in the literature in 2009. The second topic forms the subject of this article. The rationale for the use of empirical TB treatment is premised on the hypothesis that in settings worst affected by the TB-HIV epidemic, a subset of HIV-infected patients have such a high risk of undiagnosed TB and of associated mortality that their prognosis may be improved by immediate initiation of empirical TB treatment used in conjunction with antiretroviral therapy. In addition to morbidity and mortality reduction, additional benefi ts
may include prevention of nosocomial TB transmission and TB preventive effect. Potential adverse consequences, however, may include failure to consider other non-TB diagnoses, drug co-toxicity, compromised treatment adherence, and logistical and resource challenges. There may also be general reluctance among national TB programmes to endorse such a strategy. Following fruitful debate,
the conclusion that this strategy should be carefully evaluated in randomised controlled trials was strongly supported. This paper provides an in-depth onsideration of this proposed intervention.