HIV This Week

Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues.

Aït-Khaled N, Alarcon E, Bissell K, Boillot F, Caminero JA, Chiang CY, Clevenbergh P, Dlodlo R, Enarson DA, Enarson P, Ferroussier O, Fujiwara PI, Harries AD, Heldal E, Hinderaker SG, Kim SJ, Lienhardt C, Rieder HL, Rusen ID, Trébucq A, Van Deun A, Wilson N. Int J Tuberc Lung Dis. 2009 ;13:927-35.

Isoniazid preventive therapy is recognised as an important component of collaborative tuberculosis and human immunodeficiency virus (HIV) activities to reduce the burden of tuberculosis in people living with HIV. However, there has been little in the way of isoniazid preventive therapy implementation at country level. This failure has resulted in a recent call to arms under the banner title of the ‘Three I’s’ (infection control to prevent nosocomial transmission of tuberculosis in health care settings, intensified tuberculosis case finding and isoniazid preventive therapy). The authors review the background of isoniazid preventive therapy. They discuss the important challenges of isoniazid preventive therapy in people living with HIV, namely responsibility and accountability for the implementation, identification of latent tuberculosis infection, exclusion of active tuberculosis and prevention of isoniazid resistance, length of treatment and duration of protective efficacy. The authors also highlight several research questions that currently remain unanswered and offer practical suggestions about how to scale up isoniazid preventive therapy in the field, including the need to integrate isoniazid preventive therapy into a package of care for people living with HIV, the setting up of operational projects with the philosophy of ‘learning while doing’, the development of flow charts for eligibility for isoniazid preventive therapy, the development and implementation of care prior to antiretroviral treatment, and finally issues around procurement, distribution, monitoring and evaluation. The authors support the implementation of isoniazid preventive therapy, but only if it is done in a safe and structured way. There is a definite risk that ‘sloppy’ isoniazid preventive therapy will be inefficient and, worse, could lead to the development of multidrug-resistant tuberculosis, and this must be avoided at all costs.

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Editors’ note: Have you wondered why TB prophylaxis with isoniazid for people living with HIV is not getting the traction it deserves? This clear, straight to the heart of the matter article underscores the challenges of implementing isoniazid preventive therapy (IPT). These include defining clearly who is responsible, determining who should receive it, excluding active TB and preventing isoniazid resistance, and enhancing the duration of protective efficacy. Among the practical suggestions for scaling up IPT is its integration into the package of pre-antiretroviral treatment care. Pre-ART care can include regular checks of clinical status, CD4 counts, cotrimoxasole preventive therapy (CPT), nutritional support or guidance, family planning, counselling and provision of HIV prevention tools, and insecticide treated bed nets to prevent malaria. National AIDS programmes and national TB programmes need to work together to include IPT in pre-ART care and ensure the conduct of quality monitoring and operational research designed to detect and address problems quickly to improve programme performance.