Tuberculosis Preventive Treatment Scale-Up Among Antiretroviral Therapy Patients - 16 Countries Supported by the U.S. President's Emergency Plan for AIDS Relief, 2017-2019

Abstract

Tuberculosis (TB) is the leading cause of death among persons living with human immunodeficiency virus (HIV) infection. In 2018, an estimated 251,000 persons living with HIV infection died from TB, accounting for one third of all HIV-related deaths and one sixth of all TB deaths (1). TB preventive treatment (TPT) is recommended by the World Health Organization (WHO) for persons living with HIV infection without active TB disease (i.e., adults with a negative clinical symptom screen for cough, fever, night sweats, or weight loss; and children with a negative clinical screen for cough, fever, contact with a person with TB, or poor weight gain) and either without* a tuberculin skin test result or with a known positive result (2). TPT decreases morbidity and mortality among persons living with HIV infection, independent of antiretroviral therapy (ART) (3); however, in 2017, fewer than 1 million of the estimated 21.3 million ART patients started TPT worldwide. Most patients receiving TPT were treated with 6 months of daily isoniazid (1,4). This report summarizes data on TB symptom screening and TPT initiation and completion among ART patients in 16 countries supported by the U.S. President's Emergency Plan for AIDS^† Relief (PEPFAR) during April 1, 2017-March 31, 2019. During this period, these 16 countries accounted for approximately 90% of PEPFAR-supported ART patients. During April 1, 2017-September 30, 2018, TB symptom screening increased from 54% to 84%. Overall, nearly 2 million ART patients initiated TPT, and 60% completed treatment during October 1, 2017-March 31, 2019. Although TPT initiations increased substantially, completion among those who initiated TPT increased only from 55% to 66%. In addition to continuing gains in initiation, improving retention after initiation and identifying barriers to TPT completion are important to increase TPT scale-up and reduce global TB mortality.

FIGURE 1

Tuberculosis (TB) screening and TB preventive treatment (TPT) indicators^,, for persons living with human immunodeficiency virus (HIV) infection receiving antiretroviral therapy (ART patients) — 16 PEPFAR-supported countries,^¶ 2017–2019 Abbreviations: G = group; PEPFAR = U.S. President’s Emergency Plan for AIDS Relief. * Number of ART patients reports a snapshot at the end of the reporting period, accounting for net gains (e.g., new HIV diagnoses) and losses (e.g., deaths and patients lost to follow-up). ^† The South African National Department of Health (NDOH) receives PEPFAR support for health system strengthening and other non–patient care activities. NDOH annually reports ART patients in its care but does not report TPT initiation or completion. Therefore, ART patients reported by NDOH were subtracted from South Africa totals in period 1 (779,313) and in period 3 (900,463) to include data reported only by South African partners that received PEPFAR support for delivering health care services. ^§ Number of ART patients expected to complete TPT approximates number of TPT initiations. If the patient is prescribed 6 months of daily isoniazid, the patient is expected to complete treatment during the reporting period subsequent to that of initiation. Otherwise, if prescribed a shorter rifamycin-based course, the patient might be expected to complete treatment during the initiation reporting period. ^¶ Cameroon, Democratic Republic of the Congo, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Mozambique, Namibia, Nigeria, South Africa, Tanzania, Uganda, Vietnam, Zambia, and Zimbabwe.

FIGURE 2

Number of ART patients (per 100,000 population) who completed tuberculosis preventive treatment (TPT) during three reporting periods, and percentage change in TPT completion rate— 16 countries supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), October 2017–March 2019 Abbreviations: ART = antiretroviral therapy; DRC = Democratic Republic of the Congo. * The South African National Department of Health (NDOH) receives PEPFAR support for health system strengthening and other non–patient care activities. NDOH annually reports ART patients in its care but does not report TPT initiation or completion. Therefore, ART patients reported by NDOH were subtracted from South Africa totals in period 1 (779,313) and in period 3 (900,463) to include data reported only by South African partners that received PEPFAR support for delivering health care services. ^† Excluding Cameroon and Zimbabwe because of small numbers.