Objective: To assess the operational aspects of isoniazid preventive chemotherapy (IPT) for tuberculosis in persons dually infected with HIV and Mycobacterium tuberculosis identified at an independent HIV voluntary counselling and testing centre in Kampala, Uganda.
Design: HIV-infected persons were counselled, had active tuberculosis excluded by medical examination, and were offered purified protein derivative (PPD) skin testing. PPD-positive persons were offered isoniazid 300 mg daily for 6 months. Drugs were supplied, and toxicity and compliance were assessed monthly. Utilization of service, cost, and sustainability were also assessed.
Results: Between 14 June 1991 and 30 September 1992, 9862 persons tested HIV-positive. Of 5594 HIV-infected clients who returned to collect test results, only 1524 (27%) were enrolled. Of those, 1344 were tuberculin-tested (88%); 180 were not tested because of active tuberculosis, serious illnesses, refusal, and other reasons. Of the 1344, 250 (19%) did not return for test reading and 515 were negative (47% of tests read). Of 579 tuberculin-positive persons, 59 (10%) were excluded from preventive chemotherapy because of tuberculosis and other respiratory illnesses. Of 520 persons given isoniazid, 62% collected at least 80% of their drug supplies. No major toxicity was observed. One case of tuberculosis occurred in the first month of treatment. Cost of HIV counselling and testing was US $18.54 per person and cost of follow-up counselling and social support was US $7.89.
Conclusions: Important factors were identified which caused attrition, such as limited motivation by counsellors to discuss tuberculosis issues during HIV pre- and post-test counselling, insufficient availability of medical screening, shifting of sites to collect pills, and frequent tuberculin-negative tests. Active tuberculosis among 6% of persons screened suggests that voluntary counselling and testing sites may be important for tuberculosis case finding and underscores the need to exclude tuberculosis carefully before starting IPT. In developing countries, further studies assessing the feasibility of IPT within tuberculosis and HIV/AIDS programme conditions are needed. Cost-effectiveness of IPT, compared with passive case finding, and its sustainability should be assessed before national policies are established.
PIP: Those infected with human immunodeficiency virus (HIV) have a 5-10% risk per year of developing active tuberculosis, and this disease may accelerate the clinical course of HIV infection. Thus, a study was conducted in Uganda to assess the cost-effectiveness and acceptability of isoniazid preventive chemotherapy (IPT) for patients dually diagnosed with HIV and Mycobacterium tuberculosis. Of the 1344 HIV-infected patients at an independent HIV testing and counseling center in Kampala who were initially screened for participation in this study, 6% had signs of active tuberculosis. Selected for participation in the study were 520 subjects with no signs of active tuberculosis. Of these, 322 (62%) were considered compliant with the treatment regimen on the basis of their appearance for all scheduled appointments for pill distribution. One case of active tuberculosis occurred during the first month of IPT and most likely represented a case that went undetected in the screening process. No treatment-associated toxicity was reported. The cost of the HIV testing and counseling was US$18.54 per patient; that of follow-up counseling and support was $7.89. When administrative costs for the study were included in the calculation, the cost of IPT increased to $60.19 per person. Although reactivation of tuberculosis may have been prevented in up to 62% of subjects who received IPT, numerous factors mitigate against the routine implementation of such a treatment program, most notably its high cost and a shortage of voluntary HIV centers in developing countries. Needed are studies that evaluate the long-term community health, social, and economic benefits of such a program as well as further investigations of the impact of tuberculosis on the pace of progression from HIV to acquired immunodeficiency syndrome (AIDS).