Presumptive TB treatment for people living with HIV: better safe than sorry?

Babs Verblackt, CNS Special Correspondent
Photo credit: Babs Verblackt/CNS
As tuberculosis (TB) remains a major cause of death among people living with HIV (PLHIV), starting TB treatment without bacteriological confirmation is widely practiced in them as in the case of PLHIV traditional TB diagnostic tests have inadequate sensitivity. But this empirical or presumptive TB treatment is not without risks. At the 45th Union World Conference on Lung Health in Barcelona researchers discussed their investigations into who should get the treatment, and when and how.

Even when on antiretroviral therapy (ART), people with advanced HIV are at high risk of dying from TB. Existing TB diagnostics serve PLHIV poorly, with the tests having inadequate sensitivity. Starting empirical TB treatment in people with advanced HIV is common practice.

Alison Grant, LSHTM
Photo credit: Babs V/CNS
"Empirical treatment is a sensible strategy for high-risk patients in situations where diagnostic tests are unsatisfactory," said Alison Grant, Professor of International Health at the London School of Hygiene and Tropical Medicine. "The benefit clearly is to try stop PLHIV from dying of TB. But it carries risks of unnecessary toxicities and burden of additional treatment for people who may not actually have TB."

"It is not pleasant to undergo TB treatment. The duration is long with several different drugs to be taken. There is the risk of side effects such as liver toxicity. And there is interaction with antiretroviral therapy (ART)," Grant told Citizen News Service (CNS). "In less than twenty years ART has actually gone from a very complicated to a very tolerable treatment to take, but TB treatment has not, despite it being around for much longer," she said.

Taking a toll
Empirical treatment does not only take a huge toll on the patient but on health systems as well. TB programmes are generally very busy and overburdened already. Putting patients on empirical treatment adds to the workload. "Thus stretching the health care systems, with additional patients being treated for a disease they may not have, possibly makes the health care system less well for people with actual TB who are in urgent need of care," Grant explained.

Many already regard empirical treatment as the magic bullet. "But evidence is not there yet. We need to weigh the benefits and risks", Grant stressed. "Trials are needed to get the answers on that."

The evidence base to define conditions under which the benefits of empirical treatment outweigh the risks is lacking. During the Union Conference several such research was presented, each in its own way addressing the question whether empirical TB treatment reduces early mortality in people with advanced HIV. Various studies are underway evaluating different settings, populations and interventions in mostly Africa and Asia. Results are expected in 2015 and 2017.

Patients' and nurses' empowerment
One study in particular, the TB Fast Track trial in South Africa, is furthermore looking into the possibilities to define criteria which nurses in primary health care clinics can use to start empirical TB treatment, "as nurses are often delivering the treatments, because there is often no resident doctor," said Grant, who is a member of the research team. The pragmatic study aims to lead to a tool that is relatively easy to integrate and use in routine practice at clinics.

At the core of all treatment, however, remains the patient. Lucy Chesire, TB/HIV activist and a survivor of TB/HIV co-infection herself, reminded the researchers to keep this in mind.

"Back in the 1990s when I got to know my HIV status, I had thought I would not live to see the 21st century. At that time one did not hear anything on patient empowerment. Even the doctors would feel helpless when facing a TB-HIV co-infection, as they did not know what to do.. Today the tools are better. What has been presented here is amazing," she said.

But, as she remarked, one should not forget the role of the community, because at the end of the day it is really critical that beneficiaries are well aware, engaged and well informed, so that they can take decisions and make informed choices.

Babs Verblackt, Citizen News Service - CNS
31 October 2014
(WHO Global Tuberculosis Programme is supporting onsite CNS Correspondents Team's coverage around TB-HIV related issues from the 45th Union World Conference on Lung Health in Barcelona, Spain. Email: