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Preventive medicine for HIV-infected patients

An analysis of isoniazid prophylaxis for tuberculin reactors and for anergic patients

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Abstract

Objective:To analyze the policies of isoniazid prophylaxis for human immunodeficiency virus (HIV)-infected tuberculin reactors and for HIV-infected anergic patients with unknown tuberculin status.

Methods:Transition-state model of clinical immune deterioration of HIV-infection over ten years, review of published data, and a survey of AIDS experts. Outcome measures are the numbers of tuberculosis cases and deaths prevented and isoniazid toxicity cases and deaths occurring with prophylaxis.

Patients:Hypothetical cohorts of HIV-infected 40-year-olds.

Results:Because the tuberculosis activation rate is so high in HIV-infected patients, the benefits of prophylaxis far outweigh the risks of isoniazid toxicity for tuberculin reactors with HIV infection at any stage of immune function: 1,469–2,868 tuberculosis cases and 170–274 deaths are prevented per 10,000 cohort over ten years, depending upon the cohort’s initial immune state. The benefits of prophylaxis outweigh the risks of isoniazid toxicity for anergic HIV-infected patients if they come from a community with a 2% to 3% or greater prevalence of Mycobacterium tuberculosisinfection.

Conclusions:Isoniazid prophylaxis is a reasonable prevention measure for HIV-infected tuberculin reactors and for many HIV-infected anergic patients.

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References

  1. Centers for Disease Control. A strategic plan for the elimination of tuberculosis in the United States. MMWR. 1989;38(suppl):1S-25S.

    Google Scholar 

  2. Centers for Disease Control. Tuberculosis and human immunodeficiency virus infection: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR. 1989;38:236–8, 243–50.

    Google Scholar 

  3. Murray JF. The white plague: down and out, or up and coming? J. Burns Amberson lecture. Am Rev Respir Dis. 1989;140:1788–95.

    CAS  Google Scholar 

  4. Centers for Disease Control. Update: tuberculosis elimination—United States. MMWR. 1990;39:153–69.

    Google Scholar 

  5. Centers for Disease Control. The use of preventive therapy for tuberculous infection in the United States; recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR. 1990;39:9–12.

    Google Scholar 

  6. Bothamley GH, Grange JM. The Koch phenomenon and delayed hypersensitivity: 1891–1991. Tubercle. 1991;72:7–11.

    Article  PubMed  CAS  Google Scholar 

  7. Centers for Disease Control. Purified protein derivative (PPD) — tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR. 1991;40:27–33.

    Google Scholar 

  8. Blatt SP, Donovan D, Freeman T, et al. Cutaneous delayed-type hypersensitivity (DTH) skin-testing in HIV-infected patients: implications for diagnosis and chemoprophylaxis of tuberculosis [abstract]. Florence, Italy: VII International Conference on AIDS, June 16–21, 1991; MB2292.

  9. Taylor JMG, Tan S-J, Detels R, Giorgi JV. Applications of a computer simulation model of the natural history of CD4 T-cell number in HIV-infected individuals. AIDS. 1991;5:159–67.

    Article  PubMed  CAS  Google Scholar 

  10. Rubenstein RY. Simulation and the Monte Carlo method. New York: John Wiley & Sons, 1981.

    Google Scholar 

  11. Graham NMH, Zeger SL, Park LP, et al. Effect of zidovudine andPneumocystis carinii pneumonia prophylaxis on progression of HIV-1 infection to AIDS. Lancet. 1991;338:265–9.

    Article  PubMed  CAS  Google Scholar 

  12. Moore RD, Hidalgo J, Sugland BW, Chaisson RE. Zidovudine and the natural history of the acquired immunodeficiency syndrome. N Engl J Med. 1991;324:1412–6.

    Article  PubMed  CAS  Google Scholar 

  13. National Center for Health Statistics. Vital Statistics of the United States, 1985, Vol. II, Mortality, Part A. DHHS Pub. No. (PHS) 88-1101. Public Health Service. Washington, DC: U.S. Government Printing Office, 1988.

  14. Beck JR, Pauker SG. The Markov process in medical prognosis. Med Decis Making. 1983;3:419–58.

    Article  PubMed  CAS  Google Scholar 

  15. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among injection drug users with human immunodeficiency virus infection. N Engl J Med. 1989;320:545–50.

    Article  PubMed  CAS  Google Scholar 

  16. Snider DE Jr. Decision analysis for isoniazid preventive therapy: take it or leave it? Am Rev Respir Dis. 1988;137:2–4.

    PubMed  Google Scholar 

  17. Colice GL. Decision analysis, public health policy, and isoniazid chemoprophylaxis for young adult tuberculin skin reactors. Arch Intern Med. 1990;150:2517–22.

    Article  PubMed  CAS  Google Scholar 

  18. Small PM, Schecter FG, Goodman PC, Sande MA, Chaisson RE, Hopewell PC. Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection. N Engl J Med. 1991;324:289–94.

    Article  PubMed  CAS  Google Scholar 

  19. Ferebee SH. Controlled chemoprophylaxis trials in tuberculosis: a general review. Adv Tuberc Res. 1970;17:28–106.

    Google Scholar 

  20. International Union against Tuberculosis Committee on Prophylaxis. Efficacy of various durations of isoniazid preventive therapy for tuberculosis: five years of follow-up in the IUAT trial. Bull WHO. 1982;60:555–64.

    Google Scholar 

  21. Kopanoff DE, Snider DE Jr, Caras GJ. Isoniazid-related hepatitis. Am Rev Respir Dis. 1978;117:991–1001.

    PubMed  CAS  Google Scholar 

  22. Rose DN, Schechter CB, Silver AL: The age threshold for isoniazid chemoprophylaxis. JAMA. 1986;256:2709–13.

    Article  PubMed  CAS  Google Scholar 

  23. Jordan TJ, Lewitt EM, Montgomery RL, Reichman LB. Isoniazid as preventive therapy in HIV-infected intravenous drug abusers: a decision analysis. JAMA. 1991;265:2987–91.

    Article  PubMed  CAS  Google Scholar 

  24. Di Perri G, Micciolo R, Vento S, Cruciani M, Concia E, Bassetti D. CD4 count as predictor of reactivation of tuberculosis in HIV infection [abstract]. Florence, Italy: VII International Conference on AIDS, June 16–21, 1991;WB2359.

  25. Slutkin G, Leowski J, Mann J. The effects of AIDS epidemic on the tuberculosis problem and tuberculosis programmes. Bull Int Union Tuberc Lung Dis. 1988;63:21–4.

    PubMed  CAS  Google Scholar 

  26. Kochi A. The global tuberculosis situation and the new control strategy of the World Health Organization. Tubercle. 1991;72:1–6.

    Article  PubMed  CAS  Google Scholar 

  27. Dupon M, Ragnaud JM, et le Groupe des Infectiologues du Sud de la France. A retrospective cohort study of 123 HIV infected tuberculosis patients—France, 1985–1989 [abstract]. Florence, Italy: VII International Conference on AIDS, June 16–21, 1991; WB2343.

  28. Zamora L, Gatell JM, Mallolas J, Guelar A, Miro JM, Soriano E. Treatment of tuberculosis in HIV-infected patients [abstract]. San Francisco, CA: VI International Conference on AIDS, June 20–24, 1990; ThB508.

  29. Chaisson RE, Schecter GF, Theuer CP, Rutherford GW, Echenberg DF, Hopewell PC. Tuberculosis in patients with the acquired immunodeficiency syndrome; clinical features, response to therapy, and survival. Am Rev Respir Dis. 1987;136:570–4.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Mount Sinai Medical Center, Box 1009, 10029, New York, NY

    David N. Rose MD

Authors
  1. David N. Rose MD
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  2. Clyde B. Schechter MD
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  3. Henry S. Sacks PhD, MD
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Additional information

Received from the Departments of Medicine, Community Medicine, and Biomathematical Sciences, the AIDS Center, and the Clinical Trials Unit, Mount Sinai School of Medicine, New York, New York.

Supported in part by the following grants: 1/RO1 MH45686 from the National Institute of Mental Health, and UO1 AI27667 and UO1 AI27554 from the National Institute of Allergy and Infectious Diseases.

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Rose, D.N., Schechter, C.B. & Sacks, H.S. Preventive medicine for HIV-infected patients. J Gen Intern Med 7, 589–594 (1992). https://doi.org/10.1007/BF02599196

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  • DOI: https://doi.org/10.1007/BF02599196

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