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1. On LTBI, ART and TST in the developing world.

   • Ige Abraham George, MD

   Christian Medical College, Vellore, Tamil Nadu ,India

   The study by Menzies et al in the current issue of Annals show encouraging results with 4 month treatment of latent tuberculosis(TB) with Rifampicin compared with conventional treatment with 9 months of Isoniazid. However this raises a few concerns in populations where TB is endemic.

   HIV positive patients comprised less than 2 percent of the study population. Many developing countries like India have a Government initiated antiretroviral programme with Nevirapine as a backbone. Due to interactions with Rifampicin, in this population Nevirapine would have to be substituted with an Effavirenz based regimen which has a potential to escalate costs. Secondly it has been shown that Tuberculin Skin Tests (TST) is a poor predictor of both latent TB in HIV-infected individuals in TB endemic countries. Programs offering treatment for latent TB should consider including all HIV-positive patients regardless of TST status, or use other indicators, such as CD4 count(1). May we suggest that these be taken into consideration along with the author’s recommendation justifying a large scale trial comparing efficacy of the two drugs

   (1) Swaminathan S, Subbaraman R, Venkatesan P, Subramanyam S, Kumar SR, Mayer KH, Narayanan PR. Tuberculin skin test results in HIV-infected patients in India: implications for latent tuberculosis treatment.Int J Tuberc Lung Dis. 2008 ;12:168-73.

   Conflict of Interest:

   None declared

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   Published December 2, 2008
2. LTBI and HIV

   • Ahmad Kaako

   UTCOM Internal Medicne Resident

   This is very good study which opens the door and raises the need for a large scale study to evaluate the efficacy of rifampin compare to isoniazide for treatment of LTBI.

   On the other hand, there are other limitations about this study; one of them it was conducted in different centers of the world (Canada, Brazil and Saudi Arabia) with multicultural diversity where exposure and prevalence of HIV and the use of BCG vaccine are different. The compliance and reporting side effects could be variable given the culture difference as well.

   Another one; less then of 2% of the study sample are HIV patients. We know that these patients are at higher risk for LTBI in the western world. In this subgroup, treatment using rifabutin rather than rifampin as alternative for isoniazide, is the standard of care.

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   Published November 24, 2008