[e-drug] INH prophylaxis for all HIV+ children?

["Wilbert Bannenberg" <wjb@wxs.nl>]

E-DRUG: INH prophylaxis for all HIV+ children?
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[Important discussion in South Africa: should all HIV+ children get INH
prophylaxis [in addition to cotrimoxazole]? 
2 messages crossposted from DRUGINFO with thanks; WB]

Hi all

The BMJ abstracts for this study is not yet accessible on their site, but
the IOL story alone provides enough information to start the debate. Should
INH prophylaxis be given to all HIV+ children now? What effect, if any, will
this have on resistance to INH? What steps will have to be taken to prevent
inadvertant monotherapy of TB in childfren receiving prophylactic INH?

Copied as "fair use".

regards
Andy
~~~

Andy Gray MSc(Pharm) FPS
* Senior Lecturer
Dept of Therapeutics and Medicines Management
* Study Pharmacist
Centre for the AIDS Programme of Research 
in South Africa (CAPRISA)
Nelson R Mandela School of Medicine
University of KwaZulu-Natal
PBag 7 Congella 4013
South Africa
Tel: +27-31-2604334/4298 Fax: +27-31-2604338
email: graya1@ukzn.ac.za or andy@gray.za.net

---

http://www.iol.co.za/index.php?set_id=1&click_id=125&art_id=vn2006112013
1549917C270200
Cheap TB drug cuts deaths of HIV+ children 
Di Caelers 
November 20 2006 at 06:22PM  
 
In a world-beating breakthrough, Cape Town doctors have found that the use
of a cheap anti-tuberculosis drug could halve deaths among HIV-positive
children.

Snapped up by the prestigious British Medical Journal, which notched up a
first with an early electronic alert on the study results, the research at
Tygerberg and Red Cross Children's hospitals has been lauded for its
potential major impact on public health.

The study was planned to continue for two years, but early on the use of the
drug was deemed so effective at preventing deaths that the control placebo
part of the experiment was halted.

Today, in accordance with World Health Organisation recommendations, all
HIV-infected children get cotrimoxazole, or Bactrim, as a preventive therapy
following a Zambian study that showed a major reduction in deaths.

The local study could be equally significant.

The principal investigator at Red Cross, Professor Heather Zar, head of
paediatric pulmonology at the hospital, said the drug was isoniazid, widely
available and cheap, and currently used for prevention and treatment of TB.

She described the results as "phenomenal" after nearly 300 HIV-infected
children were given the drug either daily or three times a week, in addition
to the Bactrim they were already taking.

"We saw a 50% reduction in deaths and a 70% reduction in the incidence of TB
among these children," Zar said.

TB and HIV are dual epidemics in children here and throughout sub-Saharan
Africa, with TB accelerating the course of HIV, increasing illness and
death.

It is an important cause of acute and chronic pneumonia in children with
HIV, and is responsible for a major proportion of the deaths.

The Western Cape specifically has one of the highest incidences of TB in the
world, with children younger than 15 contributing about 20% of the case
load.

Zar said the use of isoniazid reduced deaths among HIV- positive children,
irrespective of how advanced their disease.

It also reduced deaths in those children with a range of different illnesses
and, in spite of whether they were classified with mild, moderate or severe
disease, they appeared to benefit equally from the treatment.

No serious side-effects were observed.

Zar believes there is potential for the routine use of isoniazid with
Bactrim, to give HIV-infected children a much better chance of survival.
"And, of course, the results are highly relevant in South Africa, where
tuberculosis is going through the roof," she added.

The researchers are now set to move to a second stage of their study, to
examine whether similar beneficial effects will be seen in children taking
anti-retrovirals (ARVs).

But Zar said the results were "very encouraging" and that isoniazid appeared
to offer an important public health intervention that could effectively
reduce deaths in HIV-infected children, particularly where ARVs were not
available.

"Its use could be especially considered for the HIV-infected children living
in an area with high TB prevalence, such as the Western Cape, which has one
of the highest TB rates in the world," she said.

This article was originally published on page 3 of Cape Argus on November
20, 2006 

---- [response by Christoph Hamelmann (GHAIN - Abuja) [CHamelmann@ghain.org]

Andy,

Glad that you came up with your questions. Most countries on the continent
are very reluctant to implement INH prophylaxis (although most have it in
their guidelines for reasons that are usually rather of political nature). I
think one thing is clear to everybody with some experience in infectious
disease control: At a time when MDR TB is running out of control and XDR TB
is emerging, INH prophylaxis under circumstances that do not even allow
routinely proper exclusion of active TB and control of adherence means to
play with fire and should therefore be stopped.

Concerning the study in children: Without being a prophet it is easy to
predict that there will be a number of cheap drugs that are happy to find
new markets (antibiotic prophylaxis seems to be currently the most promising
approach in this strategy of conquering new mass markets) and for which it
can be shown that they are beneficial in infants/children in poor living
conditions when investigated for a singular outcome parameter. Following
this strategy as a systematic approach to counter poverty and poor living
conditions would primarily require from a "scientific" perspective to
determine the threshold of cocktails that can be tolerated by
infants/children. The following public health intervention would then be to
pour everything what we have on stock of this cocktail into these small
bodies until the threshold is reached.

I can read from the article below that the next study in this direction is
already planned. Quo vadis public health?

"Its use could be especially considered for the HIV-infected children living
in an area with high TB prevalence, such as the Western Cape, which has one
of the highest TB rates in the world," she said.

The superficial approach towards epidemiology and public health is
surprising. What is Western Cape? Constantia and the hills from Tygerberg
are definitely not areas of highest TB prevalence in the world, and there
are plenty of other areas in the Western Cape with low TB prevalence. What
is suggested but not said is that there is a high prevalence of TB in areas
where children grow up in poverty and the prescription for these children is
to take a cocktail of pills from day 1 of their lives.   

To avoid any misunderstandings: It is the role of the clinician to save as
many lives as possible under the given conditions. The perspective and care
for the individual patient is what we expect from them in the first place.
But to sell the desperation in the clinical approach as a new vision for
public health is a declaration of capitulation.
 
TB control means poverty reduction. If that is not yet clear at this stage
of the epidemic in SA then we have not yet seen the worst I am afraid. 

Christoph Hamelmann 
(GHAIN - Abuja) [CHamelmann@ghain.org]