title: Global guidelines for treatment of tuberculosis among persons living with HIV: unresolved issues.
abstract: The Revised National Tuberculosis Control Programme (RNTCP) in India uses a fully intermittent thrice-weekly rifampicin-containing regimen for all tuberculosis (TB) patients, including those who are human immunodeficiency virus (HIV) infected, whereas the World Health Organization (WHO)  recommends daily anti-tuberculosis treatment at least during the intensive phase. The WHO recommendation was based on the results of a meta-analysis demonstrating increased risk of recurrence and failure among HIV-infected TB patients receiving intermittent TB treatment compared to a daily  regimen. Review of the primary evidence indicates limited, low-quality information on intermittency, mostly from observational studies in the pre-antiretroviral treatment (ART) era. Molecular epidemiology in India indicates that most of the recurrences and many of the failures result from  exogenous re-infection, suggesting poor infection control and high transmission rather than poor regimen efficacy. Subsequently published studies have shown acceptable treatment outcomes among HIV-infected TB patients receiving intermittent anti-tuberculosis regimens with concomitant ART.  Treatment outcomes among HIV-infected TB patients treated under programmatic conditions show low failure rates but high case fatality; death has been associated with lack of ART. The highest priority is therefore to reduce mortality by linking all HIV-infected TB patients to ART. While urgently  seeking to reduce death rates among HIV-infected TB patients, given the poor evidence for change and operational advantages of an intermittent regimen, the RNTCP intends to collect the necessary evidence to inform national policy decisions through randomised clinical trials.
authors.affiliation: Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India. akumar@the union.org
authors.forename: A
authors.initials: A
authors.lastname: Kumar
authors.forename: A M V
authors.initials: AM
authors.lastname: Kumar
authors.forename: D
authors.initials: D
authors.lastname: Gupta
authors.forename: A
authors.initials: A
authors.lastname: Kanchar
authors.forename: S
authors.initials: S
authors.lastname: Mohammed
authors.forename: S
authors.initials: S
authors.lastname: Srinath
authors.forename: S
authors.initials: S
authors.lastname: Tripathy
authors.forename: S
authors.initials: S
authors.lastname: Rajasekaran
authors.forename: P-L
authors.initials: PL
authors.lastname: Chan
authors.forename: S
authors.initials: S
authors.lastname: Swaminathan
authors.forename: P K
authors.initials: PK
authors.lastname: Dewan
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D014943:Global Health; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D007194:India; D017720:Molecular Epidemiology; D009313:National Health Programs / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D014944:World Health Organization
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents