Impact of HIV on novel therapies for tuberculosis control.
OBJECTIVE
The increased risk for tuberculosis in HIV-infected people has fueled a worldwide resurgence of tuberculosis. A major hindrance to controlling tuberculosis is the long treatment duration, leading to default, jeopardizing cure, and generating drug resistance. We investigated how tuberculosis is impacted by reducing treatment duration alone or combined with enhanced case detection and/or cure under different HIV prevalence levels.


METHODS
Our model includes HIV stages I-IV and was calibrated to long-term tuberculosis and HIV data from Kenya. Benefits were assessed in terms of absolute and relative reductions in new tuberculosis cases and deaths.


RESULTS
Compared with present-day strategies, at 3-20% HIV prevalence we attain a 6-20% decrease in incidence and mortality in 25 years when reducing treatment duration alone; benefits exceed 300% when combined with increased detection and cure. Benefits vary substantially according to HIV status and prevalence. Challenges arise because in absolute terms the number of infected people and deaths increases dramatically with increasing HIV prevalence, and because the relative efficacy of tuberculosis control policies displays a nonlinear pattern whereby they become less effective on a per capita basis at HIV prevalence levels greater than 15%. Benefits of reducing treatment duration may even be reversed at extreme HIV prevalence levels. Benefits of increasing cure versus detection increase as HIV prevalence increases.


CONCLUSIONS
Reducing tuberculosis treatment duration, alone or in combination with other control strategies, can provide enormous benefits at high HIV prevalence. Tuberculosis control policies need to account for HIV levels because the efficacy of different interventions varies substantially with HIV prevalence.
Sánchez
María S
MS
Department of Environmental Science, policy and Management, University of California, Berkeley, California 94720-3114, USA. msanchez@nature.berkeley.edu
Lloyd-Smith
James O
JO
Porco
Travis C
TC
Williams
Brian G
BG
Borgdorff
Martien W
MW
Mansoer
John
J
Salomon
Joshua A
JA
Getz
Wayne M
WM
D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control; D000995:Antitubercular Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D004334:Drug Administration Schedule; D015658:HIV Infections / Q000453:epidemiology; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008954:Models, Biological; D015995:Prevalence; D016896:Treatment Outcome; D014376:Tuberculosis / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control
D000995:Antitubercular Agents