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INCREASED RISK OF TUBERCULOSIS RECURRENCE IN PEOPLE WITH HIV-1 INFECTION (pp 1470, 1488)

October 25, 2000

People with HIV-1 infection are at an increased risk of recurrent tuberculosis, and could benefit from preventative treatment after the first episode of the disease, concludes research published in this week's issue of THE LANCET.

Patients with HIV-1 infection respond well to treatment for active tuberculosis, but whether such patients are at increased risk of disease recurrence after successful treatment is uncertain. As a result, most experts do not recommend more intensive tuberculosis therapy for HIV-1-infected individuals than for uninfected people, and do not recommend prophylaxis after curative treatment. Jean William Pape and colleagues from New York Hospital-Cornell Medical Centre, USA, did a randomised trial in Port au Prince, Haiti, to determine whether recurrent tuberculosis after curative tuberculosis treatment is more common in HIV-1-infected individuals than HIV-1-uninfected individuals, and to determine whether the use of post-treatment isoniazid decreases the risk of recurrent tuberculosis.

The investigators assessed patients older than 18 years who were diagnosed with a first episode of tuberculosis at the national HIV testing centre in Haiti. Patients were randomly assigned 1 year of post-treatment isoniazid or placebo, and the primary outcome measure was rate of recurrent tuberculosis after at least two years.

Of 274 patients who successfully completed treatment for pulmonary tuberculosis, 233 took part in the study. Of 142 HIV-1-positive patients, 68 were assigned isoniazid and 74 placebo. Of 91 HIV-1-negative individuals, 51 were assigned isoniazid and 40 placebo. The rate of recurrent tuberculosis was 4.8 per 100 person-years in HIV-1-infected individuals and 0.4 per 100 person-years in uninfected individuals. Among HIV-1-positive patients receiving isoniazid, the tuberculosis recurrence rate was 1.4 per 100 person-years, compared with 7.8 among HIV-1-positive patients receiving placebo. Among HIV-1-positive individuals, all cases of recurrent tuberculosis occurred in individuals with a history of HIV-1-related symptoms before initial tuberculosis diagnosis.

Jean William Pape comments: "Our study clearly shows that the rate of recurrent tuberculosis is higher in HIV-1-positive individuals than in HIV-1-negative individuals, and is strongly associated with a history of symptomatic HIV-1 disease before initial tuberculosis diagnosis. Post-treatment isoniazid prophylaxis decreases the risk of recurrence in HIV-1-positive individuals, and should be considered for HIV-1-positive individuals with a history of HIV-1-related symptoms at the time of tuberculosis diagnosis".

In a research letter also published in THE LANCET this week (p 1488), E Frances Bowen and colleagues from St Georges Hospital, London, UK, report an increased prevalence of HIV-1 infection in people with tuberculosis. In this UK study, tuberculosis patients and their contacts were anonymously tested for HIV. The investigators found that 11% of patients (from various demographic groups) with tuberculosis who attend chest clinics in south London were HIV-1 positive, more than double previous estimates; as the study excluded patients known to be HIV-1 positive, they estimate that the true co-infection rate may be as high as 17-20%. 5% of individuals seen in the tuberculosis-contact screening clinics and 4% of new entrants were HIV-1 positive. The investigators conclude that all patients with tuberculosis, irrespective of background, should be urged to have an HIV test, and point out the serious implications for the provision of currently overstretched health-care facilities for patients with tuberculosis and for asylum seekers.

Contact: Dr Warren D Johnson Jr, Division of International Medicine and Infectious Diseases, New York Hospital-Cornell Medical Center, 525 East 68th Street, New York, NY 10021, USA; T) +1 212 746 6320; F) +1 212 746 8675; E) wdjohnso@med.cornell.edu

Dr Charlotte Rayner, c/o Claire Grant, Public Relations Manager, St Georges Hospital, London, SW17 0QT, UK; T) +44 (0)20 8725 3307; F) +44 (0)20 8725 0239; E) claire.grant@stgh-tr.sthames.nhs.uk

Lancet

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