TB case finding and INH prevention feasible during pregnancy: Lesotho

In April 2011 the Lesotho Ministry of Health recommended active TB case finding and IPT to help stem the country’s TB epidemic. Although active case finding is recommended in maternal and child health settings across the world, the feasibility of this strategy in regions with concurrent HIV and TB epidemics is unknown. Lesotho has an adult HIV prevalence of 22.9%, according to UNAIDS, including 190,000 women with HIV.

To assess the feasibility of active case finding and IPT among pregnant women, researchers conducted this descriptive study at two health facilities in Lesotho. The analysis involved 160 women with HIV and 640 HIV-negative women, all of them receiving routine services.

Almost all women, 99.8%, were screened for TB. TB symptoms could be detected in significantly more women with than without HIV (11.4% versus 2.3%, P < 0.001). Among 158 HIV-positive pregnant women, 124 (78.5%) began IPT, and 102 (64.5%) completed a 6-month IPT course. Two women (1.6%) died of causes not related to IPT or TB.

Every 1-week older gestational age was linked to 7% lower odds to starting IPT (odds ratio −0.93, 95% confidence interval −0.88 to 0.98). Receiving antiretroviral therapy for treatment rather than prevention of vertical HIV transmission more than quadrupled chances of receiving IPT (odds ratio 4.59, 95% confidence interval 1.32 to 15.93). CD4 count and maternal age did not predict IPT receipt in this analysis.

“Despite the high volume of patients,” the researchers conclude, “health care workers within the maternal and child health setting achieved almost universal screening of all pregnant women for clinical symptoms and signs of TB.”

They add, however, that “the yield of active case finding for the detection of TB primarily was low” and suggest that “improved diagnostics with greater sensitivity than smear microscopy such as GeneXpert testing may identify more cases of TB, especially among HIV-positive patients with compatible clinical symptoms.”

Lesotho provides antiretrovirals for prevention of vertical transmission plus iron, folic acid, vitamin B complex, and vitamin A for the duration of pregnancy. Adding IPT to this package, the researchers propose, “may be an innovative way to improve the completion of IPT 6-month course in pregnancy and beyond; however, the safety of such an intervention would have to be independently investigated, especially in light of the high loss to follow-up that was demonstrated in this feasibility study.”

Source: Appolinaire Tiam, Rhoderick Machekano, Celine R. Gounder, Llang B.M. Maama-Maime, Keletso Ntene-Sealiete, Maitreyi Sahu, Anthony Isavwa, Oyebola Oyebanji, Allan Ahimbisibwe, Majoalane Mokone, Grace L. Barnes, Richard E. Chaisson, Laura Guay, Seble Kassaye. Preventing tuberculosis among HIV-infected pregnant women in Lesotho: the case for rolling out active case finding and isoniazid preventive therapy. JAIDS. 2014; 67: e5-e11.

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Source: IAS